Lessons learned in adapting an online intervention program for posttraumatic stress for use in Egypt

Abstract

Cultural adaptation of evidence-based treatments is a pressing priority for global health, and previous research has informed recommendations for guiding the process of translation and adaptation. As research in the domain of cultural adaptation and evaluation of evidence-based treatments progresses, it is critical that researchers communicate key lessons learned, so that models of adaptation can be continuously refined and reconsidered. The work described in this article aimed to translate and culturally adapt an online intervention to address symptoms of posttraumatic stress—the PTSD Coach Online—for use with young adults in Egypt. The cultural adaptation framework proposed by Bernal and colleagues (1995) was used, and focus groups and interviews with members of the target population, mental health professionals, and service users were conducted. The authors encountered a number of challenges in treatment adaptation that generated important insights for future work. Specifically, this case study highlights the importance of translation teams with diverse backgrounds and experiences, the critical nature of iterative feedback throughout the adaptation process, and the importance of a long time-horizon for optimal adaptation.

Keywords

cross-cultural cultural adaptation Egypt posttraumatic stress translation

Introduction

Exposure to violence and consequent mental health difficulties may be particularly high in contexts with current or recent political conflict and transition. In these settings, the availability of evidence-based interventions to address the common mental health effects of violence is an important resource. However, this need is often met with a dearth of service providers and a lack of services with culturally and contextually relevant forms of evidence-based care (Bernal, Jiménez-Chafey, & Domenech Rodríguez, 2009; Miller-Graff, 2016). Treatment adaptation is a challenging and labor-intensive process, and although researchers often present data on the outcomes of such interventions, far less is written on the actual process of treatment adaptation. Providing insight into lessons learned in the process of treatment adaptation is a critical step in forwarding best-practices in global mental health. The aim of the current article is therefore to provide a case analysis of the adaptation of an existing evidence-based online intervention for the treatment of posttraumatic stress disorder (PTSD), PTSD Coach Online, for use in Egypt. The case study is designed to highlight both the promises and challenges inherent in systematic approaches to the adaptation of psychological interventions.

The Egyptian Revolution began on January 25, 2011. The protests in Egypt, focused on the toppling of the Mubarak autocracy, took up issues such as political corruption, the suppression of free speech, and the ineffective execution of core social services (Anderson, 2011). The revolution began with demonstrations, strikes, non-violent civil resistance, and marches, predominantly in the capital city of Cairo. Within a short period, the demand for Mubarak to step down from office was met with violent collisions with security forces, resulting in the deaths of over 846 people and the injury of 6,000 more (Al-Masry Al-Youm, 2011).

In just the first two years following the Egyptian Revolution of 2011, 4,648 people lost their lives to acts of political violence. This is likely an underestimate, given that this number includes only officially documented deaths by the Egyptian Ministry of the Interior (Tadros, 2014). Beyond this, there have been dramatic increases in other types of violence, including an almost 900% increase in armed robberies from 2010 (prior to the revolution) to 2012 (Tadros, 2014). In a population survey, 61.5% of respondents reported that they had experienced violence since January 2011, including political violence, religiously motivated violence, sexual assaults, or theft/attack (Tadros, 2014). Egyptian youth and young adults were highly involved in the Egyptian revolution protests (Haas & Lesch, 2012). With the revolution’s protests centralized in Cairo, residents of the city, not surprisingly, report the highest rates of exposure to political violence (Papanikolaou et al., 2013; Tadros, 2014).

Although relatively little data on the mental health effects of the violence in post-revolution Egypt are available, it is evident from psychological research in other contexts that chronic exposure to violence dramatically increases risk for general psychological distress, as well as specific mental health problems, such as anxiety, depression, and posttraumatic stress (Briere & Spinazzola, 2005; Canetti et al., 2017; Cummings, Merrilees, Taylor, & Mondi, 2017). In one post-revolution study of Egyptian adolescents, 69% reported symptoms of anxiety, 82.9% reported subdromal symptoms of posttraumatic stress disorder (with 16.3% meeting full diagnostic criteria), and 33.3% qualified for a diagnosis of Major Depressive Disorder (Rabie, et al., 2015). In Egypt, it has also been found that the lack of perceived control over the unfolding political events may further worsen symptom severity above and beyond the experience of traumatic exposures alone (Papanikolaou et al., 2013).

The extent of psychological distress related to political, social, and economic forms of violence in Egypt is clearly evident, but the growing need for psychological services is met with a lack of available treatment resources, personnel, and expertise to effectively implement evidence-based mental health treatments, with dramatically fewer providers relative to the population compared to other Arab countries (Okasha, Karam, & Okasha, 2012; World Health Organization, 2012). Data from the World Health Organization indicate that there are just 7.3 mental health workers per 100,000 persons in the population (compared to 125.2 per 100,000 in the United States; World Health Organization, 2014).

Addressing the immediate and significant mental health burden of violence in the context of low resources and few service providers is not an uncommon problem for low- and middle-income countries, and one important way that such gaps can be addressed is through the diversification of treatment delivery options (Howell & Miller-Graff, 2016). In contexts where the number, availability, outreach, and training of treatment providers may be limited, structured internet-based interventions may play a particularly important role (Kyrios et al., 2014). Such interventions are becoming more highly usable as access to cell phones and computers rapidly increases worldwide. In fact, in surveys regarding the acceptability of mental health services in the Arab world, individuals have reported high levels of acceptability for online mental health interventions, indicating significantly higher willingness to use such resources over direct consultation with a mental health professional (Kayrouz et al., 2018).

As research on internet-based interventions has advanced, evidence is growing for their effectiveness in addressing symptoms of posttraumatic stress (Kuester, Niemeyer, & Knaevelsrud, 2016). There is also evidence that such interventions can be successfully deployed both as self-management tools and with the support of clinicians in the context of primary care settings (Possemato et al., 2017). Most internet-based treatments for PTSD that have undergone evaluation have been grounded in cognitive behavioral approaches to intervention. Cognitive models of PTSD suggest that symptoms are perpetuated by negative cognitive appraisals and memory disturbances that lead to heightened appraisals of threat and consequently activate a range of maladaptive cognitive, behavioral, and emotional responses (Ehlers & Clark, 2000). In order to remediate these processes and restore healthy functioning, Ehlers and Clark (2000) suggest that treatment should address: (1) elaboration and integration of traumatic memories, (2) correction of problematic cognitive appraisals, and (3) the reduction of thoughts and behaviors that contribute to avoidance. A number of successful mechanisms contributing to the achievement of these treatment aims have been identified and include: changes in appraisals through restructuring (Kleim et al., 2013; Gallagher & Resick, 2012), habituation through exposure (Gallagher & Resick, 2012), relaxation (as part of a more comprehensive program including other elements; Foa, Keane, & Friedman, 2000), behavioral activation (related to safety, reducing isolation, and decreasing avoidance; Ehlers & Clark, 2000), and improving sleep (Germain, Shear, Hall & Buyusse, 2007; Ulmer, Edinger, & Calhoun, 2011). Cognitive behavioral treatments have been adapted for use in Egypt, and there is evidence of their effectiveness for treating posttraumatic stress, anxiety, and depression in this context (Ghanem et al., 2011; Jalal, Samir, & Hinton, 2017; Kamal & Fathy, 2013), suggesting that this theoretical framework might be especially well-suited for online interventions in Egypt as well.

Aims

The cultural adaptation of evidence-based treatments for new contexts often presents challenges in determining how to balance treatment fidelity with adequate contextual and cultural adaptation (Bernal et al., 2009; Miller-Graff, 2016). Bernal and colleagues(2009) suggest that one way of achieving this balance is to systematize how evidence-based treatments are adapted. Specifically, they suggest modifying treatment protocols along eight dimensions: language, persons, metaphors, content, concepts, goals, methods, and context (Bernal, Bonilla, & Bellido, 1995). Despite this useful guidance, there are few resources available that have identified how such adaptation frameworks perform in practice, making it difficult for adaptation recommendations to advance. As mental health care emerges as a global health priority, the responsible adaptation of care across contexts is essential. The aim of the current paper is therefore to provide a case analysis of the adaptation of an existing evidence-based online intervention for the treatment of PTSD—PTSD Coach Online—for use in Egypt using Bernal and colleagues’ (1995) approach. The case study is designed to describe that process in order to highlight both the promises and challenges inherent in systematic approaches to adapting psychological interventions.

Case study analysis: Adapting the PTSD Coach Online

Specific background

Rationale for treatment selection

Given the dearth of mental health services and providers, as well as the acceptability of online interventions in Egypt (Kayrouz et al., 2018), an online treatment protocol that could be adapted to the culture and context of Egypt was considered to be an important and relevant contribution to mental health services. The selected intervention program, PTSD Coach Online, was developed by the United States National Center for PTSD and reflects a cognitive behavioral approach to addressing symptoms of posttraumatic stress. The online program includes 17 units addressing common PTSD symptoms, including feelings of worry and anger, traumatic re-experiencing, avoidance, isolation, sleep problems, and dissociation. When entering the online portal, participants can select a particular symptom domain and are provided with possible tools for addressing the problem. Each tool includes videos and interactive tools to assist in effective implementation. The PTSD Coach program has been found effective in preliminary evaluation studies of its perceived helpfulness (Kuhn, et. al., 2014). Randomized controlled trials of other online programs for treating posttraumatic stress have shown positive and large effects on self-reported total posttraumatic stress symptoms (Knaevelsrud & Maercker, 2007; Kuester et al., 2016; Lange, van de Ven, Schrieken, & Emmelkamp, 2001). The PTSD Coach Online program was selected for several reasons. First, it adheres very closely to the principles of evidence-based treatment for PTSD highlighted in the research literature and, given its basis in cognitive behavioral therapy, it is consistent with evidence for the most effective therapeutic modality for online implementation (Kuester et al., 2016). Second, the National Center for PTSD, who graciously shared all of the source code for a re-creation of the online program, agreed to the translation of the entirety of program materials into Egyptian Arabic. More importantly, the National Center for PTSD permitted the adaptation of the protocol so that it is suitable for the Egyptian context.

Treatment adaptation: General overview

Consistent with the recommendations of Bernal et al. (1995), we sought to adapt the PTSD Coach Online program along eight dimensions: language, persons, metaphors, content, concepts, goals, methods, and context. We review each in turn, highlighting the processes employed to achieve adaptation along the dimension, as well as challenges encountered and lessons learned. Consistent with an immersive and iterative approach to adaptation, the investigators integrated several sources of information into the adaptation, including direct knowledge drawn from immersion, interviews with local mental health professionals, focus groups, and informal exchanges with local mental health professionals and translators. Throughout these formal and informal processes, the investigators engaged in iterative revisions of, and adaptations to, the content of the intervention. At no point were those interviewed asked to reflect on their own experiences of violence or mental health treatment—only to provide reflection on the proposed treatment content. The information-gathering process to inform the adaptation was therefore deemed to pose minimal risk to participants, with a high potential benefit for the community more broadly.

The interviews were conducted with two psychiatrists and two clinical psychologists, recruited from one private mental health clinic and one public mental health clinic serving Greater Cairo. These professionals were self-selecting and were the first to respond to an email sent by a research assistant to all known professionals in the area. Furthermore, two service users from a university-based mental health clinic (both Egyptian, one female, age 21 years, unemployed, undergraduate degree, Muslim; and one male, age 25 years, full time university student, Muslim) volunteered to take part in response to flyers left in the clinic waiting room. Each key informant interview took around 45 to 60 minutes and was conducted at the home university of one of the principal investigators in Cairo by a qualified counseling psychologist with expertise in qualitative research methodology, under the supervision of a licensed clinical psychologist and professor of psychology with over 10 years of experience working within the area of trauma and research.

Two focus groups were also completed. The first group included 11 undergraduate psychology major students taking a clinical psychology class (see Table 1 for demographic details). Participants for this focus group were recruited by emailing all final year psychology majors in the university BA program who were currently enrolled in clinical psychology and asking for volunteers to take part in a study developing an online intervention in Arabic for PTSD. Students who took part were given extra credit in the course and were self-selecting. The focus group lasted 120 minutes and the students were asked to review the written text for the intervention after translation to focus on linguistic accuracy, understanding, and cultural appropriateness of content (see Appendix 1 for focus group guide and topics).

Table 1.

Sociodemographic characteristics of focus groups.

	Group 1(N = 11)	Group 2(N = 8)
Gender
Male	3	4
Female	8	4
Nationality
Egyptian	11	8
Marital status
Married	3	5
Single	8	3
Religion
Islam	8	6
Christian	3	2
Education (highest level)
Completed high school	–	–
Diploma or other	–	3
Undergraduate degree (or in completion)	11	4
Postgraduate degree	–	1
Employment status
In full time education	11	–
In full time paid employment	–	4
In part time education	2	2
Full time work at home (family/house)		2
Age (min–max)	21–32 years	20–36 years
Mean age	23 years	27.5 years

Following this initial focus group and the subsequent edits to the program content, a second focus group with eight individuals that were representative of the target population for the intervention was recruited via an advertisement on social media (see Table 1, Group 2 for demographics). The advertisement asked for participants to take part in a 120-minute focus group to discuss the practicality and usability of an online psychological intervention in amiyah (colloquial Egyptian Arabic). Lunch and transportation costs were provided. The participants were asked to view the online content of several modules of the intervention and to then discuss the linguistic accuracy and cultural appropriateness of the content. They were also asked to reflect on the usability of the interface and the quality of the video and audio content, with particular focus on the modules regarding mindfulness, as these were identified by the previous focus group and key informant interviews as problematic. Both focus groups were carried out by a bilingual Egyptian research assistant who is a qualified counseling psychologist. Subsequent analysis was carried out by the PI based in Cairo, after translation into English and in consultation with the interviewers.

Consistent with an iterative process, the questions posed to the focus groups, interviewees, and translators were different depending upon the stage of treatment adaptation. Feedback was discussed among the research team and treatment adaptations were made responsively and reflected in the program prior to the next round of feedback sought (see Appendix 1 for sample questions). Throughout the iterative process of treatment adaptation, we organized our changes into the following domains: language, persons, metaphors, content, concepts, goals, methods, and context (Bernal et al., 1995).

Language

Bernal et al. (1995) highlight language as an important vehicle of both culture and emotional expression, noting that “language-appropriate interventions are more than the mechanical translation of an intervention or the availability of the intervention in the relevant language” (Bernal et al., 1995, pp. 73–74). Regarding the translation of the program into Arabic, it is important to note context-specific dialect considerations and how they intersect with the mode of intervention delivery. Arabic has a number of different spoken dialects, and amiyah is among the most distinctive. Amiyah, however, is a spoken dialect, and written documents in Egypt (e.g., newspapers) use Modern Standard Arabic (fusha). Because the PTSD Coach Online program primarily requires clients to engage with written content, the authors initially hired a professional translator to translate the program content into fusha. Feedback from the first focus group was unequivocally negative regarding this initial translation of the program. Specifically, the participants felt that the program’s translation was too literal, and failed to capture contextually relevant forms of expression, which was highlighted by Bernal and colleagues (1995) as a critical component of adaptation in this dimension. Further, the participants felt that the translation of the program into strict fusha would preclude broader access to and understanding of the program content by young adults who may not be highly educated or fully literate. The focus groups therefore suggested a stronger integration of amiyah into the program translation, so that program content would be more widely accessible across socioeconomic classes and would also reflect a more contextually-relevant vocabulary selection. Some illustrative examples of phrasing of key concepts in fusha and amiyah are included in Table 2.

Table 2.

Sample phraseological and translational differences between fusha and amiyah.

English	Fusha (فصحه)/literal translation	Semantic meaning	Amyiah (عاميه)/literal translation	Semantic meaning	Amyiah/Culturally appropriate alternative	Semantic meaning
Assertiveness	حزم	Being determined	حازم	Determined (problem: also a popular name for men)	حسم	Decisive/Determined
Reflect	-الحق الاّذي ب -انعكاس	Do harm to someone (evil eye)Reflecting light	اعكس	Reflect Reverse	فكر	Deep thinking
More open to changing the thought	اكثر انفتاح لتغيير افكارك	More open to change your ideas	منفتح اكتر لتغيير الفكره	Open more to the change of idea	مرن اكتر لتغيير الفكره	More flexible to change the idea
Get in touch with your physical sensations	اتواصل مع احاسيسك الجسديه	Get connected with your physical sensations	اتواصل مع احاسيس جسمك	Get connected with your body sensations	اتواصل مع الاحاسيس اللي في جسمك	Connect with the sensations in your body
Practice being mindful	تدرب علي الانتباه / الوعي	Practice being attentive/aware	اتمرن علي حضور العقل	Practice the presence of your mind	اتمرن علي ان عقلك يكون حاضر	Practice having your mind in the present

Persons

The domain of “persons” refers to the relationship between the client and therapist, including the consideration of therapist–client match and differences in culturally-influenced worldviews (Bernal et al., 1995). Despite the fact that the current program is an online intervention and there is no therapist present, several steps were taken to ensure appropriate adaptation in this dimension. Specifically, all psychoeducational videos for the program were recorded using native Egyptian actors and the quality and accessibility of the videos were discussed by the second focus group. The actor initially hired for the videos, while Egyptian, was not well-liked by the focus group, primarily because of the speed and cadence of her speech. The videos were therefore re-recorded with a different actor to enhance the program’s accessibility for participants.

Metaphors

The concept of metaphors refers to the use of culturally syntonic symbols and concepts that make the client feel comfortable and understood, including both physical/visible aspects of the therapeutic experiences as well as the use of culturally relevant idioms (Bernal et al. 1995). To address this domain of adaptation, two steps were taken. First, all graphics and photos included in the PTSD Coach Online program were evaluated. In order to make the appearance of the program inclusive of symbols of Egypt, local photos taken by the research team and accompanying context-specific adaptations were integrated into the relevant units. For example, the PTSD Coach Online program includes a “relax through visualization” unit, which includes imaginal visualization exercises (with photos) of nature scenes common in the United States (e.g., a forest). Given that many Egyptians would not have direct experience with such scenes, precluding an effective imaginal experience, the investigators rewrote this section to reflect common nature scenes in Egypt. One scene, for example, includes a description of a felucca (local style of sailboat) ride on the Nile—a common and enjoyable pastime for local Cairenes. A second important consideration was the numerous references and graphics related to military service. Because the PTSD Coach Online program is produced by the United States National Center for PTSD, which is an arm of the Veterans Association, these images and metaphors are highly relevant for the population for whom the program was originally designed. The authors, however, were concerned that the strong presence of military themes in the program would produce discomfort in participants. The program was therefore modified to eliminate all graphics of military personnel and reduce the number of references to experiences of military service.

Finally, the authors took several steps to address cultural idioms. First, both authors reviewed all program content to identify culturally-specific idioms for American populations (e.g., “sleeping in” and “gray area”) and clarified, either in comments or by direct editing, the meaning of these idioms for the translation team. In the process of forward translation, the translator also identified phrases that translated poorly or suggested possible idiomatic phrases that would better convey the context-specific meaning of the program content. For example, one example item addressing thought relating to rumination used the English idiomatic phrase “to beat [oneself] up.” In conversation with the translator and back translator, we determined the appropriate equivalent in amiyah was “to exhaust [oneself of thinking].” All comments were discussed together by the translation team to determine the language content. Back translations were then conducted by a native Egyptian fluent in both Arabic and English who was a member of the target intervention population (i.e., 18–35 years of age, fluent in Egyptian Arabic) and who had no professional background or training in mental health. In this way, any over-professionalized language could be identified and corrected and cultural idioms could be evaluated in the extent to which they retained semantic meaning in translation. Any discrepancies or corrections were discussed together with the entire translation team (i.e., forward translator, back translator, authors) and resolved.

Content

Adaptation of treatment content refers to changes made to reflect cultural understandings of values, customs, and traditions (Bernal et al., 1995). Adaptation in this dimension, in particular, highlighted the critical importance of focus groups with local constituents, as the extent to which participants reported acceptability of various treatment units was surprising to both investigators, neither of whom are native Egyptian. For example, the investigators expected more pushback on units that had a strong behavioral focus, given the relative rarity of such approaches or perspectives in the context of mental health care in Egypt. These units, however, were widely liked by the first focus group, who recommended very little change to any of the content in these units. The first focus group did refine content in a number of other areas, however. For example, American football, baseball, and skiing, which were suggested activities in some of the behavioral activation units, are not activities that many Egyptians would take part in, yet they were listed in some of the measures as well as suggested as pleasurable activities. Participants suggested other more culturally appropriate activities, such as snorkeling and playing backgammon.

Concepts

The evaluation of treatment concepts refers to culturally syntonic conceptualizations of psychopathology and distress. Within this domain, two specific issues arose as primary. First, there is significant stigma surrounding both the experience of mental health symptoms, the types of traumatic events experienced by individuals (e.g., sexual assault), and seeking mental health care (Boyd, Adler, Otilingam, & Peters, 2014; Lebowitz & Roth, 1994; Soheilian & Inman, 2009). Interviews with mental health professionals all mentioned the reluctance of Egyptians to consult a mental health professional due to stigma, and the cultural norm of seeking more traditional forms of faith healing and utilizing religious practices. Focus group members also expressed significant concerns about the privacy and confidentiality of mental health data, indicating that they did not always trust that appropriate professional standards related to confidentiality of information would be maintained. For this reason, many of the individuals participating in focus groups indicated that the online intervention format was a preferred format, given that it enhanced participant privacy and addressed concerns about the stigma that might be associated with direct care experiences. On the other hand, some of the mental health professionals indicated that some persons might value in-person contact as an important component of care. As such, the implementation protocol of the program was modified so that all participants would receive a weekly phone call from one of the study team, all of whom are practicing mental health professionals. In this way, the privacy of online content was maintained, but participants could have the opportunity to voice any questions or concerns about the program and its use, if desired.

A second area of cultural conceptualization related to the PTSD Coach adaptation and pilot is controversy surrounding posttraumatic stress as a culturally relevant “disorder.” Although there is substantial support for the cross-cultural validity of PTSD, and evidence that the criteria in the most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders has improved cross-cultural validity over previous versions (Hinton & Lewis-Fernández, 2011), there is significant pushback around the conceptualization of traumatic stress symptoms as “post”-adversity, especially in contexts where violence is chronic (Eagle & Kaminer, 2013). There is also some controversy around conceptualizing PTSD in a diagnostic classification model, with concern that the focus on categorical classification, as opposed to more dimensional understandings of traumatic stress, limits its cross-cultural relevance (Afana, 2012). This was also mentioned during the interviews with mental health professionals, i.e., that the idea of being given a psychiatric diagnosis is a significant barrier to seeking out professional mental health services. For this reason, in the adaptation of the PTSD Coach program, psychoeducational content was adapted to refer to “symptoms of posttraumatic stress” rather than “PTSD,” where relevant.

Goals

Bernal and colleagues (1995) also consider the importance of evaluating the goals of treatment. In this case, the goal of the PTSD Coach Online intervention program—to reduce symptoms of posttraumatic stress—was viewed as a highly relevant goal that met both a pressing contextual need and was consistent with the values and goals of those likely to access the PTSD Coach Online program. For this reason, no adaptations were made on this dimension of the treatment protocol.

Methods

In order for an intervention to be seen as beneficial and likely to be successful, it is vital that the methods and strategies employed be congruent with the beliefs of the client’s culture (Bernal et al., 1995). In Middle Eastern culture, collectivism and the value of family support must not be underestimated when designing or adapting interventions. While the PTSD Coach Online is designed for independent use, it encourages users to draw on their protective factors and support networks, such as family, extended family, and friends. It was mentioned by both service users and health providers that Egyptians are most likely to use traditional methods of healing first, such as faith healers, engaging in practices such as Quranic readings, and that it is important to recognize these values and incorporate them into therapeutic settings. The original PTSD Coach Online also includes mention of religious and spiritual resources for coping consistent with these identified values, despite the fact that it takes a distinctive and secular approach to symptom reduction.

The student focus group also helped to identify that the PTSD Coach tools focused on “mindfulness” were difficult to understand (even amongst a group of final year psychology major students attending the country’s most elite university). Such practices are not common in Egypt, and seemed to frustrate focus group members. Given the focus group’s difficulty in coming to a resolution on how mindfulness content should be adapted to be comprehensible in-context, an additional meeting was then conducted with four professional practitioners of mindfulness in Cairo, who unanimously agreed that self-guided practice of mindfulness would be very difficult for the target population. Such a lack of cultural compatibility may lead to a lack of effectiveness of an intervention (Sue & Zane, 1987), a hypothesis which will need to be evaluated in the future pilot trial.

In addition to the relative congruencies with some aspects of local culture, the intervention also sought to address concerns about stigmatization of care. Accessing mental health interventions or going for traditional “face to face” therapy is still very taboo and stigmatized in Egypt, and other Middle East Arab countries, particularly amongst women and those from lower educational backgrounds, who are also more likely to seek help using traditional healing methods rather than modern approaches to psychiatry (Al-Krenawi, Graham, Al-Bedha, Kadri, & Sehwail, 2009). Women who seek such help from mental health services may be viewed or view themselves as damaging their future marital prospects, or risking divorce if married, so may have gender-specific anxieties. It should, however, also be noted that men in Egyptian culture may associate such help-seeking behavior (on their own part) as a diminishment of their masculinity (Al-Krenawi & Graham, 2000). The PTSD Coach Online addresses these concerns by anonymizing access to the online intervention.

Context

When adapting a mental health intervention, it is important to consider the political, economic, and social context. Additionally, it is important to consider social processes such as acculturative stress, developmental stage, and the relationship of the individual to the culture of origin (Bernal et al., 1995). In a systematic review of 22 psychosocial and mental health treatment studies in Middle East Arab countries, Gearing et al. (2013) summarized that successful treatments must consider the following nine issues that are common service barriers: lack of awareness, gender issues, stigma, poor language competency of caregivers, financial barriers, lack of transportation, diagnosis/treatment misunderstanding, medical versus traditional models, and a general mistrust of mental health services.

The approach of the PTSD Coach Online lends itself well to addressing several of these treatment barriers. Being an online intervention reduces the need for transportation for treatment and financial barriers, as the intervention will be freely accessible online after piloting. For those who find accessing the limited services available in Egypt even more difficult due to issues such as stigma, particularly women who have been sexually harassed or assaulted, an anonymous and confidential online intervention offers a potentially more acceptable mode of intervention, avoiding the shame of accessing mental health services publicly in person. It is hoped that by using social media to advertise availability and developing the increasing accessibility to such interventions online that this stigma will be reduced as awareness increases. Furthermore, the thorough iterative process of cultural adaptation that was undertaken in the piloting process led to a version of the intervention using language much more easily accessible to a wide range of potential constituents. The intervention is a self-directed tool, giving users freedom to choose which modules they may find helpful. As no data is recorded it is also hoped that this will help to overcome the barrier of mistrust of record keeping and confidentiality of mental health service provision.

Lessons learned

In general, we found that previous models for cultural adaptation provided critical and useful guidance. There were, however, a number of ways in which models could be expanded.

Program translation

First, in regards to language, we found the process of translation required far more iterative work than the standard process of translation and back translation that is common practice. This challenge has been noted by cross-cultural assessment researchers, who have made a number of useful recommendations pertaining to the translation of assessment instruments (Van de Vijver & Hambelton, 1996), but the translation of a treatment program made evident several unique challenges that inform important next steps for the field. One such challenge that arose related to the discrepancies between language used by mental health professionals in Egypt and that used by the identified constituent base for the program. As noted above, the program was targeted to be accessible to literate young adults living in Egypt, however, the more colloquial amiyah dialect was selected by the focus group as the optimal style of language for the program. Some of the core concepts of the program were also not clearly translatable into Egyptian Arabic. In such cases, the translation team consulted with local clinicians to determine the appropriate language to describe the constructs in ways that would be meaningfully contextually understood. Because the study of psychology in Egypt is very young, however, many mental health professionals were educated outside of the country or were educated in in-country schools run by institutions in the global North. Because of this, the words selected by clinicians still did not always resonate with focus group participants as meaningful. To address this problem, we made several accommodations to the structure of both the iterative process of adaptation and the translation process. Regarding the translation team, we decided to use a trained mental health professional rather than a professional translator for the forward translation. In this way, we could ensure semantic equivalence of the translation in ways that were not possible working with professional translators. As our back translator, we worked with an individual who had translation experience and who was a member of the target constituent base for the program (i.e., literate adults aged 18–35), but who had no training in mental health. His feedback assisted in identifying content that contained overly professionalized or confusing language, given the influence of foreign terminology in mental health care.

Time horizon of adaptation

Perhaps one of the most salient lessons learned over the course of this treatment adaptation was the time horizon of the adaptation process. The investigators were highly committed to producing a good cultural and linguistic adaptation of the PTSD Coach Online program, and for this reason, engaged in ongoing iterative processes of translation, adaptation, and gathering feedback from diverse constituencies over the period of approximately two and a half years. Although there were other barriers that slowed down the product timeline, it was primarily our commitment to engaging in a slow, iterative process that was critical to the responsible translation and adaptation of this program that took time. It is important to recognize, however, that this timescale and the investment of labor (by many individuals) over the treatment adaptation period reflects a challenge for practitioners seeking to scale interventions to other contexts. Direct translation—even by professionals—although quick, may prove woefully insufficient and may produce a linguistically and culturally inappropriate product, such as the one in this case that was unanimously disliked by local constituents.

Based on our experience and lessons learned in this domain, we feel that there are two important take-aways for practitioners seeking to translate programs from other contexts: (1) consider a translation team that is inclusive of a broad range of constituencies, including a professional translator, a local mental health professional, a professional with expertise in the original intervention method, and members of the targeted population of the intervention, and (2) permit significant time for translation and adaptation.

The latter point presents a significant barrier for many agencies who need to balance immediate needs with a dearth of available treatments. As such, practitioners might consider a graded implementation process that integrates translation. We found that some modules of the PTSD Coach Online program were significantly easier to translate and adapt than others. Practitioners with briefer time frames for required implementation of care could consider a graded implementation, where some modules are made available (and their effectiveness evaluated) as the program is translated. In this way, some services could be provided prior to the full translation of the program but a longer timescale could be permitted for the adaptation of more challenging units.

Subcultural groups

One of the issues and challenges noted in work on cultural adaptation of evidence-based treatments is the presence of subcultural groups (Castro, Barrera, & Holleran Steiker, 2010), referring to population segmentation that creates additional complexities as cultural groups are fractured and shaped by other, cross-cutting identities (e.g., class, gender). Writing in this domain has highlighted the challenges of cultural adaptation due to the heterogeneous nature of culture within contexts. We, too, encountered this challenge in the adaptation of the PTSD Coach Online program, although the challenges specific to Egypt highlight new areas of consideration in this domain. First, Egyptian society has deep socioeconomic divisions, with an almost non-existent middle class (Xiaoqi, 2012). For this reason, it was difficult to determine how best to adapt intervention content to reflect the wide-ranging social realities of families in Egypt. For example, one of the activities suggested in the program for relaxation was watching a TV show in the evenings, but our focus groups highlighted that many families live in single-room residences and activities needed to reflect the reality of shared bedroom/living spaces. Given the format of the program, however, we also needed to consider its limits in terms of reach. Specifically, we needed to balance the literacy level of the program with its likely constituent base. As noted above, we opted to use amiyah where possible to broaden the likelihood of understanding beyond individuals completing high levels of formal education, but even with this consideration, the PTSD Coach Online program includes a high amount of written content. For this reason, we targeted the adaptation of the program to be appropriate for use by those who have completed their secondary education. Rates of secondary education completion in Egypt are high (80–90%; UNESCO Institute for Statistics, 2016), but this nonetheless means that the program may not be accessible to a significant minority of the population who may be in need of services.

Conclusion

In conclusion, the current study offers a number of helpful insights and recommendations to undertake the adaptation of a mental health intervention in a culturally appropriate manner. The framework suggested by Bernal et al. (1995) provided helpful guidance for such an undertaking. However, further considerations beyond those they considered salient were identified. We found that an online intervention based predominantly on cognitive behavioral strategies and developed in the United States could be adapted culturally and linguistically for use by Egyptian citizens of secondary level education, in a manner that was perceived by those interviewed as potentially accessible and useful by the target population. One important question for the future evaluation of the program is whether treatment constituents perceive each unit as helpful, and to what extent some units are used over others (and with what effects). This will provide further important detail into what intervention strategies might be particularly relevant for this context.

Bernal and colleagues (1995) highlight the importance of using culturally acceptable strategies to promote the acceptance of interventions aimed at improving positive mental health. Despite the research team’s concerns, behaviorally-oriented modules were much more accepted than anticipated. This may be a reflection of the changing acceptance of modern psychological approaches to treatment amongst the constituents who took part in this study. Although previous research in the Middle East has indicated that “in person” contact is a valuable part of what constitutes a culturally acceptable treatment modality, those taking part in the focus groups, as well as local experts, indicated that the online and anonymous nature of PTSD Coach Online offered unique benefits. Specifically, it enhanced accessibility to treatment and could potentially reduce concerns about stigmatization for seeking “professional” assistance with a mental health issue. Furthermore, components of the program focused on drawing on family and social networks, in addition to religiosity or spirituality, and these forms of support were engaging aspects consistently identified as increasing acceptability of the tool. This is consistent with previous research (Kizilhan, 2014).

Some strategies and therapeutic approaches successfully employed in the original PTSD Coach, and commonly included in Western-based interventions aimed at reducing distress related to experiences of trauma, were not viewed as highly accessible and understandable to the constituents who assisted in the adaptation of the tool for use locally. Specifically, the use of mindfulness and related concepts was found to be confusing and could lead to a potential lack of trust in the tool’s credibility. Although we took numerous steps to effectively address this barrier, future steps will consider the response to the choices made around the content adaptation in this area in the context of the pilot evaluation trial. Based on feedback at this stage, we may consider the integration of other cultural adaptation research in the region, which suggests the integration of religious language to capture this practice (Jalal et al., 2017). We decided not to integrate this language into the pilot trial as it is specific to Islam, and our program is designed for broader use, including by Egypt’s Muslim and Christian populations. Although the focus groups included both Muslim and Christian participants, more Muslims were represented. Given the imbalance in representation, and religious tensions in Egypt, we did not probe for specific concerns around specific religious conceptualizations of various constructs. This information, however, might be useful and taken up in future work, particularly if the intervention shows evidence of differential effects by religious identification.

In sum, the current research identifies the need for a more complex iterative process than forward and backward translation in order to provide meaningful adaptation of assessment and intervention tools across very different cultural contexts. Consulting local mental health professionals, in an area of the world where many have trained outside of the region or at local institutions providing predominantly Western-developed curricula, does not effectively address the issue of using understandable language and terms. Local citizens frequently did not understand the words used by local practitioners once translated into the Egyptian amiyah dialect. The current study provides a strong basis for the use of a translation team, rather than the traditional implementation of forward and backward translation. It also highlights the need to assess the quality of translation over the course of a staged, iterative approach.

Limitations

Although every effort was made to include a wide-ranging team during the adaptation process of the PTSD Coach Online Arabic, a pilot study is now required to test the actual accessibility and effectiveness of the tool to allow for further refinement and in order to roll out the intervention amongst the target population in Egypt, provided the results are positive. It should be acknowledged that since those who took part in the interviews and focus groups were self-selecting and that use was made of convenience samples, this may impact on the estimation of usage of the completed PTSD Coach Online Arabic, which will be further understood after piloting. Integration of feedback from a more representative participant base in the context of the pilot trial will be another important point for further adaptation of the program.

Future directions

A randomized control trial is needed to ascertain the degree of usability, the possible problems, and final adaptation of the PTSD Coach Online Arabic. It is hoped the tool can then be made freely available online to anyone wishing to access it. Furthermore, if the results are positive, the tool could be adapted for other Arabic dialects to use amongst other Arab populations. It is also important to ascertain the extent of accessibility in terms of the required educational, linguistic, and technological abilities of the target group, in order to understand for whom the tool can be useful and ways to increase accessibility amongst other socioeconomic groups.

Footnotes

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: No commercial or pharmaceutical company was involved in, nor supported this study.

Ethics approval

Ethical approval for this study was granted by the Institutional Review Board of the American University in Cairo (2015-2016-209).

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Kate Ellis

Kate Ellis is an Assistant Professor of Psychology in the Psychology Department at the American University in Cairo. She is a qualified clinical psychologist who completed her Doctorate in Clinical Psychology at Canterbury Christ Church University, in England. Dr Ellis works predominantly with refugees and individuals who have experienced trauma. Her research focuses on the impact of violence and conflict, with a particular focus on young people, which was the focus of her first PhD awarded by the University of Ulster in Northern Ireland. During her time in Egypt, Dr Ellis, has become increasingly involved in developing culturally appropriate interventions for trauma and for working with refugees. Dr Ellis is also the course coordinator of the Leadership in Mental Health course, Eastern Mediterranean Region, held annually at the AUC. This course was developed in collaboration with the WHO, in order to provide training to mental health professionals in the region, with the aims of upscaling mental health services and putting mental health on the national health agenda in under-resourced and low economic status countries. Dr Ellis is also a member of the University of California Davis Arab region consortium working on a longitudinal study called “Transforming refugee mental health: Training practitioners.”

Laura Miller-Graff is an Associate Professor of Psychology and Peace Studies at the University of Notre Dame. She earned a PhD in clinical science from the University of Michigan in 2013. Working within an ecological framework, Miller-Graff’s research seeks to understand how various systems (i.e., individual, family, and community) interact to promote or inhibit healthful development following violence exposure. With a focus on children who have multiple traumatic exposures, she investigates resulting patterns of resilience and psychopathology, including the development of posttraumatic stress symptoms. In addition to conducting basic research on the effects of violence on development, Miller-Graff also seeks to identify effective intervention practices for children and families affected by violence. This line of work considers the status of psychosocial interventions currently available in international conflict settings and seeks to identify evidence-based intervention practices that facilitate resilience in families and communities. Specific aims of this work include identifying culturally appropriate assessment and treatment practices and developing efficacious and cost-effective psychosocial interventions that can be readily disseminated in conflict settings.

Appendix 1. Sample questions: Focus groups and key informant interviews

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