Assessing Therapeutic Alliance in the Context of mHealth Interventions for Mental Health Problems: Development of the Mobile Agnew Relationship Measure (mARM) Questionnaire (Preprint)

BACKGROUND Digital health interventions in the form of smartphone apps aim to improve mental health and enable people access to support as and when needed without having to face the stigma they may experience in accessing services. If we are to evaluate mobile health (mHealth) apps and advance scientific understanding, we also need tools to help us understand in what ways mHealth interventions are effective or not. The concept of therapeutic alliance, a measure of the quality of the relationship between a health care provider and a service user, is a key factor in explaining the effects of mental health interventions. The Agnew Relationship Measure (ARM) is a well-validated measure of therapeutic alliance in face-to-face therapy. OBJECTIVE This study presented the first attempt to (1) explore service users’ views of the concept of relationship within mHealth mental health interventions and (2) adapt a well-validated face-to-face measure of therapeutic alliance, the Agnew Relationship Measure (ARM), for use with mHealth interventions. METHODS In stage 1, we interviewed 9 mental health service users about the concept of therapeutic alliance in the context of a digital health intervention and derived key themes from interview transcripts using thematic analysis. In stage 2, we used rating scales and open-ended questions to elicit views from 14 service users and 10 mental health staff about the content and face validity of the scale, which replaced the word “therapist” with the word “app.” In stage 3, we used the findings from stages 1 and 2 to adapt the measure with the support of a decision-making algorithm about which items to drop, retain, or adapt. RESULTS Findings suggested that service users do identify relationship concepts when thinking about mHealth interventions, including forming a bond with an app and the ability to be open with an app. However, there were key differences between relationships with health professionals and relationships with apps. For example, apps were not as tailored and responsive to each person’s unique needs. Furthermore, apps were not capable of portraying uniquely human-like qualities such as friendliness, collaboration, and agreement. We made a number of changes to the ARM that included revising 16 items; removing 4 items due to lack of suitable alternatives; and adding 1 item to capture a key theme derived from stage 1 of the study (“The app is like having a member of my care team in my pocket”). CONCLUSIONS This study introduces the mHealth version of the ARM, the mARM, that has good face and content validity. We encourage researchers to include this easy-to-use tool in digital health intervention studies to gather further data about its psychometric properties and advance our understanding of how therapeutic alliance influences the efficacy of mHealth interventions. CLINICALTRIAL International Standard Randomized Controlled Trial Number (ISRCTN) 34966555; http://www.isrctn.com/ISRCTN34966555 (Archived by WebCite at http://www.webcitation.org/6ymBVwKif)

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The Therapeutic Alliance in Digital Mental Health Interventions for Serious Mental Illnesses: Narrative Review (Preprint)

10.2196/preprints.17204 ◽

2019 ◽

Author(s):

Hailey Tremain ◽

Carla McEnery ◽

Kathryn Fletcher ◽

Greg Murray

Keyword(s):

Mental Health ◽

Therapeutic Alliance ◽

Narrative Review ◽

Mental Illnesses ◽

Health Interventions ◽

Face To Face ◽

Digital Interventions ◽

Mental Health Interventions ◽

Serious Mental Illnesses

BACKGROUND Digital mental health interventions offer unique advantages, and research indicates that these interventions are effective for a range of mental health concerns. Although these interventions are less established for individuals with serious mental illnesses, they demonstrate significant promise. A central consideration in traditional face-to-face therapies is the therapeutic alliance, whereas the nature of a digital therapeutic alliance and its relationship with outcomes requires further attention, particularly for individuals with serious mental illnesses. OBJECTIVE This narrative review aims to encourage further consideration and critical evaluation of the therapeutic alliance in digital mental health, specifically for individuals with serious mental illnesses. METHODS A narrative review was conducted by combining 3 main areas of the literature: the first examining the evidence for digital mental health interventions for serious mental illnesses, the second illuminating the nature and role of the therapeutic alliance in digital interventions, and the third surrounding practical considerations to enhance a digital therapeutic alliance. RESULTS Results indicated that a therapeutic alliance can be cultivated in digital interventions for those with serious mental illnesses, but that it may have unique, yet-to-be-confirmed characteristics in digital contexts. In addition, a therapeutic alliance appears to be less directly associated with outcomes in digital interventions than with those in face-to-face therapies. One possibility is that the digital therapeutic alliance is associated with increased engagement and adherence to digital interventions, through which it appears to influence outcomes. A number of design and implementation considerations may enhance the digital therapeutic alliance, including human support and technological features. CONCLUSIONS More research is required to further understand the nature and specific role of a therapeutic alliance in digital interventions for serious mental illnesses, particularly in informing their design. This review revealed several key research priorities to advance the therapeutic alliance in digital interventions.

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The Therapeutic Alliance in Digital Mental Health Interventions for Serious Mental Illnesses: Narrative Review

JMIR Mental Health ◽

10.2196/17204 ◽

2020 ◽

Vol 7 (8) ◽

pp. e17204 ◽

Cited By ~ 1

Author(s):

Hailey Tremain ◽

Carla McEnery ◽

Kathryn Fletcher ◽

Greg Murray

Keyword(s):

Mental Health ◽

Therapeutic Alliance ◽

Narrative Review ◽

Mental Illnesses ◽

Health Interventions ◽

Face To Face ◽

Digital Interventions ◽

Mental Health Interventions ◽

Serious Mental Illnesses

Background Digital mental health interventions offer unique advantages, and research indicates that these interventions are effective for a range of mental health concerns. Although these interventions are less established for individuals with serious mental illnesses, they demonstrate significant promise. A central consideration in traditional face-to-face therapies is the therapeutic alliance, whereas the nature of a digital therapeutic alliance and its relationship with outcomes requires further attention, particularly for individuals with serious mental illnesses. Objective This narrative review aims to encourage further consideration and critical evaluation of the therapeutic alliance in digital mental health, specifically for individuals with serious mental illnesses. Methods A narrative review was conducted by combining 3 main areas of the literature: the first examining the evidence for digital mental health interventions for serious mental illnesses, the second illuminating the nature and role of the therapeutic alliance in digital interventions, and the third surrounding practical considerations to enhance a digital therapeutic alliance. Results Results indicated that a therapeutic alliance can be cultivated in digital interventions for those with serious mental illnesses, but that it may have unique, yet-to-be-confirmed characteristics in digital contexts. In addition, a therapeutic alliance appears to be less directly associated with outcomes in digital interventions than with those in face-to-face therapies. One possibility is that the digital therapeutic alliance is associated with increased engagement and adherence to digital interventions, through which it appears to influence outcomes. A number of design and implementation considerations may enhance the digital therapeutic alliance, including human support and technological features. Conclusions More research is required to further understand the nature and specific role of a therapeutic alliance in digital interventions for serious mental illnesses, particularly in informing their design. This review revealed several key research priorities to advance the therapeutic alliance in digital interventions.

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Employees’ Perspectives on the Facilitators and Barriers to Engaging With Digital Mental Health Interventions in the Workplace: Qualitative Study

JMIR Mental Health ◽

10.2196/mental.9146 ◽

2018 ◽

Vol 5 (1) ◽

pp. e8 ◽

Cited By ~ 16

Author(s):

Stephany Carolan ◽

Richard O de Visser

Keyword(s):

Mental Health ◽

Controlled Trial ◽

Health Intervention ◽

Health Interventions ◽

Mental Health Intervention ◽

Depression And Anxiety ◽

Occupational Setting ◽

Mental Health Interventions ◽

Facilitators And Barriers ◽

Workplace Setting

Background Prevalence rates of work-related stress, depression, and anxiety are high, resulting in reduced productivity and increased absenteeism. There is evidence that these conditions can be successfully treated in the workplace, but take-up of psychological treatments among workers is low. Digital mental health interventions delivered in the workplace may be one way to address this imbalance, but although there is evidence that digital mental health is effective at treating stress, depression, and anxiety in the workplace, uptake of and engagement with these interventions remains a concern. Additionally, there is little research on the appropriateness of the workplace for delivering these interventions or on what the facilitators and barriers to engagement with digital mental health interventions in an occupational setting might be. Objective The aim of this research was to get a better understanding of the facilitators and barriers to engaging with digital mental health interventions in the workplace. Methods Semistructured interviews were held with 18 participants who had access to an occupational digital mental health intervention as part of a randomized controlled trial. The interviews were transcribed, and thematic analysis was used to develop an understanding of the data. Results Digital mental health interventions were described by interviewees as convenient, flexible, and anonymous; these attributes were seen as being both facilitators and barriers to engagement in a workplace setting. Convenience and flexibility could increase the opportunities to engage with digital mental health, but in a workplace setting they could also result in difficulty in prioritizing time and ensuring a temporal and spatial separation between work and therapy. The anonymity of the Internet could encourage use, but that benefit may be lost for people who work in open-plan offices. Other facilitators to engagement included interactive and interesting content and design features such as progress trackers and reminders to log in. The main barrier to engagement was the lack of time. The perfect digital mental health intervention was described as a website that combined a short interactive course that was accessed alongside time-unlimited information and advice that was regularly updated and could be dipped in and out of. Participants also wanted access to e-coaching support. Conclusions Occupational digital mental health interventions may have an important role in delivering health care support to employees. Although the advantages of digital mental health interventions are clear, they do not always fully translate to interventions delivered in an occupational setting and further work is required to identify ways of minimizing potential barriers to access and engagement. Trial Registration ClinicalTrials.gov: NCT02729987; https://clinicaltrials.gov/ct2/show/NCT02729987?term=NCT02729987& rank=1 (Archived at WebCite at http://www.webcitation.org/6wZJge9rt)

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Employees� Perspectives on the Facilitators and Barriers to Engaging With Digital Mental Health Interventions in the Workplace: Qualitative Study (Preprint)

10.2196/preprints.9146 ◽

2017 ◽

Author(s):

Stephany Carolan ◽

Richard O de Visser

Keyword(s):

Mental Health ◽

Controlled Trial ◽

Health Intervention ◽

Health Interventions ◽

Mental Health Intervention ◽

Depression And Anxiety ◽

Occupational Setting ◽

Mental Health Interventions ◽

Facilitators And Barriers ◽

Workplace Setting

BACKGROUND Prevalence rates of work-related stress, depression, and anxiety are high, resulting in reduced productivity and increased absenteeism. There is evidence that these conditions can be successfully treated in the workplace, but take-up of psychological treatments among workers is low. Digital mental health interventions delivered in the workplace may be one way to address this imbalance, but although there is evidence that digital mental health is effective at treating stress, depression, and anxiety in the workplace, uptake of and engagement with these interventions remains a concern. Additionally, there is little research on the appropriateness of the workplace for delivering these interventions or on what the facilitators and barriers to engagement with digital mental health interventions in an occupational setting might be. OBJECTIVE The aim of this research was to get a better understanding of the facilitators and barriers to engaging with digital mental health interventions in the workplace. METHODS Semistructured interviews were held with 18 participants who had access to an occupational digital mental health intervention as part of a randomized controlled trial. The interviews were transcribed, and thematic analysis was used to develop an understanding of the data. RESULTS Digital mental health interventions were described by interviewees as convenient, flexible, and anonymous; these attributes were seen as being both facilitators and barriers to engagement in a workplace setting. Convenience and flexibility could increase the opportunities to engage with digital mental health, but in a workplace setting they could also result in difficulty in prioritizing time and ensuring a temporal and spatial separation between work and therapy. The anonymity of the Internet could encourage use, but that benefit may be lost for people who work in open-plan offices. Other facilitators to engagement included interactive and interesting content and design features such as progress trackers and reminders to log in. The main barrier to engagement was the lack of time. The perfect digital mental health intervention was described as a website that combined a short interactive course that was accessed alongside time-unlimited information and advice that was regularly updated and could be dipped in and out of. Participants also wanted access to e-coaching support. CONCLUSIONS Occupational digital mental health interventions may have an important role in delivering health care support to employees. Although the advantages of digital mental health interventions are clear, they do not always fully translate to interventions delivered in an occupational setting and further work is required to identify ways of minimizing potential barriers to access and engagement. CLINICALTRIAL ClinicalTrials.gov: NCT02729987; https://clinicaltrials.gov/ct2/show/NCT02729987?term=NCT02729987& rank=1 (Archived at WebCite at http://www.webcitation.org/6wZJge9rt)

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Improving mental health among people living with HIV: a review of intervention trials in low- and middle-income countries

Global Mental Health ◽

10.1017/gmh.2015.17 ◽

2015 ◽

Vol 2 ◽

Cited By ~ 22

Author(s):

K. J. Sikkema ◽

A. C. Dennis ◽

M. H. Watt ◽

K. W. Choi ◽

T. T. Yemeke ◽

...

Keyword(s):

Mental Health ◽

Health Intervention ◽

Health Interventions ◽

People Living With Hiv ◽

Mental Health Intervention ◽

Middle Income ◽

Middle Income Countries ◽

Mental Health Interventions ◽

Intervention Trials ◽

Living With Hiv

People living with HIV (PLWH) experience greater psychological distress than the general population. Evidence from high-incomes countries suggests that psychological interventions for PLWH can improve mental health symptoms, quality of life, and HIV care engagement. However, little is known about the effectiveness of mental health interventions for PLWH in low- and middle-income countries (LMICs), where the large majority of PLWH reside. This systematized review aims to synthesize findings from mental health intervention trials with PLWH in LMICs to inform the delivery of mental health services in these settings. A systematic search strategy was undertaken to identify peer-reviewed published papers of intervention trials addressing negative psychological states or disorders (e.g. depression, anxiety) among PLWH in LMIC settings. Search results were assessed against pre-established inclusion and exclusion criteria. Data from papers meeting criteria were extracted for synthesis. Twenty-six papers, published between 2000 and 2014, describing 22 unique interventions were identified. Trials were implemented in sub-Saharan Africa (n = 13), Asia (n = 7), and the Middle East (n = 2), and addressed mental health using a variety of approaches, including cognitive-behavioral (n = 18), family-level (n = 2), and pharmacological (n = 2) treatments. Four randomized controlled trials reported significant intervention effects in mental health outcomes, and 11 preliminary studies demonstrated promising findings. Among the limited mental health intervention trials with PLWH in LMICs, few demonstrated efficacy. Mental health interventions for PLWH in LMICs must be further developed and adapted for resource-limited settings to improve effectiveness.

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Digital Mental Health Intervention Uptake Among Distressed New Zealand High School Students in a Comprehensive Survey: Implications for Digital Help Provision

10.26686/wgtn.14471310 ◽

2021 ◽

Author(s):

Jessica Shaw

Keyword(s):

Mental Health ◽

High School Students ◽

Mental Distress ◽

Digital Health ◽

Health Resources ◽

Health Interventions ◽

School Students ◽

Comprehensive Survey ◽

Mental Health Interventions ◽

To Receive

Background: High rates of mental distress are reported among adolescents. Emerging evidence suggests that digital mental health interventions, such as computerised psychotherapy, informative websites, and non-clinical helplines, may help. However, it is unclear whether these resources are reaching those who experience distress in real-world settings. Aim: The aim of this research is to explore adolescent uptake of digital mental health interventions offered via a comprehensive youth health survey, with a particular focus on adolescents experiencing probable mental distress. Methods: Data were drawn from the Youth19 Rangatahi Smart Survey. At the end of the survey participants were provided the opportunity to opt-in to receive digital health resources. Participants’ opt-in and access to these digital health resources, as well as if they accessed the specific mental health resources, was remotely monitored. We compare opt-in and access among participants with and without probable mental distress. Results: Of those who completed the Youth19 survey (n = 7721), a substantial minority of participants opted-in to receive the digital health resources (n = 1720). However, of those who opted-in, access was low (n = 187). Participants with probable mental distress were more likely than their non-distressed counterparts to opt-in and access the digital health resources, although these differences were small. Importantly, only seven participants went on to access digital mental health interventions. Discussion: The moderate number of participants to opt-in to receive Youth19 digital health resources suggests that digital resources may be a valuable component of supporting diverse groups of adolescents. The high attrition, however, indicates that adolescents may be experiencing barriers to accessing these interventions. Smart design to increase appeal, addressing barriers that limit access, and providing multiple options for different groups could increase adolescents’ engagement with digital mental health interventions.

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Surveying the Role of Analytics in Evaluating Digital Mental Health Interventions for Transition-Aged Youth: Scoping Review (Preprint)

10.2196/preprints.15942 ◽

2019 ◽

Author(s):

Brian Lo ◽

Jenny Shi ◽

Elisa Hollenberg ◽

Alexxa Abi-Jaoudé ◽

Andrew Johnson ◽

...

Keyword(s):

Mental Health ◽

Scoping Review ◽

Care Delivery ◽

Digital Health ◽

Controlled Trial ◽

Health Interventions ◽

Health Apps ◽

Mental Health Interventions ◽

Usage Data

BACKGROUND Consumer-facing digital health interventions provide a promising avenue to bridge gaps in mental health care delivery. To evaluate these interventions, understanding how the target population uses a solution is critical to the overall validity and reliability of the evaluation. As a result, usage data (analytics) can provide a proxy for evaluating the engagement of a solution. However, there is paucity of guidance on how usage data or analytics should be used to assess and evaluate digital mental health interventions. OBJECTIVE This review aimed to examine how usage data are collected and analyzed in evaluations of mental health mobile apps for transition-aged youth (15-29 years). METHODS A scoping review was conducted using the Arksey and O’Malley framework. A systematic search was conducted on 5 journal databases using keywords related to usage and engagement, mental health apps, and evaluation. A total of 1784 papers from 2008 to 2019 were identified and screened to ensure that they included analytics and evaluated a mental health app for transition-aged youth. After full-text screening, 49 papers were included in the analysis. RESULTS Of the 49 papers included in the analysis, 40 unique digital mental health innovations were evaluated, and about 80% (39/49) of the papers were published over the past 6 years. About 80% involved a randomized controlled trial and evaluated apps with information delivery features. There were heterogeneous findings in the concept that analytics was ascribed to, with the top 3 being engagement, adherence, and acceptability. There was also a significant spread in the number of metrics collected by each study, with 35% (17/49) of the papers collecting only 1 metric and 29% (14/49) collecting 4 or more analytic metrics. The number of modules completed, the session duration, and the number of log ins were the most common usage metrics collected. CONCLUSIONS This review of current literature identified significant variability and heterogeneity in using analytics to evaluate digital mental health interventions for transition-aged youth. The large proportion of publications from the last 6 years suggests that user analytics is increasingly being integrated into the evaluation of these apps. Numerous gaps related to selecting appropriate and relevant metrics and defining successful or high levels of engagement have been identified for future exploration. Although long-term use or adoption is an important precursor to realizing the expected benefits of an app, few studies have examined this issue. Researchers would benefit from clarification and guidance on how to measure and analyze app usage in terms of evaluating digital mental health interventions for transition-aged youth. Given the established role of adoption in the success of health information technologies, understanding how to abstract and analyze user adoption for consumer digital mental health apps is also an emerging priority.

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Evidence on Digital Mental Health Interventions for Adolescents and Young People: Systematic Overview

JMIR Mental Health ◽

10.2196/25847 ◽

2021 ◽

Vol 8 (4) ◽

pp. e25847

Author(s):

Susanna Lehtimaki ◽

Jana Martic ◽

Brian Wahl ◽

Katherine T Foster ◽

Nina Schwalbe

Keyword(s):

Mental Health ◽

Cost Effectiveness ◽

Young People ◽

Digital Health ◽

Health Interventions ◽

Middle Income ◽

Middle Income Countries ◽

Mental Health Interventions ◽

Meta Analyses ◽

Low And Middle Income

Background An estimated 1 in 5 adolescents experience a mental health disorder each year; yet because of barriers to accessing and seeking care, most remain undiagnosed and untreated. Furthermore, the early emergence of psychopathology contributes to a lifelong course of challenges across a broad set of functional domains, so addressing this early in the life course is essential. With increasing digital connectivity, including in low- and middle-income countries, digital health technologies are considered promising for addressing mental health among adolescents and young people. In recent years, a growing number of digital health interventions, including more than 2 million web-based mental health apps, have been developed to address a range of mental health issues. Objective This review aims to synthesize the current evidence on digital health interventions targeting adolescents and young people with mental health conditions, aged between 10-24 years, with a focus on effectiveness, cost-effectiveness, and generalizability to low-resource settings (eg, low- and middle-income countries). Methods We searched MEDLINE, PubMed, PsycINFO, and Cochrane databases between January 2010 and June 2020 for systematic reviews and meta-analyses on digital mental health interventions targeting adolescents and young people aged between 10-24 years. Two authors independently screened the studies, extracted data, and assessed the quality of the reviews. Results In this systematic overview, we included 18 systematic reviews and meta-analyses. We found evidence on the effectiveness of computerized cognitive behavioral therapy on anxiety and depression, whereas the effectiveness of other digital mental health interventions remains inconclusive. Interventions with an in-person element with a professional, peer, or parent were associated with greater effectiveness, adherence, and lower dropout than fully automatized or self-administered interventions. Despite the proposed utility of digital interventions for increasing accessibility of treatment across settings, no study has reported sample-specific metrics of social context (eg, socioeconomic background) or focused on low-resource settings. Conclusions Although digital interventions for mental health can be effective for both supplementing and supplanting traditional mental health treatment, only a small proportion of existing digital platforms are evidence based. Furthermore, their cost-effectiveness and effectiveness, including in low- and middle-income countries, have been understudied. Widespread adoption and scale-up of digital mental health interventions, especially in settings with limited resources for health, will require more rigorous and consistent demonstrations of effectiveness and cost-effectiveness vis-à-vis the type of service provided, target population, and the current standard of care.

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Mental disorder and mental health interventions for children and youth: the cases of non-suicidal self-harm and unruly behaviour A philosophical inquiry

10.26686/wgtn.14685405.v1 ◽

2021 ◽

Author(s):

Snita Ahir-Knight

Keyword(s):

Mental Health ◽

Mental Disorder ◽

Interesting Case ◽

Health Intervention ◽

Health Interventions ◽

Children And Youth ◽

Mental Health Intervention ◽

Mental Health Interventions ◽

Self Harm ◽

Outcomes For Children

Thesis abstract This dissertation is a contribution to the philosophy of mental disorder with a focus on children and youth and questions about what interventions they need. I start by asking whether non-suicidal self-harm in youth is a mental disorder. Non-suicidal self-harm involves someone causing themselves harm with no intent to try to kill themselves. Young people cutting themselves alone and when with peers may be viewed as destructive, abnormal and irrational. Yet, I argue that non-suicidal self-harm in youth is never a mental disorder in its own right. Although non-suicidal self-harm in youth is not a disordered behaviour, that does not imply that it never merits intervention. This leads to the question of what criteria should be applied when deciding whether to offer mental health interventions. I claim that whether one has a mental disorder should not determine whether one is offered a mental health intervention. The argument is made through considering the cases of non-suicidal self-harm in youth and unruly behaviour in children and youth. Unruly behaviour includes a wailing toddler, a child deliberately breaking items and a youth crossing police lines when protesting. Unruly behaviour is another interesting case. In some instances, there is a high likelihood of negative outcomes for some children and youth who are behaving in an unruly way. However, unruly behaviour may also be part of a passing phase and helpful for development. Furthermore, in some cases, unruly behaviour may be praiseworthy, and encouraging unruliness may advance an individual’s welfare. The case of unruly behaviour, then, raises the question of when mental health clinicians should intervene. The cases of non-suicidal self-harm and unruly behaviour help make my central claims. I say that behaviours and thoughts that are usually part of a passing phase and produce goods appropriate to that phase of life are not mental disorders; that managing life in the best way one can with the abilities available at a particular stage of life is not disordered; and, furthermore, that whether one has a mental disorder should not determine whether one is offered a mental health intervention. Finally, I say that, rather than depending on whether a person has a mental disorder, interventions should be offered only when they will advance the welfare of the service user. My dissertation will appeal to philosophers. I also hope that youth, parents, teachers, clinicians, policy makers and similar will be interested in the contents. This is because important practical questions are asked that challenge common views, and that guide policies and clinical practice to improve the welfare and service outcomes for children and youth.

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cThe Cultural Adaptation of Step-by-Step: An intervention to address depression among Chinese young adults (Preprint)

10.2196/preprints.19535 ◽

2020 ◽

Author(s):

Hao Fong Sit ◽

Rui Ling ◽

Agnes Iok Fong Lam ◽

Wen Chen ◽

Brian Hall

Keyword(s):

Mental Health ◽

Young Adults ◽

Cultural Adaptation ◽

Ecological Validity ◽

Health Intervention ◽

Health Interventions ◽

Content Adaptation ◽

Mental Health Intervention ◽

Mental Health Interventions ◽

Chinese Young Adults

BACKGROUND Digital mental health interventions leverage digital communication technology to address the mental health needs of populations. Culturally adapting interventions can lead to a successful scalable mental health intervention implementation, and cultural adaptation of digital mental health interventions is a critical component to implementing interventions at scale within contexts where mental health services are not well supported. OBJECTIVE The study aims to describe the cultural adaptation of a digital mental health intervention Step-by-Step in order to address depression among Chinese young adults. METHODS Cultural adaptation was carried out in four phases following Ecological Validity Model: 1) Stage setting and expert consultation; 2) Preliminary content adaptation; 3) Iterative content adaptation with community members; 4) Finalized adaptation with community feedback meetings. Cognitive interviewing was applied to probe for relevance, acceptability, comprehensibility, and completeness of illustrations and text. Six mental health experts and 34 Chinese young adults were recruited for key informant interviews and focus group discussions. RESULTS We adapted the text and illustrations to fits the culture among Chinese young adults. Eight elements of the intervention were chosen as the targets of cultural adaptation (e.g., language, metaphors, content). Samples of major adaptations included: adding scenarios related to university life (relevance), changing leading characters from a physician to a peer and a cartoon (acceptability), incorporating two language versions (traditional Chinese and simplified Chinese) in the intervention (comprehensibility), and maintaining fundamental therapeutic components (completeness). CONCLUSIONS This study showed the utility of using Ecological Validity Model and a four-point procedure framework for cultural adaptation and achieved a culturally appropriate version of the Step-by-Step program for Chinese young adults.

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