Thesis

Design and cultural adaptation of an e-mental health intervention for depression

HARPER SHEHADEH, Mélissa Joanne

Abstract

This thesis employs mixed methodologies, including systematic review and meta-analysis, qualitative research and pre-post design empirical testing. It comprises the in-depth formative work for designing and testing the Step-by-Step e-mental health intervention for depression. We found that a Western only model of mental distress does not capture important local features relevant to informing the design and conduction of efficacy studies of interventions for common mental disorders. We also found that local adaption of self-help psychological interventions can contribute to increased intervention efficacy. Systematically carrying out cultural adaptation of Step-by-Step with local actors was crucial. The feasibility testing of Step-by-Step provided valuable information to inform the design of future large-scale efficacy testing and hinted that Step-by-Step is a potentially promising intervention for reducing the symptoms of depression. An adapted, minimally guided, internet-delivered intervention like Step-by-Step could help close the treatment gap for depression if integrated responsibly into an existing care system.

Reference

HARPER SHEHADEH, Mélissa Joanne. Design and cultural adaptation of an e-mental health intervention for depression. Thèse de doctorat : Univ. Genève, 2020, no. Sc. Bioméd. - S. Glob. 007

DOI : 10.13097/archive-ouverte/unige:145930 URN : urn:nbn:ch:unige-1459308

Available at: http://archive-ouverte.unige.ch/unige:145930

Disclaimer: layout of this document may differ from the published version.

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DESIGN AND CULTURAL ADAPTATION OF AN E-MENTAL HEALTH INTERVENTION FOR DEPRESSION

LE DÉVELOPPEMENT ET L’ADAPTATION CULTURELLE D’UNE INTERVENTION PSYCHOLOGIQUE EN LIGNE POUR LA DÉPRESSION Doctoral Thesis/Thèse Doctorale

Doctorate : Biomedical Sciences, Global Health Doctorat: Sciences Biomédicales, Santé Globale Institut de santé globale Université de Genève

Melissa Harper Shehadeh [email protected]; [email protected] No part of this thesis may be reproduced, stored or transmitted without prior permission of the author, or, when appropriate the publishers of the constituent papers.

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Table of Contents

Chapter 1: Outline and Abstract ...... 7 Abstract ...... 10 Résumé ...... 13 Chapter 2: Introduction ...... 17 Chapter 3: Person Generated Outcome Measurement in Pakistan and Kenya ...... 33 Chapter 4: Extent and effect of cultural adaptation on self-help interventions – systematic review and meta-analysis ...... 61 Chapter 5: Conceptualisation of a scalable, internet delivered intervention for depression (Step-by- Step) ...... 89 Chapter 6: Cultural and contextual adaptation of Step-by-Step ...... 101 Community cognitive interviewing to inform local adaptations of an e-mental health intervention in Lebanon……………………………………………………………………………………………………………………………………93 Cultural Adaptation of a Scalable World Health Organization E-Mental Health Program for Overseas Filipino Workers ...... 127 Chapter 7: Step-by-Step feasibility testing in Lebanon ...... 145 Chapter 8: Methodological contributions ...... 177 Contribution to the qualitative analysis of PSYCHLOPS data (chapter 3) ...... 179 Contribution to the systematic review on cultural adaptation of self-help and minimally guided interventions (chapter 4)...... 179 Contribution to the pilot e-mental health project in Lebanon (chapters 5 to 7) ...... 179 Chapter 9: Discussion ...... 183 Key findings ...... 185 Comparisons with other studies and contextualization ...... 188 Clinical and policy implications ...... 189 Suggestions for future research ...... 190 Chapter 10: Conclusions ...... 193 Appendices ...... 197 Appendix 1: List of abbreviations ...... 197 Appendix 2: Adaptation monitoring form (Chapter 6) ...... 198 Appendix 3: Methodological reflections and lessons learned ...... 199 Appendix 4: About the author ...... 206 References for Thesis body text ...... 209

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Acknowledgements

I would like to say a big thank you to my family, especially those who contributed to buying my laptop, upon which I spent many hours reading and writing the materials that constitute this doctoral thesis. Thank you to Mark van Ommeren at the World Health Organisation, who took me on to work on this project, provided advice and support and enabled me to submit its outputs as part of this thesis manuscript. Heartfelt thanks also go to Jinane Abi Ramia, Ken Carswell, Edith van’t Hof, Eva Heim and Rabih El Chammay, my closest colleagues on the Step-by-Step project and whose hard work was instrumental to its success. Finally, I thank my supervisor Emiliano Albanese and wish him well in his newly acquired role at the University of Lugano.

Academic outputs during the study period

Academic articles submitted as part of the doctoral thesis

• Harper Shehadeh M., Abi Ramia J., Cuijpers P., El Chammay R, Heim E, Kheir W., Saeed K., van Ommeren M., van’t Hof E., Watts S., Wenger A., Zhogbi E., Carswell K. (2020). Step-by-Step, an e- mental health intervention for depression: a mixed methods pilot study from Lebanon. Frontiers in Psychiatry. 10, 986

• Harper Shehadeh M., van‘t Hof E., Schafer A., van Ommeren M., Farooq S., Hamdani S.U., Koyiet P., Akhtar P., Masood A., Nazir H., Dawson K., Albanese E. (2019). Using a person generated mental health outcome measure in large clinical trials in Kenya and Pakistan: Self-perceived problem responses in diverse communities. Transcultural Psychiatry. 57, (1):108-123

• Garabiles M.R., Harper Shehadeh M., Hall B.J. (2019). The cultural adaptation of a scalable WHO eMental Health program for overseas Filipino workers. JMIR Formative Research. 3 (1): e11600

• Abi Ramia J., Harper Shehadeh M., Kheir W., Zoghbi E., Watts S., Heim E., El Chammay R. (2018). Community cognitive interviewing to inform local adaptations of an e-mental health intervention in Lebanon. Global Mental Health. 5, e39.

• Carswell K., Harper Shehadeh M., Watts S., Heim E., van’t Hof E., Abi Ramia J., Wenger A., van Ommeren M. (2018). Step by Step: A new WHO online intervention for depression. mHealth. 4:34

• Harper Shehadeh M, Heim E, Chowdhary N, Maercker A and Albanese E. (2016). Cultural Adaptation of Minimally Guided Interventions for Common Mental Disorders: A Systematic Review and Meta-Analysis. JMIR Mental Health. 3, (3): e44

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Other academic works published during the study period

• Dawson K.S., Watts S., Carswell K., Harper Shehadeh M., Jordans M.J.D., Bryant R.A., Miller K.E., Malik A., Brown F.L., Servili C., Van Ommeren M. (2019). Improving access to evidence-based interventions for young adolescents: Early Adolescent Skills for Emotions (EASE). World Psychiatry.

• Burchert S, Alkneme M.S, Bird M, Carswell K., Cuijpers P., Hansen P., Heim E., Harper Shehadeh M., Sijbrandij M., van't Hof E and Knaevelsrud C. (2019). User-Centered App Adaptation of a Low- Intensity E-Mental Health Intervention for Syrian Refugees. Frontiers in Psychiatry.

• Heim, E., Harper Shehadeh, M., van 't Hof, E., & Carswell, K. In Cultural Clinical and PTSD. (2019). Cultural adaptation of scalable interventions. In A. Maercker, E. Heim, & L. J. Kirmayer (Eds.), Cultural and PTSD. Boston, MA: Hogrefe Publishing.

• van’t Hof E., Dawson KS., Schafer A., Chiumento A., Harper Shehadeh M., Sijbrandij M., Bryant R.A., Anjuri D., Koyiet P., Ndogoni L., Ulate J., van Ommeren M. (2018). A qualitative evaluation of a brief multicomponent intervention provided by lay health workers for women affected by adversity in urban Kenya. Global Mental Health.

• Bryant, R.A., Schafer, A., Daws