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Table 1 Bernal framework of adaptations and examples of key adaptations

From: Making therapies culturally relevant: translation, cultural adaptation and field-testing of the Thinking Healthy Programme for perinatal depression in China

DimensionOperationalizationExamples of key adaptations*
1. LanguageEmotional expression, gestures, verbal style• All the materials were translated into the simplified Mandarin.
• Language was kept specifically colloquial rather than formal.
Translations were conceptual rather than literal and word-to-word, to make the participants understand the underlying ideas and the concepts of THP
2. MetaphorsSymbols and concepts; sayings / proverbs• Addition of common Chinese proverb “The old man is a treasure” to elaborate the importance of the mother’s relationship with the elderly family members around her as per Chinese family culture.
• Addition of local idioms like “How do you know the pleasure of fish?” – which implies that do not judge the situations based only on your thoughts.
• Images embodying local avatar were used (Fig. 1C).
• A made-up story of a Chinese mother “Huifang” experiencing perinatal depression and having the life circumstances closer to the general population of Xi’an was added. The purpose was to help the participants understand the occurrence and preventive measures of perinatal depression as clearly as possible.
3. ContentFamiliarity with local values, customs and traditions• Local traditions and practices of treatment (e.g. meditation, prayers, acupoint massage) were referred.
• Somatic concepts (Chinese traditional model of body, health and sub-health) were added.
• Examples of the stressors that were culturally and socially suitable, e.g. Family conflicts in the relationship of mother-in-law and daughter-in-law; occupational stresses during pregnancy were added.
4. ConceptsConstructs of theoretical model - how clients problem is perceived and communicated, including availability of locally used terms for theoretical concepts• Family concept (e.g., single child with multiple carers) was adapted.
• Social concepts (e.g., more egalitarian status of women) were adapted. There was a challenging situation in the original manual where the mothers are not allowed by the family to take part in the program. This was replaced with the situation where the mothers are not willing to take part in the programme.
• South Asian concept of the ‘evil eye’ was substituted with the similar but slightly different concept of ‘the curse’.
• Cultural concepts (i.e. suffering is caused by a ‘curse’; and one month of the mother’s rest and confinement period after delivering the baby were added in the content.
5. GoalsReflecting knowledge of values, culture, customs and traditions• To encourage active participation of the mothers, additional activities about problem solving discussions were added and mothers were given more chance of active-participation by choosing activities from health calendar rather than the therapist being prescriptive.
• Healthy activities that were locally relevant (e.g., tai chi, gong qi and exercises) were added.
6.Healthcare contextHealth systems within which intervention is delivered• All the THP materials were modified for integration into the Chinese perinatal healthcare context.
7. PeopleDelivery agent and the client-counselor relationship• Nurses were identified as acceptable delivery agent as they were seen as custodians of pregnancy and postpartum care.
8. MethodsProcedures to deliver interventionAs majority of Chinese women go to work and cannot spare time for THP sessions separately, the frequency THP face-to-face individual sessions was reduced from 16 home-based sessions to 7 sessions to be delivered to the mother at the hospital. So that number of sessions remains congruent with the number of women’s usual anticipated perinatal checkup visits at the hospital to ensure the sustainable delivery of THP sessions.