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

Maternal depression is the second leading cause of disease burden in women worldwide [1]. An episode of depression experienced during perinatal period, which is generally considered from pregnancy to one year after delivery, is classified as perinatal depression [2, 3]. The prevalence of perinatal depression, which includes prenatal as well as postnatal depression, is 10–15% in high-income countries and 15–20% in low and middle-income countries (LMICs) [4‐6]. Perinatal depression is associated with increased functional impairment, reduced self-care, reduced social support and poor nutrition as well as increased risk of preeclampsia, and other pregnancy and labor complications in the women [7‐9]. In children, the consequences of perinatal depression can lead to conditions like preterm and low weight birth, poor immunization rates, high rates of diarrhea and other infectious diseases, poor cognitive development and emotional disorders, disruptive behaviors, and poor academic performance [10‐13]. Thus, perinatal depression is fast assuming significance as a global public health priority [1].

As the world’s most populous country, China accounts for about a fifth of the world’s population. The prevalence of perinatal depression ranges from 15 to 20% and according to recent pregnancy and childbirth estimates it translates to potentially 5 to 7 million women with perinatal depression [14, 15]. In contrast, there are only 1.7 psychiatrists and 0.05 mental health hospitals per 100,000 people [16]. Besides the shortage of health care human resources, equity of health-care is a big challenge. The total number of health institutions is same in Eastern and Western regions of China, but the health care workforce is much higher in the Eastern developed regions (3·7 million) compared to Western less-developed ones (2·2 million) [17]. However, the prevalence of perinatal depression is higher in the under-developed regions compared with that of the developed ones, based on a recent systematic review of 96 studies from 23 regions of China [Unpublished observation, Anum Nisar, Juan Yin, Ahmed Waqas. Prevalence of perinatal depression and its determinants in Mainland China: A systematic review and meta-analysis. 2019]. Thus, those in greatest need for service are least likely to have access to it, and this is especially true for mental health conditions [16].

Psychological therapies, including cognitive behavioural, interpersonal, supportive and group therapy, are recommended as the front-line management for perinatal depression [18]. In High-Income countries, such interventions are generally provided by mental health specialists, while in LMICs mental health service provision is low due to scarcity of specialized mental health resources. A systematic review of interventions for pre- and postnatal depression in low- and middle-income countries has found that evidence-based interventions delivered by non-specialists can be effective in treating the condition, as well as improving outcomes in the children of treated mothers [19]. Interventions include cognitive behaviour therapy and interpersonal therapy, as well as supportive and psycho- educational interventions. Despite this evidence, the vast majority of women with the condition remain untreated. To bridge the treatment gap, The World Health Organization (WHO), based on this review of available evidence for such interventions in LMICs, recommended the Thinking Healthy Programme (THP) as a therapy of choice for women requiring psychological intervention for perinatal depression in primary health care settings [20]. The Thinking Healthy Programme was originally developed in Pakistan after thorough formative research and robust evaluation through a randomized controlled trial [21, 22]. It employs specific as well as non-specific elements of Cognitive Behaviour Therapy (CBT), such as building an empathetic relationship, focusing on the here and now, behaviour activation and problem solving. The programme is fully manualized and has culturally appropriate pictorial illustrations aimed at helping mothers reflect on their thinking process and encouraging family support. The sessions are organised into five modules covering the period from the third trimester of pregnancy to one-year postnatal. THP, delivered by community health workers, was tested in a large community-based randomized controlled trial in Pakistan, where it more than halved the prevalence of perinatal depression and significantly improved child health outcomes like diarrheal episodes and vaccination coverage [22]. A key feature of the THP is that non-specialists can be trained to deliver the programme under specialist’s supervision, and the intervention can be integrated into primary health care system. Thus, it is ideally suited to regions where there are not enough mental health specialists. THP is part of the WHO’s flagship mental health gap action programme (mhGAP) and has been translated into a number of languages and is being implemented in many countries [20, 23‐25].

Based on the current evidence, there is reason to believe that THP would be an effective and feasible way of managing perinatal depression in China. The aim of this study was to translate and adapt THP for the Chinese population and to establish its acceptability, comprehensibility and cultural relevance, when delivered to depressed women in perinatal period by non-specialists.

Perinatal mental health is a global public health priority. Evidence-based psychosocial interventions such as the Thinking Healthy Programme, recommended as first-line treatment by the WHO, need to be rapidly adapted to the cultural and health-care context of populations before implementation. Appropriate translation and adaptation of intervention materials is a vital first step towards evaluation and implementation of any intervention. This study provides a systematic way of translating and adapting an intervention developed in one culture for use in another very different language and culture. It therefore provides a replicable model that other researchers can us not only to translate, but to also document the changes made to the original intervention.

The study shows that the core structure, process and techniques of the Thinking Healthy Programme were culturally compatible with our target Chinese population and did not require major changes. However, subtle but critical adaptations were required which were done relatively quickly using standard methods involving participant consensus and rapid field-testing. These subtle conceptual changes were critical to make the intervention acceptable. The study thus provides a methodology that can be considered for rapid translation and adaptation as well as a prototype adapted manual that can be used for further implementation and evaluation studies in the Chinese context.

The original Thinking Healthy Programme manual recommended local adaptations to be conducted prior to implementation, but did not provide a standardized methodology for conducting such adaptations [19]. Thus, researchers have employed different methods. The utilization of Bernal framework facilitated structured content adaptations and documentation across various domains, allowing other researchers to clearly see the level of changes made to the original version and their rationale. Cognitive interviewing was found to be an effective and rapid method to pre-test the adapted version with the target population prior to field-testing. This method, recommended by the WHO has been used successfully to rapidly adapt a self-help intervention for psychological distress among refugees in an African context [29]. In Peru, the Replicating Effective Programmes (REP) framework was used to guide the implementation process of THP, but the authors relied on a pre-translated Spanish version of the manual conducted by a community-based organisation for their local programmes [24, 35]. It is therefore difficult to evaluate the process of adaptation and the key changes made to the original THP and their rationale. In Vietnam, an adaptation framework derived from the WHO’s International Management of Childhood Illnesses adaptation toolkit was used to translate and adapt the intervention [36]. As in our study, it also involved participant consensus and field testing [25]. THP-Vietnam findings were similar to our study, i.e., THP core structure, processes and techniques were transferrable across cultures but required some linguistic and cultural adaptations. The results of our study, and studies conducted in other settings indicate that the key constructs of the Thinking Healthy Programme are culturally transferable [22, 24, 25].

Furthermore, the intervention is perceived to be acceptable by the target population. THP is based on principles of cognitive behavior therapy (CBT). This is corroborated by several small-scale studies conducted in various regions of China, indicating that similar CBT based interventions were effective in the local populations [37‐39]. However, the main advantage of the Thinking Healthy Programme is that it is designed to be integrated into existing health systems and therefore scalable. Our adapted version of THP incorporates local concepts (such as ‘Confinement month’, traditional exercises (such as Tai Chi and Qi gong) and traditional practices (such as acupoint massage). There is some evidence (although of poor quality studies with small sample sizes) that these traditional practices and exercise are very effective when combined with conventional therapy [40].

THP can be a potential value added component to the China’s existing universal healthcare programme for the health and wellbeing of the pregnant women, the mothers and the infants. China is making efforts towards integration of hospital and community settings for mental health equity. In 2004, Project 686 attempted to integrate the joint resources of psychiatry hospitals and community health systems [33]. Key innovation of project 686 was to Integrate of management and treatment for severe mental disorders in hospital and community settings. Under this project trainings were provided for psychiatrists, clinical nurses, administrators, community health workers, policemen and patients’ families in order to provide a systematic care for those in need. From 2004 to 2015, they successfully trained 11,457 psychiatrists, 6600 trainees, 385,700 patients’ family members [41]. Another similar integration of hospital and community settings can be proposed for the treatment of perinatal depression in Chinese women. China has a strong three tier primary health care model with community level health centers staffed by trained health nurses accessible to all. The community health stations are very organized national organization, established throughout the country at all social levels, including small communities [42]. Their purpose is to work towards health and wellbeing of community residents. This suggests that primary health care is an ideal site for the integration of mental health intervention like THP into maternal health promotion programmes, with the hospital-based specialist workforce taking the responsibility of training and supervision of the intervention. However, in order to achieve effective coverage and successful integration of mental health services into existing health care model, both supply-side barriers and demand-side barriers related to stigma and range of mental disorders need to be addressed. Investing in increasing demand for mental health services through active engagement of the community, to strengthen service user leadership can be a potential way forward. Task sharing with community-based workers in a collaborative stepped-care model is a feasible approach for scale up and integration within the national health care systems [43]. Interventions such as the Thinking Healthy Programme ensure this possible, and the approach also ensures that the content and delivery of mental health interventions are culturally and contextually appropriate.

Following translation and adaptation, preliminary feedback from users and delivery agents indicate that the Thinking Healthy Programme may be transferable to the Chinese cultural and healthcare context. However, further research, including randomized controlled trials, will be required to establish the effectiveness and barriers to scale-up.