Table 3.

Cultural adaptations described using Bernal's framework.

Principle	Adaptation	Rationale
Language: use of culturally centred language as part of the intervention
Translation into local language	Manuals and patient materials were translated into the local language ∗[26], ∗[27].	To match the language spoken by patients and therapists to enhance understanding of the therapy concepts, methods and goals.
Technical terms replaced by colloquial expressions	Cognitive–behavioural therapy renamed ‘Thinking healthy’ Use of terms such as ‘stressed’ or ‘burdened’ where necessary and avoidance of psychiatric labels such as ‘depression’ [27].	Using literal translations or translations that are not culturally acceptable is one of the major barriers in therapy. Depression is not well understood as a term. Stressed or burden more understandable in the local context. To minimise stigma.
Therapist: consideration of the role of cultural similarities and differences in the client–therapist dyad
Therapist –patient matching	Therapists matched from the same local community, speaking the local language ∗[26], ∗[27], ∗[29].	Local credibility and acceptability, fluency in local dialect, shared experience in norms and events impacting community, and familiarity with local idioms of distress.
Therapist–patient relationship	Therapist attempted to develop friendly relationships with the mothers and to empathise with their expressed concerns [22].	To ensure patient engagement in the treatment process.
Use of non-mental health workers	Use of Lady Health Worker within the primary care system, nurses, community workers. Role enhancement of the non-specialist health workers was highlighted most of whom were available in the clinics and were often closely connected to local neighbourhoods ∗[26], ∗[27].	To reduce stigma and preserve patient's privacy (especially during home visits) from inquisitive neighbours and family members. Also to make best use of already available, low cost resources.
Metaphors: the symbols and concepts that are shared by a particular cultural group
Use of material with cultural relevance	Designation of a ‘health corner’ in each house, and a ‘health calendar’ provided to each mother to monitor homework and chart progress. Using culturally appropriate illustrations, for example, characters depicting mothers and infants [27].	By using the illustrated characters, the health workers could avoid direct confrontation with women and their families where it was not appropriate. It facilitated work with non-literate women.
Use of stories, local examples	Groups used methods such as picture-card games, role play, and story-telling to help discussions about the causes and effects of typical problems in mothers and infants, and devised strategies for prevention, homecare support and consultations. Case studies imparted through contextually appropriate stories [29].	Patient scould understand new ideas when described using familiar stories/figures and enhanced acceptability of treatment.
	Use of examples that were relevant to the specific population [26].	To increase cultural relevance
Use of idioms and symbols	Key domains were explored using tools such as: feeling cups to identify and quantify the intensity of feelings; the ‘feel, think, do’ method of problem solving and goal setting; and tokens to encourage peer support [24].	To convert an abstract concept such as mood into a more concrete, easy to understand concept.
Content: cultural uniqueness (values, customs) integrated into all aspects of the treatment
Addressing stressors	Intervention to focus on addressing economic and social problems faced by mothers and families ∗[21], ∗[25].	Marked social problems interfere with recovery if left unaddressed.
Accounting for cultural norms surrounding the concept of infancy and child care practices	Focus on issues related to Chinese postpartum practice 'Zou Yue Zi' ie. ‘doing the month’, which refers to the traditional Chinese custom of having new mothers rest at home, often under the care of their mother-in-law, for a month after delivery [25].	To contextualise the treatment to address issues that are relevant to the cultural group.
	Ensuring culturally appropriate homework activities (e.g. not expecting outdoor activities during the chilla (40-day confinement of mothers after delivery) when mothers do not go out of the house [27].	To increase access to care and reduce participant burden. Acknowledgement of the traditions and values allowed the therapy teams entry into these families and increased the possibility of follow-through.
Concepts: the way in which the presenting problem of a woman is conceptualised and communicated
Skill building	Problem solving was conceptualised as a form of self-control training, that is, the women ‘‘learns how to solve problems’ and thus discovers for herself the most effective way of responding [28].	To preserve congruence with cultural beliefs and physical/somatic belief models of illness causation.
	Cultural norms surrounding the concept of infancy and child care practices were taken into account with the aim of sensitising the mother to her infant's individual capacities and needs ∗[21], ∗[22], ∗[24].
Goals: consideration of the specific values, customs, and tradition of the woman's culture when agreeing on treatment goals
Client-derived goal	Focus on mother and infant health rather than maternal depression and have an a priori agenda of achieving optimal infant development through the intervention [27].	Infant care was seen as a shared responsibility and this helped engage not only the mother, but the whole family in a supportive role for the mother.
Extending goals beyond depression	Focus on empowerment - named the project Mamekhaya, which means ‘respect for women’ in Xhosa [24].	Addressing broader social issues for longer term impact.
	Emphasis was laid on group members' role development into community advocates as depression improves [27].	Underscoring impact of depression treatment on wider community development goals (e.g. farming initiatives, school attendance).
Methods: procedures followed for the achievement of the treatment goals
Structural adaptations	Delivering treatment by telephone, home visits [25].	To increase accessibility and feasibility
	Integrating the intervention into routine day to day work of the non-specialist health workers [27].
	Sessions arranged to follow routine childbirth education sessions with 20-min apart [25].
Adaptation in techniques used to deliver treatment	Less use of written material and limiting homework to simple suggestions rather than writing tasks [26].	To overcome limited literacy levels.
	Worksheets for the mothers, with educational material related to the topics covered in the manual; personal diary, intended to provide the mother with a means through which she can reflect on her individual experience, share private thoughts and explore her own development [21].	To make treatment understandable and reinforce the therapists work.
Context: consideration of the woman's broader social, economic, and political context
Context-specific issues addressed	Addressing issues related to baby's gender (e.g. women attributed responsibility for the baby's gender to themselves) [25].	Contextual stressors were seen as one of the major contributors to depression.
	Where other caregivers (for example, fathers, grandparents) were present, they were encouraged to take part in the intervention. Focus on improving relationship and reducing conflict with husbands as well as mothers in law ∗[22], ∗[25], ∗[27].	Acknowledges the central role of the family in the treatment process
	Home-made toys and books and materials in the home were used to keep the intervention low cost [22].