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Table 4 Summary of adaptations

From: Cultural adaptation of a scalable psychological intervention for Burundian refugee adolescents in Tanzania: a qualitative study

Bernal code Adaptation made
1.Language 1. The phrase ‘caregivers and parents’ was used throughout the intervention due to cultural implications of the word ‘caregivers’ in Kirundi, which typically indicates foster parents only.
2. The word ibishobo literally translates to emotion but often implies a happy or exciting state of mind, so this was replaced by inyiyumvo, which was perceived to be understood as more inclusive of a range of emotions.
3. ‘Bullying’ was replaced with ‘beating’ or ‘provoking’.
4. The word ‘imagine’ was changed to ‘think about’ (e.g., think about sweeping the floor).
5. The term ‘emotional problems’ can be stigmatising; it was changed to ‘difficult feelings’.
6. Language was included to describe local idioms which were included in the translation, for example, akabonge, which connotes dwelling over what is lost along with social withdrawal and sadness.
7. Some somatic sensations related to emotions such as a ‘buzzing sensation’ or ‘face feeling hot’ were not easily identified, these terms were replaced with other bodily sensations or visible behaviours, such as ‘teeth showing’ for happy or excited feelings.
8. Self-harm was not easily understood, so we altered the language used to describe that this includes ending your own life as well.
9. Tentative statements were removed because ‘maybe’ was often perceived to mean ‘no’.
10. The concept of respect (in group sessions) can be understood differently in different contexts, therefore the word ‘non-judgemental’ was added to clarify the intended meaning.
2. People 1. The concept of the therapeutic alliance as relevant to working with children was added to the training materials in greater detail.
2. It was decided that the intervention would be provided in the community during the piloting stage and not at schools. This was because there was a large population of non-school going adolescents at the camp. In addition, we identified increased risks of sexual violence at school.
3. The main character was described and illustrated in as gender neutral a manner as possible. A gender-neutral Burundian name was chosen, Niyo, which can be used as a nickname for boys or girls. The names of caregivers were also adapted so they were easier to be identified as from the same community. Further, identifying information to make her/him look like children in this setting was added, such as a vaccination mark on the arm. We included instructions to the facilitators so that children could be asked to colour in so that the main character was easier to identify with, if needed.
4. It was decided that sessions would be held separately for boys and girls and ages 10–12-year olds and 13–14-year olds. Caregiver sessions would also be conducted in a gender segregated manner as this is more culturally appropriate and would encourage women and men to speak openly.
5. Adaptation to make activities appropriate to the age and gender of the group were made throughout, for example, that facilitators should choose age-appropriate session opening activities and provided examples (such as a game or a dance).
3. Metaphors 1. On an emotion recognition activity (‘feelings’ pot’) involving colouring, colour connotations may be different for Burundian children. It was highlighted that it is important that children use the colours in the storybook as an example only and alternative codes were suggested e.g. the use of shapes or drawings to illustrate an emotion.
2. Using positive ‘strength’ words was perceived as important and the qualitative enquiries demonstrated that positive qualities such as being caring, loving, patient, merciful and wise are prioritised. We added in the culturally appropriate metaphor to a key breathing exercise such that it was described as ‘breathing in strengths and saying the word ‘peace’ when breathing out.
3. Self-control was highlighted by community members, with a metaphor on ‘being the master of oneself’ being central. Caregivers as role models learning to manage their own feelings was added, emphasising its importance for strengthening the parent-child relationship.
4. ‘Running away’ was used as an example as part of the vicious cycle to explain how emotions can affect behaviours.
4. Content 1. Activities relevant to Burundian refugee adolescents were referenced throughout, Certain other common activities such as fetching water and collecting firewood, were purposefully not referenced as both of these were associated with increased risk of sexual violence. Facilitators were then advised on how to manage these if these examples came up.
2. References to prayer as a potential coping strategy were removed due to the association between some religious settings and violent practices in the context of mental health and suicide.
3. A community awareness strategy was developed to increase the acceptability of the intervention by the community.
4. Symptoms of shame in describing vicious cycles were added.
5. Losing parents or being orphaned was included as a stressor for adolescents and in discussions on self-care with caregivers.
6. Child Friendly Spaces as an example location where behavioural activation activities could be conducted was added.
7. The addition of seeking social support from ‘a trusted adult’ was given in order to account for some children not having parents and some children not feeling like a teacher is a safe adult for them.
8. Further information was added for caregivers on the impact of parental stress on well-being of adolescents and examples referencing stressors experienced by caregivers at the camp.
9. What it means to stay well in this community was included such as spending time with friends and family, praying, seeking advice from others, being patient etc.
10. Bird watching was challenging to identify with for young adolescents and likely to be misunderstood as bird hunting, so a caveat was introduced to indicate that alternative examples that were locally could be used instead.
11. Missing school was taken out as an example from the manual as it was associated with parents preventing children from going to school, which had a different mean from what was intended.
12. In the training manual it is added that you cannot change behaviours and social norms overnight.
13. Revenge as an unhelpful way to solve problems was highlighted in training as it is a commonly used strategy.
14. Examples were added of quality time spent with children, such as eating together, going for a walk together on the weekend, sitting under a tree, telling simple stories, joining parents during farming activities, and asking your child ‘how are you?’ or ‘how was your day?’.
5. Concepts 1. Content on myths regarding causality, especially as they relate to suicide, were included.
2. The session ‘managing my problems’ was revised to provide a simpler explanation without losing core instructions. This was especially important for younger adolescents.
3. It was emphasised that somatic complaints can be related to distress, which may need to be followed up by a health worker.
6. Goals 1. Safety planning strategies were emphasised in the training and in the facilitators’ version of the manual due to the risk of sexual violence.
7. Methods 1. While discussing alternatives to physical punishment with caregivers and adolescents, a more tailored explanation was provided, for example, by saying hitting instead of shouting. Further, emotional abuse was added in addition physical punishments.
2. Illiteracy options were introduced throughout the intervention manual and facilitators trained in engaging with children who could not read or write. This was of particular relevance to the ‘managing my problems’ session. This also applied to caregiver sessions as literacy was not high.
3. Training for facilitators included ways of managing disclosure of experiences of sexual violence as this was prevalent in the community.
4. Children may be reluctant to share feelings, so facilitators were trained and advised that this is a common experience in children’s interventions.
5. Guidance was added to the training manual on how to manage time when managing distress and strong emotions during the session (e.g., crying).
6. In case of children missing the intervention sessions, additional instructions were included in the review of the previous session, in order to allow participants to catch-up with missed content.
7. The vicious cycle described in the intervention was complex; instructions were added on how facilitators could explain it step-by-step.
8. Concepts of planning and breaking things down in written form were not familiar adolescents. Additional training was provided on these concepts.
8. Context 1. References to the camp context were included and those not relevant excluded. For example, removing references to phone usage/reminders as caregivers almost never had phones.
2. In a breathing exercise described in the storybook, adolescents were advised to keep a balloon under their pillow, however, refugee adolescents in this setting do not sleep on pillows. It was agreed that instead of a balloon under their pillow, the picture indicate a ball of clothes used as a pillow, which was more common, and that, as an example, the balloon be kept besides where one sleeps and not under the pillow.
3. Training for all staff on suicide protocols was expanded to increase facilitators’ confidence and comfort in talking about suicide, as there was a large stigma associated with suicide in the community.
4. It was highlighted that all efforts should be made to ensure confidentiality if sessions were held in outdoor spaces. Consistency in location was to be maintained throughout for piloting to asses any effects on intervention delivery.
5. There was a clear preference for weekend sessions by adolescents and caregivers/ We reached consensus that the feasibility of implementing this would be assessed in the next phase.
6. Facilitators and supervisors were aware that references to child labour were to be managed by the supervisors in accordance to child protection procedures.
7. Childcare facilities for caregivers attending EASE sessions were not feasible at this stage, however this may be a barrier for mothers, so facilitators encouraged them to bring another family member along to care for the young child.
8. The storybook ends with the family moving to a new town but this was not appropriate for refugees, so the end was altered to reflect a similarly themed but context appropriate story, for example, with the father leaving the camp to earn money.
9. Exercises were adapted so that they could be done within the constraints of a refugee camp and facilitators were guided to adapt EASE exercises to the camp context where helpful.
10. References to food and a good diet were problematic, these were removed where possible as discussions may be derailed and cause tension. Facilitators were trained to use this as an example minimally and to manage discussion if derailed.