Cultura! Diversity and Ethnic Minority Psychology 2014. Vol. 20, No. 2, 293-301

© 2014 American Psychological Association 1099-9809/14/$12.00 DOI: 10.l037/a0035021

Cultural Adaptation and Health Literacy Refinement of a Brief Depression Intervention for Latinos in a Low-Resource Setting Zorangeli Ramos and Margarita Alegría Harvard Medical School, Center for Multicultural Mental Health Research, Somerville, Massachusetts

Few studies addressing the mental health needs of Latinos describe how interventions are tailored or culturally adapted to address the needs of their target population. Without reference to this process, efforts to replicate results and provide working models of the adaptation process for other researchers are thwarted. The purpose of this article is to describe the process of a cultural adaptation that included accommodations for health literacy of a brief telephone cognitive-behavioral depression intervention for Latinos in low-resource settings. We followed a five-stage approach (i.e., information gathering, preliminary adaptation, preliminary testing, adaptation, and refmement) as described by Barrera, Castro, Strycker, and Toobert (2013) to structure our process. Cultural adaptations included condensation of the sessions, review, and modifications of materials presented to participants including the addition of visual aids, culturally relevant metaphors, values, and proverbs. Feedback from key stakeholders, including clinician and study participants, was fundamental to the adaptation process. Areas for further inquiry and adaptation identified in our process include revisions to the presentation of "cognitive restructuring" to participants and the inclusion of participant beliefs about the cause of their depression. Cultural adaptation is a dynamic process, requiring numerous refinements to ensure that an intervention is tailored and relevant to the target population. Keywords: cultural adaptations, health literacy, depression treatment. Latinos, evidenced-based treatments

Cultural adaptations of evidenced-based treatments (EBTs) have developed from a number of factors, including a marked increase in ethnically diverse populations, professional (e.g., American Psychological Association) and governmental agency (e.g., U.S. Department of Health and Human Services) mandates for the provision of treatments deemed sensitive to the needs of multicultural populations, and third-party payer requirements for EBTs (Bernai & Sáez-Santiago, 2006; Lau, 2006). Despite the requirements, many researchers have noted a dearth of participants from ethnically diverse backgrounds in most clinical trials (Bemal & Sáez-Santiago, 2006; Lau, 2006), witb a majority of EBTs developed and tested solely among European American populations (Bemal & Sáez-Santiago, 2006). As Pan, Huey, and Hernandez (2011) have pointed out, these treatments may fail to account for the cultural beliefs and

practices that influence therapeutic processes and may compromise both the engagement and retention of multicultural populations. Moreover, differential engagement of racial and ethnic minorities in clinical trials is detrimental to the generalizability of evidence-based interventions (Lau, 2006). Therefore, the challenge of adapting treatments to a particular cultural or ethnic group is to ensure that they are relevant to the needs of the target population, efficacious, and consequently increase treatment engagement of ethnic minority populations (Bernai & Sáez-Santiago, 2006; Castro, Barrera, & Holleran Steiker, 2010). It is well established that culturally adapted EBTs are generally more effective than control or usual care conditions, improving mental health and health outcomes, and consequently are more salient to the needs of the target population (Barrera, Castro, Strycker, & Toobert, 2013; Benish, Quintana, & Wampold, 2011; Castro et al., 2010; Griner & Smith, 2006; Smith, Domenech Rodriguez, & Bernai, 2011).

This article was published Online First March 3, 2014. Zorangeli Ramos and Margarita Alegría, Department of Psychiatry, Harvard Medical School, Center for Multicultural Mental Health Research, Somerville, Massachusetts. This publication was made possible by Grant P60 MD002261-S from the National Institute on Minority Health and Health Disparities. We thank all the research assistants and collaborators from the Center for Multicultural Mental Health Research for their assistance in completing this article. In particular, we want to thank Shed Lapatin, Amy Russell, Anna Lessios, and Anne Valentine. Correspondence conceming this article should be addressed to Zorangeli Ramos, Center for Multicultural Mental Health Research, 120 Beacon Street, Fourth Floor, Somerville, MA 02143. E-mail: Zorangeli [email protected]

Considerations for Cultural Adaptations Although the literature on culturally adapted EBTs is growing, several limitations remain, including a lack of consensus with respect to guidelines for adapting interventions (Pan et al., 2011) and a paucity of studies detailing the adaptation process (Castro et al., 2010; Griner & Smith, 2006; Huey & Polo, 2008). In tbe present study, we addressed botb of these concerns. In response to criticism about the lack of consensus surrounding adaptation guidelines, Castro et al. (2010) suggested the use of existing models to guide cultural adaptations. In the current study, we used the five-stage approach described by Barrera et al. (2013). In Stage 1, information gathering, researchers determine whether 293

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an adaptation is needed and which components of the intervention should be modified. In Stage 2, preliminary adaptation design, the information gathered from the previous stage is used to inform the preliminary adaptation, making sure that the core components of the intervention are preserved unless the literature informs differently. In Stage 3, preliminary adaptation testing, researchers conduct a pilot study and integrate feedback from relevant stakeholders. In Stage 4, the adaptation is refined using data from the pilot study. In Stage 5, cultural adaptation trial, the efficacy of the adaptation is tested in a full clinical trial and feedback is collected for further adaptations. Some examples of cultural adaptations following stage models include Chu, Huynh, and Areán (2012); Domenech Rodriguez, Baumman, and Schwartz (2011); Lau (2012); Matos, Torres, Santiago, Jurado, and Rodriguez (2006); Sáez-Santiago, Bemal, Reyes-Rodriguez, and Bonilla-Silva (2012); and Hwang (2012). In addition. Barrera and colleagues (2013) recommend a detailed description of the core components of the intervention and mechanisms by which the adaptation was carried out, information about the cultural competency of the clinicians delivering the intervention, and the amount of training required to effectively implement the adapted EBT. Determining the efficacy of a cultural adaptation of an EBT is hindered if no description of the process is provided. Indeed, both the quality and scientific rigor of the adaptation process cannot be determined in the absence of descriptive methods. It is also exceedingly difficult to determine the level of adaptation conducted if the process is not well described. As Falicov (2009) notes, cultural adaptations cover a range of possible iterations fiom the translation of content delivered by bilingual clinicians, to the explicit reference to cultural values and contextual Stressors of the target population, to the incorporation of the target population's understanding of why the problem developed and how it can be resolved. These forms of adaptation may involve different methodologies and scope and should not be understood as identical processes. For example, as Hwang (2012) explains, an adaptation can be considered "top-down" (theory driven and guided by clinical knowledge and research) or "bottom-up"(in which new ideas are generated from relevant stakeholders, such as participants from the target population and clinicians, and theory-driven ideas are confirmed by them). Barrera et al. (2013) maintain that exemplary adaptations combine both "top-down" and "bottom-up" approaches and conceive of these as a middle ground between an intervention that is applicable to all cultures and the development of one that emerges from the culture. The adaptation presented in this article uses both "top-down" and "bottom-up" approaches, combining the theory-driven adaptations with input from the target population.

Considerations for Health Literacy Refînements Fundamental to the adaptation process is the consideration of the target population's health literacy as it relates to the content of the intervention. Health literacy is the capacity to obtain, process, and understand basic health information and services in order to make appropriate health decisions (Seiden, Zorn, Ratzan, & Parker, 2000). A majority of health information has scientific jargon that patients may not fully understand. If patients cannot understand information presented, they may be

unable to identify symptoms of illness, seek appropriate treatment, provide informed consent, and make choices regarding treatment recommendations. In this case, translating an intervention into the native language of patients is insufficient if it is not translated at an educational level that participants can comprehend (Guerra & Shea, 2007). A person's health literacy is determined by using measures assessing literacy skills such as reading, searching, and comprehending information presented in different forms (e.g., books, magazines, tables, maps, food labels) and a person's ability to perform quantitative tasks such as computations (Kutner, Greenberg, Jin, & Paulsen, 2006). Health literacy is impacted by a person's native language, level of education, socioeconomic status, age, cultural background, life experiences, and cognitive abilities (U.S. Department of Health and Human Services, 2010). As referenced in the National Action Plan to Improve Health Literacy (U.S. Department of Health and Human Services, 2010), only 12% of English-speaking adults in the United States can read and understand the information typically included qualifying someone as proficient in health literacy. The U.S. Department of Health and Human Services notes that some groups are more likely than others to have low health literacy, particularly those for whom English is a second language. Based on a pooled analysis of published results on health literacy, Paasche-Orlow, Parker, Gazmararian, Nielsen-Bohlman, and Rudd (2005) estimated that approximately 60% of Latinos have low to marginal health literacy levels even in their native language Spanish. Low health literacy may impact depression care among Latinos because of failure to recognize or report of symptoms, little knowledge about treatment options, and difficulties in knowing how to access or navigate the health care system (Bennett, Culhane, McCoUum, Mathew, & Elo, 2007; Coffman & Norton, 2010). For this reason, the Joint Commission on Accreditation of Healthcare Organizations requires consideration of both literacy level and language requirements of the target population in all forms of patient communication. The Joint Commission (2007) recommends that health information be presented in simple language that is mindful of context, that such information be repeated several times, and that drawings or models be used to demonstrate important points. In our study, we sought to make information understandable to immigrant Latino patients and presented in simple language given previous studies reporting low levels of health literacy (Bennett et al., 2007; Paasche-Oriow et al, 2005) and low levels of education.

Rationale for the Study Depression rates in Latinos are comparable to those found among non-Latino Whites (Alegria, Canino, et al., 2008; González et al., 2010; Menselson, Rehkopf, & Kubzansky, 2008). In general. Latinos undemtiUze depression treatment more often than nonLatino Whites, with only 18% having access and quality treatment for past-year depression (Alegria, Chatterji, et al., 2008). Identified barriers to quality care include difficulties with engagement in treatment, premature termination, a dearth of clinicians who speak Spanish, and difficulties accessing services due to inadequate transportation or child care and long work hours (Alegria, Chatterji, et al., 2008; Miranda et al., 2003). Despite these barriers and the enormous gap in mental health services for Latinos, few

CULTURAL ADAPTATION OF TREATMENT FOR LATINOS interventions have been developed and/or adapted for Latinos outside of clinical settings (Miranda, Schoenbaum, Sherboume, Duan, & Wells, 2004; Sánchez-Lacay et al., 2001; Wells, Miranda, Bruce, Alegria, & Wallerstein, 2004). To address this gap, we chose to adapt a telephone depression intervention. We found in the literature telephone depression interventions to be effective in alleviating depression symptoms when compared with control conditions (Mohr, Vella, Hart, Heckman, & Simon, 2008; Simon, Ludman, & Operskalski, 2006), to have similar effects when compared with face-to-face interventions (Mohr et al., 2012), and to be an effective way of addressing barriers related to access to treatment and engagement in care by requiring less in-person contact with patients. Mohr et al. (2008) found lower attrition rates in the phone condition as compared with a face-to-face condition and similar improvements in depression across the phone and in-person conditions. We chose cognitive-behavioral therapy (CBT) to be the modality of the phone and face-to-face intervention because it has been identified as an EBT for depression. CBT is a modality that easily engages clients from racial and ethnic minorities because of its emphasis on collaboration between patient and clinician in exploring the patient's beliefs within his or her cultural values and woridview (Hays, 2009; Vera, Vila, & Alegría, 2003). Several CBT interventions have been adapted for Latino populations and have been found to be more effective than usual care in primary settings (Cabassa & Hansen, 2007). To address criticisms about the lack of description regarding the cultural adaptation process, we offer a detailed description of our adaptation process. We followed the Barrera et al. (2013) fivestage approach. In addition, we considered it highly important to review the health literacy of the intervention to ensure that it was at a sixth-grade reading level given that previous studies have shown low literacy among Latino patients (Paasche-Orlow et al., 2005). It was our purpose to ensure that the scientific rigor and replicability of our process could be verified, and offer a model for future researchers on how to culturally adapt and consider the health literacy of participants.

Method This study is part of a larger project that evaluated the acceptability, feasibility, and efficacy of a brief depression intervention for immigrant Latinos (National Institute on Minority Health and Health Disparities Grant P60MD002261-04S1). The Engagement and Counseling for Latinos (ECLA) intervention is an integrated case manager and CBT therapy that includes psychoeducation about depression and its treatment, promotes behavioral activation, seeks to challenge negative thoughts and assumptions, and provides for the creation of a self-care plan. Participants in the larger project were assigned to one of three conditions: (1 ) ECLA offered over the phone, (2) ECLA offered in person, and (3) usual care provided by primary care. Written informed consent was obtained from all participants and study methods were approved by the institutional review boards at the participating institutions. As noted, we followed a five-stage approach as described by Barrera et al. (2013). We organized our Method and Results sections following these stages.

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Stage 1: Information Gathering We conducted a literature search on effective brief depression interventions that targeted Latinos outside of clinical settings. In particular, we wanted to address the problem of Latinos' access to care and treatment engagement.

Stage 2: Preliminary Adaptation Design After selecfing the most appropriate intervention for our target population, we worked on its preliminary cultural adaptations and reviewed the literacy level to ensure it matched the needs of the target population, which we expected was going to be at sixth-grade reading level. Our goal was to make sure that the language of the intervention was understandable for our participants. We used feedback from the research team for recommendations on how we could simplify the material presented in the intervention.

Stage 3: Preliminary Adaptation Test Over a 4-month period, we trained study clinicians in the core elements and delivery of the intervention. Study clinicians included five bilingual, bicultural Latinas with Master's degrees in social work, mental health counseling, and psychology; and one clinician who was a clinical psychology postdoctoral fellow. The training began with two intensive days of workshops and practice sessions with one of the authors of the original intervention. Topics covered included CBT and motivational interviewing, a detailed description of the content covered in each session of the intervention, and typical participant's responses to the intervention. In addition, clinicians had the opportunity to role play each session and provide feedback on the content and administration. After the initial training, each clinician role played all the sessions twice with another member of the research team for a period of 8 to 10 weeks. Each clinician then delivered the intervention with two pilot cases for a period of 8 to 10 weeks while receiving close supervision from an expert clinician in CBT who was trained in the manualized intervention. Pilot participants were immigrant Latinos recruited from four community-based health clinics. In these clinics, primary care physicians regularly screen patients for depression using the Patient Health Questionnaire (PHQ-9; Kroenke & Spitzer, 2002), a depression instrument used in primary care settings to screen, monitor, and measure severity of depressive symptoms. Patients were referred to the pilot study by their primary care physicians or were recruited by telephone or face-to-face contact in the clinics if they scored a 10 or more on the PHQ-9. Eligible patients had moderate to severe depressive symptoms as indicated by their PHQ-9 scores ( a 10), and had not received any specialty mental health care in the past 6 months. Exclusion criteria included reported diagnosis of psychosis, bipolar disorder, active suicidality, and any psychotherapy treatment in the past 6 months. Patients receiving antidepressant medications by their primary care provider were not excluded from participating because researchers have found that patients in primary care fail to pick up their prescribed medications or do not take their medications as prescribed (Aisenberg, Dwight-Johnson, O'Brien, Ludman, & Golinelli, 2012).

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Once patients were referred, a research assistant contacted them over the phone to explain the pilot study, all elements of informed consent, and invited them to participate in the study. Patients who agreed to participate then signed an informed consent and were randomly assigned to study clinicians. All pilot participants received the phone intervention to ensure that the core concepts of the intervention were understood during a telephone interaction. A total of 11 people agreed to participate in the pilot study. Participants' ages ranged from 21 to 61 years (M = 43.5 years, SD = 10.8). Level of education ranged from sixth grade to fewer than 2 years in college. All participants were immigrants from Latino countries and their first language was Spanish. Seven participants were from Central America, two were from South America, and two were from the Caribbean. During the pilot stage, clinicians received regular supervision by a Latina CBT-trained clinical psychologist. During the last session of the intervention, clinicians asked pilot participants to provide informal feedback about its content and delivery. For instance, participants were asked whether there were topics covered that were hard to understand and whether they could relate to the workbook examples. Clinicians shared pilot participants' feedback with their supervisor and research team. Throughout the training, we collected feedback from clinicians about the level of comprehension of the material presented, the cultural adaptations, and recommendations to facilitate presentation and delivery. To make determinations as to which participants' and clinicians' suggestions we should implement in Stage 4, research team members met to review all suggestions and came to a consensus. We chose those suggestions that repeated across participants and clinicians, were consistent with previous research and clinical knowledge, and did not compromise the core components of the intervention. In addition, we reviewed the literature on cultural adaptations of cognitive-behavioral EBTs and motivational interviewing strategies with Latinos.

Stage 4: Adaptation Refinement We implemented the adaptations proposed in Stage 3 by clinicians, pilot participants, and relevant literature. Following these adaptations, we conducted a full trial with the adapted intervention. Results from that trial will be reported in a subsequent article.

Stage 5: Feedback Gathered After Clinical Trial At the end of the clinical trial, we conducted a focus group with study clinicians to leam about their experiences delivering the intervention, their perception of participants' understanding and engagement with the material, and further recommendations about possible adaptations. Clinician feedback was collected and summarized; general themes of this feedback are presented in the Results section. Clinicians also completed a survey asking them to describe the strongest aspects of the intervention, what sections of the manual they found most helpful, what sections of the manual were most problematic or difficult for participants, what clinicians would add and remove from the manual including the examples, what techniques were most helpful in engaging participants, and what recommendations they would provide to other clinicians delivering this intervention.

Results Stage 1: Information Gathering We found two brief depression interventions provided over the phone; Simon, Ludman, Tutty, Operskalski, and Von Korff (2004), which was initially adapted by Dwight-Johnson et al. (2011), and Mohr et al. (2000). We chose the Dwight-Johnson et al. intervention because of its previous use with migrant Latino workers. The intervention consisted of eight sessions (with the option of two additional booster sessions) of structured CBT psychotherapy provided over the phone. Participants received a workbook containing psychoeducation on depression, depression treatment, behavioral activation, methods for challenging negative thoughts, and the creation of a self-care plan.

Stage 2: Preliminary Adaptation Design We condensed the intervention from eight sessions (with the option of two booster sessions) to six sessions of psychoeducation and the option of two booster sessions to monitor progress and review core concepts. The decision to abbreviate the intervention came from previous investigations showing that participants do not attend longer duration treatments (Dwight-Johnson et al., 2011; Unützer et al., 2002) and/or are unable to attend many sessions because of multiple commitments (Miranda et al., 2004). We combined sessions on behavioral activation (engaging in activities that change mood) and challenging negative thoughts into two sessions per topic rather than three sessions per topic. Given the diflerences between the original intervention's target population (i.e., mainly Mexican migrant workers on the West Coast, with 73% of them having an education level equal to or higher than sixth grade) and our target population, we decided to further adapt the intervention. We reviewed the language used and modified words considered regionalisms. Certain concepts were renamed to accommodate expected literacy rates. For instance, behavioral experiment was changed to behavioral experience. We found the vignettes and the examples from die original intervention to be relevant to Latinos in urban areas, but eUminated a few that required a higher level of education to be understood (e.g., "being a scientist of your thoughts") and that referred to American pop culture (e.g., "try to imagine that your negative thoughts come from Darth Vader"). We edited the treatment manual and the participant workbook for brevity, organization, and clarity, while making sure that the core elements of the original intervention were preserved. The editing of the content included integration of relevant information and elimination of redundant information and multiple vignettes. The original intervention contained 27 vignettes, which we adapted to 12 vignettes, which were mostly summaries of the original ones. We added bullet points to break up the text and improve overall flow. In addition, we added visual aids and graphics to reinforce the nature of the different components presented and facilitate comprehension. As in the original intervention, each session included a review of the session's objectives and establishment of the agenda, a structured assessment of depressive symptoms with the PHQ-9 and monitoring of medications and side effects, review of previous homework assignments, introduction of new material, description of the new homework assignment, motivational assessment focused on the homework

CULTURAL ADAPTATION OF TREATMENT FOR LATINOS assignment, and review of main points learned in the current session as well as scheduling of the next session.

Stage 3: Preliminary Adaptation Test The following are recommendations made by clinicians during their training: (a) further abbreviate the material in the participant workbook, (b) add metaphors to improve cultural relevance and engagement with the material, (c) include spiritual/religious activities to the repertoire of behavioral experiences suggested to participants, (d) abbreviate the medication and side effects monitoring section, and (e) combine the clinician manual with the participants' workbook to help guide the administration of the intervention. The following was feedback collected from pilot participants regarding the manual in its initial phase: (a) Pilot participants reported having difficulties understanding concepts related to challenging thoughts, for example, using the reasonable approach (which involves asking different questions about negative assumptions) and understanding what bappens with our assumptions when we ignore the evidence against our negative assumptions; and (b) although the use of a ruler with numeric anchors to measure motivation has been reported to be effective with Latino patients (Añez, Silva, Paris, & Bedregal, 2008), it was not a concept participants seemed to grasp when asked over the phone: They were often not able to come up with a number and did not bave a visual of the ruler in front of them. Recommendations gathered from the literature on CBT and motivational interviewing with Latinos included tbe following: endorsed use of proverbs, consideration of participants' sociocultural environment when working on behavioral activation, and incorporation of cultural values.

Stage 4: Adaptation Refinement As mentioned above, during Stage 4, we incorporated additional cultural and health literacy adaptations that were collected during Stage 3. These considerations are organized into clinician's suggestions, health literacy considerations, and cultural considerations. In response to clinicians' suggestions, we created a clinician manual, whicb incorporated instructions for the clinician with the material presented in the participants' workbook. We highlighted instructions to the clinician and essential information that clinicians needed to pay attention to or discuss by using bold italicized font and instruction boxes. We added to the clinician's manual the Paykel Suicide Scale (Paykel, Myers, Lindenthal, & Tanner, 1974), a measure of suicidality to be completed when patients scored 1 or more on the suicide question of the PHQ-9 and an emergency protocol for instances when patients endorsed Questions 4 or 5 on the Paykel, indicating they had made plans or attempted to take their life. Also, we revised the medication assessment/adherence section to ask three rather than eight questions about whether the participant was taking medications, had changes in medication use, or had side effects to help abbreviate the time spent on this section. To enhance health literacy, we added analogies to explain rationale for symptom assessments at every session. For instance, the depression screener was called the depression thermometer. Instead of using numeric anchors to assess for motivation and confidence in completing homework, we decided to use semantic

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anchors, that is, very confident, confident, and not confident at all. Health literacy considerations also involved further condensation of the psychoeducational material and special consideration of the section on cognitive structuring. For instance, in the original intervention, concepts about negative thoughts, negative assumptions about ourselves and the world around us, and about ignoring the evidence that contradicts our negative thoughts were presented in two consecutive sessions. The adapted intervention presented the concepts of negative thoughts, negative assumptions, and ignoring the evidence all in one session to condense the sessions. In terms of cultural adaptations, we added the following considerations. To further integrate the value of personalismo into the intervention and aid tbe participant to trust the clinician, we added a question to be asked by the clinicians in the ftrst session, "What helps you to feel more comfortable when you meet someone for the first time?" (Añez et al., 2008). Also, we asked clinicians to share a Httle bit about their backgrounds with participants in the first session (e.g., where they arefrom,how many years in the United States, and hobbies) before asking participants to share their own backgrounds. Also, we included instructions for tbe clinicians to prepare participants for termination of treatment beginning in Session 4. We added dichos (cultural proverbs and phrases) to the clinicians' manual to increase participants' comprehension and engagement with the material (Bemal, Bonilla, & Bellido, 1995). Examples include the following: Proverb. "It is better to prevent than lament." Use this proverb to illustrate the importance of having a self-care plan. Proverb. "Do not leave for tomorrow what you can do today." Use this proverb to illustrate the itnportance of self-monitoring of depression symptoms. We incorporated cultural values to help participants engage in treatment, for example, doing one's part {poniendo de su parte) or doing one's part for the sake of the family (Interian, Martinez, Iglesias RÍOS, Krejci, & Guamaccia, 2010). During Session 2, when discussing potential activities as part of behavioral activation, we added instructions for the clinicians to inquire about common activities in the participant's environment as a way of understanding and including activities that are normative to the person's environment, given the varying practices associated with different cultural values and levels of acculturation (Interian, Allen, Gara, & Escobar, 2008). Also, we added spiritual and religious practices to the inquiry of potential activities in which participants could get involved. Another consideration was the amount of homework given to participants. In a previous study. Aguilera, Garza, and Muñoz (2010) found minimal adherence in completing homework among Latino participants. In the original intervention, participants were assigned homework on a daily basis. For the adapted intervention, we asked participants to complete the assignments for at least two of the days in tbe following week.

Stage 5: Feedback Gathered After Clinical Trial Results from the clinical trial showed that the intervention was efficacious, resulting in a significant decrease in depressive symptoms (these results will be presented in another publication).

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The following are general feedback comments provided by clinicians regarding the adapted intervention after the clinical trial. When asked about their experience delivering the intervention, clinicians came to a consensus about the usefulness of the clinician's manual in structuring the intervention and facilitating its delivery. Clinicians agreed that learning the manual was fundamental in giving them the flexibility to present the material in a way that was congment with their style and met the needs of the participants. Clinicians found the examples presented in the clinician's manual and parficipants' workbook to be concrete, practical, and facilitating participants' ability to relate to the material. When asked about their perception of participants' understanding and engagement with the material, several clinicians reported that the material presented in the workbook was helpful and gave participants a perspecfive on their stmggles with mood through general information on depression and ways of dealing with depression. However, clinicians reported that participants had difficulties understanding some of the concepts related to the section on challenging negative thoughts. For instance, several clinicians noted that some participants had difficulty even understanding the concept of negative thoughts, let alone identifying and observing them. Clinicians agreed that the condensation of sessions related to cognitive restmcturing performed during the adaptation process made Sessions 4 and 5 (distancing and challenging negative thoughts) too long and presented many concepts (e.g., negative thoughts, negative assumptions, ignoring the evidence, and several methods and techniques of challenging negative thoughts) that made it difficult for participants to understand and retain the amount of information. More specifically, clinicians agreed that after the adaptation process, participants continued to have difficulties understanding the technique of challenging negative thoughts using questions from the reasonable approach such as "What is the evidence that supports your negative thought?" and "What are other explanations?" Clinicians thought the reasonable approach was hard to explain and required patients to remember too many questions to ask themselves when challenging a negative thought. Clinicians recommended the use of metaphors to explain the value of the reasonable approach. They also suggested asking for participants' personal examples to use these to illustrate how to use the different questions included in the reasonable approach. Clinicians noted that the cognitive challenging techniques of exaggerating negative thoughts, imaging someone else telling you what you are thinking, and asking yourself "What if the worst were to happen?" were not helpful to some patients. Clinicians explained that these techniques might not have been helpful to patients with trauma histories because their negative thoughts seemed more related to traumatic memories, for example, the patient thinking that the worst had already happened. When asked about suggestions for future adaptations, clinicians recommended the following additions and changes to the manual: the use of one or two characters who could be presented in each session to illustrate the main points and to follow these same characters throughout the six sessions rather than having different characters throughout the sessions, the need to include prompts in the manual for clinicians to elicit participants' own examples as a way of illustrating the main points and checking on participant comprehension, and making further edits to the materials presented

in Sessions 4 and 5 to make them simpler. In addition, several clinicians recommended that the manual should include information related to situational events that can cause depression in Latino patients (e.g., limited resources, unemployment, separation from family members, immigration, and family problems) and to elicit participants' understanding of the causes of their depression. Clinicians noted that several patients had trauma histories (e.g., childhood abuse, domestic violence) and were dealing with the impact of these experiences on their mood and thoughts (e.g., depressed mood, having intmsive memories of their traumatic experiences). Hence, clinicians recommended the inclusion of instmctions on treatment provisions for participants with trauma histories and relaxation exercises to manage anxiety symptoms. Finally, several clinicians suggested the use of audio aids to reinforce the homework exercises for those participants with hmited literacy.

Discussion This article details how the process of cultural adaptation and health literacy refinement occurs over several stages to ensure that the psychological intervention is relevant to the target population. This adaptation was unique because it resulted in an effective intervention that was delivered over the phone for depressed Latinos of different acculturadon levels in a lowresource setting. Similar to other cultural adaptations of interventions targeting Latinos, the current adaptation added important cultural considerations to the material presented such as the inclusion of cultural values, proverbs, and metaphors. Also, the adaptation process changed the organization and format of the psychoeducational material presented to participants. These adaptations were implemented while preserving the intervention's core components. In addition to illustrating the importance and practicality of using a stage approach in implementing the adaptation process, this study highlights the significance of incorporating feedback and recommendations of the target population. Similar to other studies, this adaptation was informed by input from relevant stakeholders (Matos et al., 2006) and by research on previous cultural considerations and adaptations of CBT interventions for Latino patients (Interian et al., 2008; Osuna et al., 2011). The stage approach allowed for the systematic incorporation and verification of information subsequently used to inform the adaptation of the intervention. A difference between this adaptation and others presented in the literature is the explicit considerations related to health literacy. It was deemed essential to consider the level of comprehension of the psychoeducational material as the average education of the participants was less than high school. At every stage of the process, we used participants' and study clinicians' feedback to ensure that the intervention was at a level that participants could comprehend. By asking for participants' feedback, we not only made sure that the intervention was relevant to the target population but we empowered participants to collaborate in adapting the intervention. Reviewing the health literacy of the intervention by considering and incorporating clinicians' and participants' input allowed us to identify core concepts presented that remained difficult to understand after adaptation. Some participants had

CULTURAL ADAPTATION OF TREATMENT EOR LATINOS difficulties understanding concepts related to cognitive restructuring such as negative thoughts, observing negative thoughts, and looking at the evidence against negative thoughts. It is unclear whether the difficulties had to do with how the concepts were presented or whether these concepts were not consistent with the Latino culture. As Hays (2009) points out, one of the limitations of adapting CBT is the emphasis on the value of rationality, which contrasts with a less linear cognitive style found in many non-Western cultures. As part of the adaptation process, we recommend a debriefing session with participants to identify concepts that require further simplification and to gather ideas as to how these concepts can be presented in a way that is comprehensible and consonant with their culture. Our level of adaptation, which we considered as both a "bottom-up" and "top-down" approach, did not include a systematic and explicit incorporation of our target population's understanding of the causes of their depression. However, when clinicians using their clinical judgment inquired about the reasons why participants believed they were depressed, the explanations included contextual factors that have been found to relate to depression in Latinos, such as separation from their family due to immigration, financial problems, and family problems (Cabassa, Lester, & Zayas, 2007; Hays, 2009). In a meta-analysis, Benish et al. (2011) found cultural adaptations to be particularly effective over conventional treatments when they explicitly included participants' understanding of the causes of their illness. Therefore, we recommend for future adaptations the explicit inclusion of participants' beliefs about their illness.

Limitations There are certain limitations that merit consideration. First, we did not test how the intervention worked before the adaptations, which limits the comparisons about its effectiveness. Second, we did not have a debriefing session with participants after the full clinical trial in order to clarify those concepts that were harder to understand and discuss ways in which these concepts can be better explained.

Conclusion This study is one of few that presents a detailed description of its adaptation process and could be used as a model for future researchers looking to adapt interventions for ethnic minority populations. In addition, this study highlights areas for future adaptations such as considerations about how cognitive restructuring may be presented to immigrant Latinos and treatment provisions for patients with trauma histories. This process shows the importance of following a stage approach to adaptations and the inclusion of relevant stakeholders throughout the stages of adaption. Finally, this study shows how the process of adaptation is a dynamic one and continues to take place even after the full clinical trial.

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