JMIR FORMATIVE RESEARCH

Garabiles et al

Original Paper

Cultural Adaptation of a Scalable World Health Organization
E-Mental Health Program for Overseas Filipino Workers
Melissa R Garabiles1,2, PhD; Melissa Harper Shehadeh3, MSc; Brian J Hall2,4, PhD
1Ateneo de Manila University, Manila, Philippines

2

Global and Community Mental Health Research Group, The University of Macau, Macau, China

3

Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland

4

Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States

Corresponding Author:
Brian J Hall, PhD
Global and Community Mental Health Research GroupThe University of Macau
E21-3040
Avenida da Universidade
Macau, 99908
China
Phone: 86 62899837
Email: brianhall@um.edu.mo

Abstract
Background: Electronic mental (e-mental) health interventions can address mental health needs of different populations. Cultural
adaptation of these interventions is crucial to establish a better fit with the cultural group and to achieve better treatment outcomes.
Objective: This study aimed to describe the cultural adaptation of the World Health Organization’s e-mental health program
Step-by-Step for overseas Filipino workers. We used a framework which posits that cultural adaptation should enhance (1)relevance, wherein the cultural group can relate with the content; (2) acceptability, where the cultural group will not find any
element offensive; (3) comprehensibility, where the program is understandable; and (4) completeness, wherein the adapted version
covers the same concepts and constructs as the original program. We aimed to have English and Filipino and male and female
versions.
Methods: Overall, 3 experienced Filipino psychologists provided their perspectives on the program and how it might be adapted
for overseas Filipino workers. We then adapted the program and obtained feedback from 28 overseas Filipino workers fromdiverse industries through focus group discussions. We conducted 7 and 9 focus group discussions with male and female
participants, respectively. Per discussion, cognitive interviewing was used to probe for relevance, acceptability, comprehensibility,
and completeness of illustrations and text. Participant feedback guided iterative program adaptations, which were again shownto participants for validation and improvement.
Results: Several issues were raised by participants about the generic version of Step-by-Step. There were elements deemed
irrelevant, like unfitting characters, lack of Filipino values, and unsuitable problems and activities. There were unacceptablecomponents that were stigmatizing, political, inappropriate to context or subgroups, and too feminine for male users. Someelements were incomprehensible, unclear, or complicated. To address these issues, we made key adaptations. To enhance relevance,
we adapted the narrative to match the experiences of overseas Filipino workers, incorporated Filipino values, and illustrated
familiar problems and activities. To increase acceptability, our main characters were changed to wise elders rather than healthprofessionals (reducing mental health and help-seeking stigma), political or unacceptable content was removed, and the program
was made suitable for overseas Filipino workers from different sectors. To increase comprehension, we used English and Filipino
languages, simplified the text to ease interpretation of abstract terms, and ensured that text and illustrations matched. We also
used Taglish (ie, merged English and Filipino) when participants deemed pure Filipino translations sounded odd orincomprehensible. Finally, we retained the core elements and concepts included in the original Step-by-Step program to maintaincompleteness.
Conclusions: This study showed the utility of a 4-point framework that focuses on acceptance, relevance, comprehensibility,
and completeness in cultural adaptation. Moreover, we achieved a culturally appropriate adapted version of the Step-by-Step

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program for overseas Filipino workers. We discuss lessons learned in the process to guide future cultural adaptation projects ofe-mental health interventions.
(JMIR Form Res 2019;3(1):e11600) doi: 10.2196/11600
KEYWORDS
cultural adaptation; migrant workers; e-mental health; overseas Filipino workers

Introduction

aspect and suggests that in some studies what counts as a cultural
adaptation may be poorly defined.

Background

Cultural adaptation involves an integration of top-down andbottom-up approaches [12]. The original program (top-down)
is modified based on feedback from the intervention target
population (bottom-up), that is, the original program is adapted
based on input from the cultural group to be responsive to thecultural group’s context and specific mental health concerns[8].

The use of technology to deliver mental health interventions
proliferated in recent years, with electronic mental (e-mental)
health interventions providing accessibility to needed mental
health interventions [1,2] for more people [3] and at greater
frequency [4]. The use of e-mental health interventions is
especially promising for vulnerable and marginalized
populations such as migrants. They help reduce the stigma
associated with help-seeking and minimize treatment barriers
such as geographical distance and culture, religion, and language
differences between users and providers [2,5].
E-mental health interventions that undergo cultural adaptation
are more effective. Cultural adaptation is “the systematic
modification of an evidence-based treatment (EBT) orintervention protocol to consider language, culture, and context
in such a way that is compatible with the client’s cultural
patterns, meanings, and values” [6]. Cultural adaptation is
warranted when an intervention developed for one cultural groupwill be implemented within a different cultural group. Whenan intervention is adapted, a better fit between the program andthe cultural group is expected, which in turn leads to better
treatment outcomes [7].
Culturally adapted interventions are effective. A meta-analysis[8] of 78 studies revealed that culturally adapted face-to-faceinterventions performed better than the comparison conditions(another active intervention or no intervention), with an average
effect size of g=.67. Furthermore, culturally adaptedinterventions are more effective than their original unadapted
versions, with a medium effect size of g=.52. Anothermeta-analysis [9] of e-mental health interventions found that
cultural adaptation resulted in a greater reduction in depression
and anxiety symptoms. Essential elements for adaptationaccording to the Bernal and Saez-Santiago framework [10]include language, persons, metaphors, content, concepts, goals,
methods, and context. Every additional element adapted resulted
in a 14% increase in intervention efficacy.
It should be noted, however, that cultural adaptation does notequate with completely rewriting the program. In fact, asystematic review [11] on cultural adaptation of interventions
for depressive disorders showed that all the studies included in
the review preserved the original treatment’s framework andcore principles that were deemed acceptable. The adaptations
were made to establish cultural relevance, improve treatment
acceptability, and remove barriers to care (eg, lack of trained
professionals and limited literacy). Inclusion of barriers to care
could be considered as implementation rather than a cultural

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The World Health Organization is developing several
evidence-based interventions—including transdiagnostic
programs—designed to be scaled up to reach populations
globally that lack access to needed mental health services [13].
We adapted one of these, the Step-by-Step program, an e-mental
health program based on the principles of behavioral activation
treatment for depression, along with additional strategies suchas psychoeducation, stress management, and help-seeking [14].
Following the internet- and mobile-based intervention
categorization [1], Step-by-Step is considered a minimally
guided self-help program, wherein a nonspecialist eHelper may
provide technical support and assistance in accomplishingprogram activities through phone calls or text messaging for up
to 20 min a week.
In places with more established services, Step-by-Step may besuitable for use within a stepped-care structure, where users
who show mild-to-moderate levels of symptoms could bereferred to higher-intensity services should they require it oncompletion of the program. The program contains text andstories with corresponding illustrations and 2 main characters.
The first character is an expert who helps the second characterby sharing behavioral techniques to overcome problems and by
explaining the concepts behind the problems and the techniques
offered in the program. The second character narrates theirexperience of using the Step-by-Step techniques to overcome
depression, reporting their previous encounters with typicalproblems and psychological symptoms of the target populationand explaining how they employed the program to reduce these
problems.
The original version already has 3 of the 4 desired features ofeffective e-mental health interventions, as it is based on theempirically tested theory of behavioral activation, it isstructured, and it is interactive or experiential [15]. The lastdesired feature of being targeted for a specific group [15] must
be addressed through cultural adaptation. To ensure high-quality
adaptation of Step-by-Step, we followed the approach used by
Manson [16] and van Ommeren et al [17]. Manson [16]theorized that the end product needs to be (1) acceptable, withnothing in the program offensive or potentially offensive to thecultural group; (2) relevant, in that the program’s content is
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related to the cultural group and does not contain unrelated
phenomena; (3) comprehensive or understandable by the culturalgroup; and (4) complete, in that the program covers the same
semantics, concepts, and theoretical constructs as the original
version.
In this study, Step-by-Step was adapted for overseas Filipino
workers (OFWs). There are 2.24 million OFWs around theworld [18]. The majority (85%) work in Asian countries suchas Saudi Arabia, United Arab Emirates, Qatar, Singapore, andChina (ie, Macao and Hong Kong Special Administrative
Regions, SARs). There are roughly the same number of maleand female OFWs, but occupational differences exist between
the groups. Male OFWs are mostly plant and machine operators
and assemblers (24.7%) and craft and related trade workers(23.1%), whereas female OFWs are mostly employed ashousehold service workers and cleaners and in other low-skilledoccupations (56.2%). In Macao SAR of the People’s Republicof China, OFWs are the second largest migrant group at 29,426[19]; roughly half of them are household service workers, morecommonly referred to as domestic workers, followed by hotel
and restaurant workers.
Previous studies focused on the risks and challenges that OFWs
and other labor migrants experience. OFWs’ primary reason
for working abroad is the desire to escape poverty or to achievesocioeconomic mobility, mainly for their family, rather than
individual aspirations [20,21]. However, while abroad, andsimilar to other labor migrants, OFWs are at higher risk ofexperiencing mental health–related issues such as loneliness,stress, anxiety, depression, and serious mental illness [21,22].
However, resolving these challenges is problematic as labor
migrants tend to have poor access to mental health services[23-25] and poor support systems [26]. E-mental healthinterventions are a way to address their mental health needs as
more than 90% are smartphone users, and there is high potential
uptake as 68% are likely to use a Web-based program when one
is available [27].

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Objectives
This study aimed to culturally adapt the WHO Step-by-Step
program for overseas Filipino labor migrants. We made English
and Filipino and male and female versions. It was intended foruse by OFWs engaged in different occupations.

Methods
Participants
There were 31 participants, all of whom were selected throughpurposive sampling. We used a 2-stage approach (refer to Figure1), first interviewing 3 Filipino psychologists with considerable
experience and expertise in psychological practice and inworking with OFWs, using Zoom video conferencing (eachapproximately 120 min long). The second stage consisted offocus group discussions (FGDs) with 28 OFWs in Macao. Of
the FGD participants, 16 were women, aged 24 to 52 years(mean 36.31, SD 9.44), and employed as domestic workers,
caregivers, and food and beverage workers. In addition, 9 ofthem were married, 6 were single, and 1 was widowed. The
length of time working in Macao ranged widely, from 1 month
to 12 years (mean 4.28 years, SD 3.46). Furthermore, 12participants were men, aged 23 to 47 years (mean 30.58, SD
7.66), and employed in hotel and casino, food and beverage,
and facilities management industries. Half of them were single
and half were married. They had been working in Macao for an
average of 1.63 years (SD 1.12), with a range of 6 months to 4
years. FGDs were conducted separately for male and female
participants, with each FGD covering 1 to 3 sessions of the
program. Due to scheduling difficulties, participants were notable to join all FGDs to discuss all the sessions of the program.
Each participant joined at least 1 FGD and at most 6 FGDs.
There were 7 male and 9 female FGDs in all, with 2 to 11
participants per FGD. The FGDs lasted between 2 and 3.5 hours
and were conducted in private rooms in a local nongovernmentalorganization (NGO) or in a university. The FGDs were held on
Saturday nights and Sundays, either after participants’ work or
during their day off. The participants were remunerated MOP$100 or roughly US $12 per FGD.

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Figure 1. Flow of the adaptation process.

Materials
The intervention material was a generic version of theStep-by-Step program. The program starts with registration andintroduction (session 0), followed by sessions 1 to 5. Eachsession is meant to be completed on the Web by the user once
per week, with each session lasting between 30 and 40 min.
In advance of the interviews with expert Filipino psychologists,
we provided a summary of the program’s content, the complete
intervention content, and examples of possible illustrations with
instructions to review all materials before the interview. For the
FGDs with OFWs, we made Microsoft PowerPoint presentations
that showed the entire initial adapted texts and illustrations (after
Filipino psychologist interviews). Each slide consisted of about
3 to 5 sentences, most with simple illustrations. We started onlywith the intervention text for sessions 0 to 2, as the illustrations
were not yet ready. Eventually, we showed both texts andillustrations to the participants side by side for the remaining 3
sessions.
We also utilized interview and FGD guides. The interview guidefor the psychologist interviews consisted of questions about
their opinions on whether or not the Step-by-Step program canaddress OFWs’ mental health needs, the type of OFWs that the
program will be most or least suitable for (ie, hotel staff anddomestic workers), appropriateness of the content of the
program, considerations we had to make with regard to Filipino
culture and OFW culture, and challenges they foresaw in using
the program. We added questions on which specific groups weneeded to consider for content tailoring (eg, younger or older
OFWs), suggestions on the characters in the story, and opinionswith regard to the characteristics of the eHelpers.
For the FGDs with OFWs, we started cognitive interviews (atechnique whereby participants think aloud [28]) with a broad
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if the content is relevant or relatable, understandable, or
acceptable and the ways by which we can improve the text orillustrations. We also asked if the text and illustrations on eachof the slides match, and if not, how we can change the text orillustrations to ensure they correspond with each other. Whenasking these questions, we told participants to think about all
OFWs globally (eg, Would all or most OFWs understand thistext?) and not just themselves or just OFWs in Macao to increase
generalizability to OFWs across ages, marital statuses,
occupations, and countries where they are employed.

Procedure
FGDs were conducted in English to adapt an English-language
version and in Filipino to adapt a Filipino-language version.
We matched the sex of the facilitator with the sex of theparticipants (ie, male facilitator during male FGDs).
We first gave participants consent forms to read and sign, andthen, we introduced the interview or group discussion and theStep-by-Step program. We then proceeded with the interviews
or FGDs. The first FGDs concerned developing the illustrationsof the main characters. After this, once illustrations had beendeveloped, further groups were conducted based on theremainder of the stories and activities. The entire adaptation
process was thoroughly documented. We used note-taking,wherein we wrote participants’ feedback for each slide. We also
used audio recording to review the sessions if any of our notes
were unclear. After an interview or FGD, we (MRG and BJH)
discussed what transpired and reviewed our notes. We decided
on pertinent changes that needed to be made on each slide.
Throughout the process, we used the approach of Manson [16]and van Ommeren et al [17] in that we focused on adaptations
that would better ensure relevance, acceptability, andJMIR Form Res 2019 | vol. 3 | iss. 1 | e11600 | p. 4
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comprehensibility to as many OFWs as possible, while retaining
completeness of the Step-by-Step program. When participants’opinions differed in terms of whether to make changes or not(ie, a sentence was understandable to some participants but
others suggested to simplify or provide more explanation), we
decided to make adaptations to ensure the content wasappropriate to the broadest possible audience, and thesemodifications were then brought back to the community for any
further comment and approval. When there were variedsuggestions on how to adapt text and illustrations (ie, different
suggestions on what words to use or how to change illustrations),
we chose what the majority preferred and what was applicable
to most OFWs (ie, applicable to the majority of male and female
OFWs, young and old).
All changes in text and illustrations were documented using
standard forms developed by the World Health Organization.
We deemed making changes based on our notes sufficientbecause participant feedback on the slides was simple andstraightforward (ie, participants mentioned which sentenceswere confusing, and they shared which part of the illustrations
did not match the text), and participants provided us withconcrete suggestions on what changes to make (ie, theysuggested words to use and what to add or omit in theillustrations). Furthermore, each slide contained relatively shorttext and simple illustrations to begin with. The questions we
asked them were also direct (ie, Can most OFWs understandthe text? How might we improve the text to make it more
understandable? Can you relate to the character? How might
we make the character more relatable?).
Suggested changes to the illustrations were sent to a professional
illustrator. He was the same illustrator who made the illustrations
for the original Step-by-Step program and was familiar withthe program and cultural adaptation process. Using the original

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Garabiles et alillustrations as the starting point, we gave instructions on whatchanges to make (ie, character’s facial expression should behappier or omit certain hand gestures) and at times accompanied
instructions with sample photos taken from the internet to guidethe development of new illustrations.
Changes in illustrations and in stories were then shown toparticipants during subsequent FGDs. We reminded participantsof their comments on the past illustrations and text and showed
them the revisions made. We asked for their feedback on thechanges and then their approval (ie, Is this what you meant?
Anything else that is unrelatable, unacceptable, or hard tounderstand?). If the changes were still unsatisfactory, we asked
for more input from them, made necessary revisions, and thenshowed them the newly revised slides in the next FGD. For
example, it took 3 FGDs to finalize the appearance and get
participants’ approval for one of the characters (refer to Figure
2).
After we conducted all the FGDs on the English and female
versions and after revising the texts, we sent the texts to aprofessional translator. The translator was a Filipino fluent inboth Filipino and English, with a BA in Malikhaing Pagsulat
or Filipino creative writing. We gave her a background of theadaptation process and informed her of the desired tone of thestory and personality of the characters as per the interview andfocus group feedback. We then edited the translated text tocapture the OFW experiences better (ie, words they often usedin FGDs to describe their experiences). The edited translations
were then shown to female FGD participants during subsequentcognitive interviewing. Their comments and suggestions tosimplify the texts, especially words that were too difficult tounderstand or lines that were too long, were then used to makeadditional translation edits. We then showed the revised slides
during the next FGD for feedback and approval.

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Figure 2. Character adaptations. In focus group discussion (FGD) 1, two sample illustrations of the main character were presented to participants for
feedback with regard to appearance. Participants gave vivid descriptions on how they wanted her to look (ie, short hair with bangs, with jewelry, etc)
In FGD 2, revised illustration based on FGD 1 feedback was shown to participants who gave partial approval. They liked how the character looked but
not her personality. Participants suggested making her appear warm and happy. In FGD 3, revised illustration based on FGD 2 feedback was shown toparticipants, who then gave full approval.

Reflexivity and Procedures for Verification
This study was conducted by a research group that aimed to
improve the health of migrants globally and within the Macao
SAR. As such, the implementing researchers (MRG and BJH)
were familiar with the OFW context, through prior knowledge
and interactions with the study population, and worked withorganizations providing support to this community (eg,Philippine Government, churches, and NGOs) for years,
including those based in the Macao SAR. MRG is a native
Filipino who speaks the Filipino language fluently and has a
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similar cultural background as the participants. During datacollection, MRG was an OFW herself but was only involvedin the project as an investigator but not a participant. BJH isfrom the United States of America and emigrated to China over
5 years ago. However, neither researcher is employed in thesame sector as the participants. We also had higher educational
attainment, occupational prestige, and socioeconomic status.
Although we are migrants ourselves and have a richunderstanding of the OFW context, our experiences are different
from the participants’ and other typical OFWs. With thisacknowledgment, we attended to our own beliefs by assuring
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participants their feedback on the materials were crucial in
improving the program and that they were the experts when it
came to OFW experiences. We also probed participants’ answers
to get more information and asked them to confirm ourunderstanding of their input. Furthermore, we presented to them
the interim changes we made on the stories and illustrations forvalidation. They verified many of the changes, but at times,
they provided clarifications and more details for additionalchanges. We also presented the findings to a group of
stakeholders, which included Philippine Government staff(Consul General, Labor Attaché), NGO workers, a Macao
government official, Macao mental health professionals, andFilipino priests and nuns, for their feedback. They did notsuggest changes in the adapted program and instead raised
concerns regarding logistics and eHelpers.

Results
Acceptability
On the basis of key informant interview data and FGD data,
there were 3 main issues with regard to the acceptability of thegeneric version of Step-by-Step. This includes stigma regarding
mental health problems and mental health help-seeking in thePhilippines. On the basis of interview data with experts, the useof a doctor pathologizes the users’ experiences and connotes
there is something wrong with them. This would then serve asa barrier for the OFW population to use the program. This
opinion is also backed by previous research [29]. Another issue
was, from the participants’ viewpoint, that some of the originalcontent was politically charged or socially unacceptable to all
OFWs. For example, the initial illustrations included hand
gestures that reminded participants of political parties. The text
also mentioned drug use as a negative coping strategy, butparticipants shared that this was reminiscent of the popular but
polarizing drug war campaign of the current administration in
the Philippines. Another example was illustrations that depicted
the characters doing household chores, which leaned too muchtoward domestic work. Although many OFWs are skilledworkers, there are many professionals such as nurses, managers,
and teachers as well, which makes doing household chores
unsuitable for all OFWs. Other instances were coping strategies
originally depicted as negative but are normative or evenpositive coping strategies in the OFW context. For example, anillustration and text were about a character staying in bed allday, but participants shared that for OFWs in physicallydemanding jobs, this is a good strategy to recover from stressat work. Another was drinking alcohol because it is culturally
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their friends. Finally, some male participants mentioned thatsome text and illustrations looked too feminine (ie, crying in
bed). Due to strong traditional gender roles, it was important
for them to maintain a masculine stance or at least not exude
femininity, including emotional weakness.
To address these issues raised by participants, adaptations werethen made to make Step-by-Step acceptable. These include
reducing content that may increase the stigma associated withmental health and help-seeking, changing content that appeared
political or potentially unacceptable to an OFW subgroup anddepicted as negative when it is socially acceptable in the OFW’scontext, and making considerations for the male version. Theseare explained below.
To address the issue of stigma, we made 3 modifications. First,
instead of stating the original program goal of “helping the user
cope with difficult emotions and problems” explicitly, wechanged it to “helping the user become a successful OFW, fortheir families’ sake.” The latter deemphasizes the focus on
mental health and increases emphasis on positive goals andoutcomes. The latter also still addresses the original goal but
focuses on a common and integral OFW experience and valueof working abroad to contribute to family’s expenses, at times
as the family’s sole provider. Second, we developed thecharacter that explains Step-by-Step concepts to the user (ie,stress and sadness) into an older OFW who has been successful
in his or her work rather than a medical or mental healthprofessional (refer to Figure 3). Changing the character to afellow OFW normalizes the experience of problems and removes
the stigma. Furthermore, interview and FGD data showed thatmaking the character successful incorporates the aspirations of
the target group. Third, we changed text such as “suffering at
the moment” to “stressed at the moment” to make them soundless grave and more normative, as advised by FGD participants.
Some of the content was removed from Step-by-Step orchanged. We removed certain hand gestures and drug use as anegative coping strategy to make the program apolitical. We
removed the illustration and text about a character staying in
bed all day as a negative coping strategy because this is anacceptable, even helpful, coping strategy for OFWs. We changed
the illustration on characters doing household chores to sending
remittances in a bank and filling up a package or what Filipinos
call balikbayan box (literal translation: back to country) to thePhilippines and preparing to go to work (refer to Figure 4) tobe more neutral and suitable across occupations. These areubiquitous OFW experiences, regardless of job orsocioeconomic status.

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Figure 3. Illustration of characters in the original Step-by-Step version and in Step-by-Step for overseas Filipino workers.

Another is “drinking alcohol,” which we changed to “drinking
too much alcohol.” Participants recommended adding the term
“too much” to make it a negative coping strategy.
We also made considerations for the male version. As much as
possible, we ensured that female and male versions had similarstorylines, activities, and illustrations so as to limit genderstereotyping as much as possible. However, for someillustrations, we made them slightly different to appeal to male
OFWs by avoiding what male FGD participants believed tolook too feminine. For example, in a scene that shows thecharacter is isolated from others, the male character is in his
bedroom looking lonely, with legs in v-position, elbows restingon his thighs, and hands clasped together. In the female version,
the character is still alone in her bedroom but is in fetal positionand hands covering her face (refer to Figure 5).

Relevance
There were 4 issues with regard to the relevance of the originaltext and illustrations of Step-by-Step. The first issue was interms of the characters. The generic version used Lebanese andMuslim characters (ie, characters had names like Zeina andKarim, females wore hijab, and males had thick beards; referhttps://formative.jmir.org/2019/1/e11600/

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to Figure 3), which were different from typical Filipino names
and appearance. The second issue was in terms of the lack ofrelatable values in the stories. For example, participants foundthe tone of the stories and personality of the characters to be
too serious and robotic, which they felt were not attuned to theFilipino value of showing warmth and hospitality. The thirdand fourth issues were in terms of the lack of relatable problems
and activities. Some of the problems in the generic version
included destruction of one’s home and community. Althoughthese happen to some OFWs, participants felt these were not
the most pertinent problems in their community. Moreover,participants deemed some of the activities in the generic version
atypical or unfeasible, such as planting herbs and spending timewith family. These were irrelevant to OFWs because whileabroad, there is no ample space to plant herbs, and OFWs cannot
be physically together with their families. Participants addedthat planting herbs would not come across as a fun activity formany OFWs.
To increase relevance, we made the following adaptations: (1)choosing appropriate names and appearance of main characters,(2) highlighting Filipino values, (3) using relatable problems,and (4) using relatable activities.

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Figure 4. Illustration of providing support to others in the original Step-by-Step version and in Step-by-Step for overseas Filipino workers.

Figure 5. Illustration of isolating oneself from others in the original Step-by-Step version and in Step-by-Step for overseas Filipino workers.

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We first developed the characters’ names and appearances tomake them sound and look Filipino. The older characters had
Spanish-sounding names (Kuya Ronald and Ate Sonia), whereas
the younger characters had more modern andAmerican-sounding names (John and Leona), both of which arecommon naming practices that are related to the colonial andchanging cultural context of the Philippines. We also ensured
that the names had positive meanings (ie, a wise person and afighter) and were approved or chosen by the participants. For
the older characters, we added the terms Ate or Kuya before
their names, which mean respected older sister or older brotherin Filipino, often associated with being sensible and experienced.
For the characters’ appearances (refer to Figure 3), participants
wanted their hair straight and black and their skin color warmor olive in tone. The participants also wanted the characters tolook successful as they link being a migrant for years to having
saved money and made investments but added that they neededto dress comfortably as they are busy at work. They proposed
making their clothing simple, comfortable but modern, andadorned with jewelry such as watches for the male charactersand earrings, necklaces, and watches for the female characters.
We highlighted Filipino values in 3 ways. First, experts andparticipants advised adapting the personality of the programand characters to exude desirable Filipino values of familyorientation, showing warmth and care for others, sociability,and positive thinking. Participants added changing the tone of
the text to become more conversational and story-like to soundmore engaging and realistic such that the characters seem to betalking to the users. Participants also recommended that thecharacters addressed the user as kabayan or countryman, acommon term used among OFWs, which denotes similarity andfamiliarity with fellow Filipino migrants. The older characters
also acted as mentors or coaches to the younger characters anduser. The younger characters called the user sis or bro to denotekinship. They showed eagerness to share their stories andemotions with the users and to learn and become better.
Participants advised for all characters to offer encouragement
or reassurance to the user, with lines such as “Keep up the goodwork!” and “You can do it!” They recommended matching thesewith illustrations where the characters gave warm smiles towelcome and bid the users goodbye and thumbs-up sign to show
approval.
Second, the texts were changed to highlight that OFWs consider
their family as motivation for going abroad and working hard,even making sacrifices for them. Participants suggested
matching the illustrations by showing OFWs thinking of theirfamilies often and missing them. Furthermore, participants
wanted to emphasize being with friends and family as crucial
to one’s mental health and as culturally appropriate andexpected. Participants proposed matching the text with
illustrations of characters spending time and having fun withfriends who were also OFWs and with family throughWeb-based communication.
Third and last, as suggested by all 3 experts during individualinterviews, we mentioned additional Filipino values such as
bayanihan and utang-na-loob in the stories. Bayanihan means

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Garabiles et alworking together to help someone, which we added in an activity
where an OFW helped a main character in a task. Utang-na-loobmeans debt of gratitude, which we mentioned as a motivator
for a main character to reach out to a friend who helped themin the past.
We adapted the content in terms of the problems the characters
experienced to make them more typical, based on interview and
FGD data. Examples of problems included leaving their family
behind, having personal conflicts, and having too much workor having no break or day off.
We likewise adapted the content in terms of the activities thecharacters engaged in to make them enjoyable and doable to as
many OFWs as possible. On the basis of FGD data, examples
include eating merienda or afternoon snacks with friends,
visiting nearby historic sites, celebrating events with family
using Web-based communication, and singing videoke (video
karaoke) with friends (refer to Figure 6). These are typical fun
activities that Filipinos engage in. Filipinos are fond of eating
meals together, exploring new sites when abroad, connectingwith families back home, and listening to music and singing.
These activities are also relatively inexpensive and not thattime-consuming, which make them feasible to do during days
off and even with limited finances.

Comprehensibility
The generic version of Step-by-Step had elements that wereincomprehensible, unclear, or too complex. In the text, there
were sentences that participants deemed too long or repetitive
and, therefore, difficult to understand. Some participants
expressed finding some terms (ie, peers, pace, and social
support) complicated. Finally, participants found that some
texts and illustrations were not clearly linked. For example, one
passage in the text was about isolating oneself from other people
when one feels sad. Although participants understood the text,
they mistook the illustration where the character is facing awayfrom 2 other characters as friends gossiping about the character(refer to Figure 5).
To make the adaptation comprehensible, we used Filipino andEnglish languages. Filipino is the national language in thePhilippines. Both Filipino and English are official languages
and are widely spoken by OFWs as primary mediums ofcommunication, that is, Filipino with fellow OFWs who comefrom different regions in the Philippines and English with theiremployers. Filipino is derived from Tagalog, the main languageof 35.1% of households in the Philippines [30].
On the basis of FGD data, we also simplified the text in 3 ways
to boost comprehension: shortening long sentences by removing
words, dividing long sentences into 2 sentences, and using
simplest words and phrases (ie, changed the word peers tofriends and pace to speed). When a term or an idea was too
abstract, we changed the words or added extra words or lines
to clarify what they meant. For example, instead of the abstract
concept of social support, we used helping hands as suggested
during an FGD because although participants understood whatsocial support meant, they could not verbalize theirunderstanding of the term.

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Figure 6. Illustration of enjoyable activities in Step-by-Step for overseas Filipino workers.

For the Filipino version, participants suggested simplifying text
by removing sentences when paragraphs sounded repetitive andconfusing. We retained those lines in the English version as
they did not sound repetitive in English. Moreover, some English
words or phrases when translated to Filipino sounded awkward;
hence, we retained the original words in English. For example,
we retained the word congratulations because its Filipinotranslation of binabati kita or “I compliment you” sounded odd
to participants. We removed English words or phrases that did
not translate well into Filipino, as suggested by participants.

Filipinos generally. We illustrated how the 4-point framework
to improve acceptance, relevance, comprehensibility, andcompleteness is useful in navigating the process of culturally
adapting the Step-by-Step program. It was a practical guide toboth us, the researchers, and the participants as it enabled us tocapture and flesh out crucial elements to make the finishedproduct attuned and sensitive to the context and experiences of
OFWs. In turn, we were able to make the program culturally
specific for this group, which is essential among the 4 featuresof effective e-mental health interventions [15].

We adapted texts and illustrations that were not clearly linked,
following participants’ recommendations. For example, for theillustration about isolating oneself, we had the illustration
changed so that the character is in bed alone (refer to Figure 5).

Lessons Learned

CompletenessAll key concepts in the original version are intact in the adapted
Step-by-Step for OFW. We also made sure that the English andFilipino versions were as similar as possible, so that if an OFW
chooses to use the English version, they would have an
equivalent program to the Filipino version and vice versa. For
the Filipino version, instead of translating all English words toFilipino, we retained some English words because OFWs use
these words to describe their experiences. The combination ofFilipino and English (ie, Taglish) is an unofficial language [30]that is normative and accepted among Filipinos. An example isbeing homesick as they are away from their family. Participants
recommended retaining the English word homesick instead ofusing the Filipino translation of hinahanap-hanap ang pamilya(yearning for family) because the word homesick is a common
OFW term and is deeply tied to working abroad far from one’s
family.

Discussion
Principal Findings
To our knowledge, this is the first study that culturally adapted
an e-mental health intervention for the OFW population andhttps://formative.jmir.org/2019/1/e11600/

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For future cultural adaptations, we recommend that all
illustrations and content be adapted at the same time. In our
experience, participants were more engaged in the presence ofvisual stimuli (recall that we were not able to present
illustrations for sessions 0-2). Furthermore, it was easier forthem to understand the texts and key concepts while being able
to see the illustrations.
We recommend that the same set of participants be part of the
FGDs from start to finish to avoid spending time explaining the
program, the mechanics of the cognitive interviews anddiscussion, and details from previous sessions. We were able
to do this with the majority of our FGDs, but scheduling
limitations hindered participants from attending all sessions.
Therefore, to accommodate the realities of the population, weallowed the FGDs to be open to newcomers. Some participants
were more able to provide input than others. As in any FGD, it
is important to select participants who are more open, less shy,
and comfortable to freely share their thoughts. In the context
of this adaptation study, norms of social hierarchy and harmony
within the cultural group may have influenced how much people
shared within the groups.
Another limitation is the lack of standard and systematic
evaluation on whether the inputs from members of the FGD
represent the entire community. Further investigation is also
recommended to determine which elements were most salient

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to the participants to more clearly know when adaptations aregood enough for the cultural group.

adaptation but also provide the audience a replicable accountof how to conduct such formative research.

Relevance of the Research

Following the Medical Research Council Guidelines forComplex Interventions and the WHO scalable psychologicalinterventions program [31,32], this adapted program will be
rigorously evaluated. The initial feasibility trial and subsequent
full-scale randomized controlled trial both include processevaluation components. Subsequent changes to the illustrations,content, and program story will be made, if needed.

The methods and detailed results of formative adaptation work
as described in this study are often not shared by researchers or
program implementers in mainstream literature [9,11]. As it issuch a crucial step in planning and care provision, we hope that
this study will not only highlight the importance of cultural

Acknowledgments
The authors thank Ken Carswell for his comments on earlier drafts of the paper and Mark van Ommeren for his guidance andsupport, both from the Department of Mental Health and Substance Abuse, and World Health Organization. The authors also
thank Macau Caritas, and especially Julia Lam, Kitty Tam, and Paul Pun, for their ongoing partnership in this research. The
authors also thank the Macau Foundation for their generous funding, which made this work possible. The authors would also liketo thank expert Filipino Psychologists: Imelu Mordeno, Fr Nilo Tanalega, and Gary Faustino, who provided their advice at the
inception of this work. The authors also thank Karim Al-Dahdah and Christa De La Cruz for their excellent work on illustrations
and translations, respectively. The authors thank the Philippine Consulate General in Macao SAR, Consul General Lilybeth
Deapera, Vice Consul Ira Valdez, and Labor Attaché Vivian Tornea. The authors also thank GCMH research members Jo Wang,
Sammy Yang, Grace Zhen, Elise Chan, Edward W W Chan, and Ruth Shen. Finally, the authors thank the OFWs of Macao for
their time, effort, and guidance in the adaptation of Step-by-Step.

Conflicts of Interest
None declared.

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Abbreviations
EBT: evidence-based treatment
e-mental: electronic mental
FGD: focus group discussion
NGO: nongovernmental organization
OFW: overseas Filipino worker
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SAR: Special Administrative Region

Edited by G Eysenbach; submitted 16.07.18; peer-reviewed by S Burchert, B Puschner; comments to author 08.10.18; revised version
received 26.10.18; accepted 24.01.19; published 29.03.19
Please cite as:
Garabiles MR, Harper Shehadeh M, Hall BJ
Cultural Adaptation of a Scalable World Health Organization E-Mental Health Program for Overseas Filipino Workers
JMIR Form Res 2019;3(1):e11600
URL: https://formative.jmir.org/2019/1/e11600/
doi: 10.2196/11600
PMID: 30924784©Melissa R Garabiles, Melissa Harper Shehadeh, Brian J Hall. Originally published in JMIR Formative Research(http://formative.jmir.org), 29.03.2019. This is an open-access article distributed under the terms of the Creative Commons
Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete
bibliographic information, a link to the original publication on http://formative.jmir.org, as well as this copyright and license
information must be included.

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