Adaptation of a Behavioural Activation Intervention for Depression in People with Diabetes in Bangladesh and Pakistan: DiaDeM Intervention

The cultural tailoring of interventions is a cost-effective approach to reach underserved populations. There are multiple frameworks for intervention adaptation, however, information on their use in practice, and sources to guide the adaptations is limited. The aim of this paper is to describe our experience using intervention adaptation frameworks and illustrate the adaptation process of a behavioural activation intervention for depression in people with type 2 diabetes in Bangladesh and Pakistan. We were guided by the intervention mapping adaptation framework for development and evaluation of health interventions and the Bernal and the Escoffery frameworks to address the cultural components of the adaptation. We performed a needs assessment, developed a logic model and systematically searched for available evidence-based interventions. To obtain evidence to guide the adaptations, we conducted a literature review, a qualitative study and workshops with community, expert advisory panels and a co-design group which systematically fed into the adaptation process. We co-produced the materials (training manual and booklet) with stakeholders. Finally, an implementation and evaluation plan was produced to test the feasibility and effectiveness of the intervention. We selected 3 interventions that had a good fit for our target population. Guided by the logic model, we identified core components of these interventions that could not be changed. We made changes in the language, pictures, illustrations, intervention dose and delivery (self-guided versus facilitator), inclusion of carers and/or family members, and training intensity. We developed a protocol to test the feasibility and effectiveness of the intervention considering key changes from the original intervention and the characteristics of the new setting and target population. Intervention adaptation frameworks proved to be valuable tools to guide the intervention process, and ensure the inclusion of multiple sources of evidence and key stakeholders.