In the past 30 years, the U.S. has admitted over 3 million refugees for resettlement (U.S. Department of State, 2015). Refugees face barriers to integration, including pre-migration trauma, poverty, lack of stable employment, and discrimination (Beiser & Hou, 2016; Posselt et al., 2014), which contribute to mental and emotional distress and harmful substance use (Posselt et al., 2014). Lack of cultural and linguistic congruence is one of the most cited barriers for refugees to access effective mental health and substance use treatment. Cultural adaptation of evidence-based interventions is one way to increase access and promote behavioral health treatment efficacy for refugees.
Existing literature describes models of cultural adaptation and documents outcomes of culturally adapted interventions for refugees. However, significant gaps remain related to consensus on definitions of cultural adaptation, application of these models in real-world settings, and evidence for specific models of adaptation. The purpose of this narrative systematic literature review was to explore processes of cultural adaptation of evidence-informed behavioral health interventions for refugees.
Ten social work and social science databases were searched using a set of key synonyms for cultural adaptation, intervention, refugee, and behavioral health, resulting in 1,164 unduplicated articles, books, dissertations, and white papers. The following inclusion criteria were used: published since 1980, English language, focused on cultural adaptation of an evidence-informed behavioral health intervention, adapted for refugees, and included a description of the cultural adaptation processes. Three independent reviewers evaluated the article abstracts for fit with inclusion criteria and inconsistencies were discussed and resolved via consensus. Ten articles were included in the final dataset. A literature review of models of cultural adaptation was also conducted.
Data were analyzed using narrative analysis and two rounds of inductive coding. Articles were read through once by two independent reviewers and initial codes were generated. Inconsistencies were discussed and resolved via consensus and updated codes were then applied to the data. Comparison to formal models of cultural adaptation was also performed.
Analysis revealed six categories: use of and fidelity to cultural adaptation models, adaptation of content, adaptation of delivery, inputs to the adaptation process, challenges to adaptation processes, and outcomes of cultural adaptation. Significant gaps were identified between suggested models of cultural adaptation and documented processes of adaptation in practice. Although successful outcomes were identified in the articles, it remained unclear which cultural adaptation practices contributed to the successful outcomes. Analysis also revealed that significant inputs were needed to support cultural adaptation and that a variety of challenges were faced in the adaptation process.
Conclusions and Implications
While cultural adaptation of behavioral health interventions for refugees is important, suggested best practices for adaptation can be vague, poorly described, or difficult to apply in real-world settings. Further research is needed to better understand the complexities of cultural adaptation in real-world settings.