This research aimed to culturally adapt the Mental Health First Aid Guidelines for depression currently used in English-speaking countries to the Sri Lankan context. To this end, a Delphi consensus study was conducted with 92 Sri Lankan mental health professionals and 23 consumers and carers. The final set of guidelines consisted of 165 endorsed statements in total.
Comparison with the guidelines for English-speaking countries
Overall, a large proportion of the guidelines originally used in English speaking countries (89%, 156 out of 175 statements) was included in the culturally adapted Sri Lankan version, indicating broad agreement between Sri Lanka and English-speaking countries on ways to provide mental health first aid to someone living with depression. However, there were some notable differences. Ten of the statements in the original guidelines were excluded and nine new statements introduced. Several key issues related to cultural adaptation to Sri Lanka were noted.
Statements related to respect for a person’s autonomy such as respecting the person’s right to reject help, respecting the person’s feelings, personal values and experiences as valid even if the first aider disagrees with them and not pushing the person to do activities that they may feel are too much for them were not endorsed. In a collectivist cultural context such as Sri Lanka, a first aider may be expected to prioritise a person’s health, safety and functioning over respect for their autonomy [35]. In the same vein, family involvement was emphasized in a new statement that was added (e.g., If the first aider is not a family member, they should ask family members of the person about their symptoms). In Sri Lanka, individuals are strongly embedded in their family networks and rely on family for care and support in recovery [36]. Therefore, family involvement appears to be assumed rather than seen as a choice [37]. These additions are similar to those seen in the cultural adaptation of the English-language guidelines for China [30].
The importance of giving the person hope for recovery and letting them know that their life is important was highlighted in the original guidelines. In the Sri Lankan version, a new item was endorsed around reminding the person of their valuable role in society (e.g., The first aider should tell the person that they have a valuable role in society). This may further reflect a collectivist world-view whereby a person’s sense of worth or value is related to their role and contribution to society [38].
A new item around the importance of understanding culturally specific manifestations of depression was included after a panellist’s suggestion. This is consistent with previous research that suggests that in South Asia, depression may present as a range of somatic complaints [15, 18].
Certain statements from the original guidelines related to discourse style, language use and non-verbal cues were omitted. For example, guidelines on maintaining an open body posture and not using patronising language or overly compassionate looks of concern were not endorsed. Newly added items provided culturally-appropriate ways of approaching the topic of depression (e.g., If the first aider thinks someone may be depressed, they should try to start the conversation by talking about neutral topics, e.g., day-to-day life issues or topics in common) and guidance on not forcing the conversation (e.g., “the first aider should let the person know that if they don’t want to talk, they are happy to do this at another time). Previous research suggests that when the communication style is not perceived as culturally sensitive, the impact of health messages and patient satisfaction are reduced [39]. Therefore, the inclusion of elements related to communication style may enhance the likelihood that mental health first aid is accepted.
Strengths and limitations
A notable strength of the current study was that it combined a well-established, evidence-based approach to the provision of mental health first aid with a systematic approach to cultural adaptation. This allowed for cultural differences in attitudes towards autonomy, communication styles and culture-specific manifestations of symptoms to be reflected in the adapted guidelines. Moreover, a large number of mental health professionals (n = 92) spread across multiple geographical districts participated in the study.
Even though the study adhered to the minimum recommended number of experts for a Delphi study [40], due to recruitment difficulties, a smaller number of consumers and carers participated in the study (n=23) compared to mental health professionals (n=92) and the correlation between final statement endorsement rates was also lower than that seen in other cultural adaptation studies [30], possibly due to lower mental health literacy in the general population in Sri Lanka [5, 21]. Other limitations include the lack of involvement of consumer advocacy organisations and also that allied health professionals may be under-represented in the sample. Allied health professionals’ involvement in mental health service provision is an emerging area within the Sri Lankan context and the current study may not have captured their perspective adequately. Comparisons with the English-language guidelines are limited by potential differences in understanding terminology in English and Sinhala. However, as the guidelines are not clinical guidelines and do not use highly technical language, and the non-health professional participants were able to answer the questions or to make comments where items were unclear, we don’t believe this to be a significant limitation. Finally, the guidelines were not translated into Tamil (the second official language of Sri Lanka) during the Delphi study stage and the endorsed items may not represent the perspectives of Tamil speakers.
Considerations for future use of the adapted guidelines
The culturally adapted guidelines will be made available as a stand-alone document and also used to inform the development of an MHFA training manual and curriculum. Translation of the guidelines into Tamil and inclusion of evidence-based culturally relevant information such as symptoms of depression [18] are important considerations in the implementation process given that overcoming linguistic discrimination and language-based disparities in access to resources is an ongoing priority in post-conflict Sri Lanka [41].
There is also a need to further explore ways in which the adapted guidelines and training may be disseminated in the Sri Lankan context across healthcare, education and community settings. Given previous research, carers of those living with depression and university students may be an important target of initial intervention as gaps in knowledge and sigma were identified.
In the Australian context, MHFA has reached over 2% of the population and there is evidence that training is associated with improved helping behaviours [26]. If similar dissemination outcomes were seen in Sri Lanka, population level increases in depression literacy and reduction in stigma could be achieved.