Current Practice and Expert Perspectives on Cultural Adaptations of Digital Health Interventions: Qualitative Study

Some people are less likely to benefit from digital health interventions (DHIs) than others. Culture, along with other factors, contributes to these differences. DHIs that do not address a population's cultural norms or concerns are likely to be less effective. One way to create culturally sensitive DHIs is through cultural adaptations. Yet, there is currently little evidence-based guidance on when and how to adapt DHIs.

We aimed to capture the experiences of experts to understand the (1) current practices, (2) challenges, and (3) recommendations around culturally adapting DHIs.

We conducted semistructured interviews (n=15) via Zoom (Zoom Video Communications, Inc) between May and August 2023, with academic experts who have previously undertaken cultural adaptations of DHIs. Experts were identified through publications and snowball sampling. We used a thematic analytical approach, beginning with a preliminary deductive codebook and then following a three-stage analysis. All transcripts were coded with the MAXQDA (VERBI Software GmbH) software. Codes were reviewed, and similar or related codes were categorized into broader themes, consolidating one or multiple codes into a single topic.

Our analysis produced 30 codes, which were categorized into (1) defining culture, (2) justifying the adaptation, (3) choosing the adaptation elements, (4) implementing the adaptation, (5) understanding the challenges, and (6) recommendations. Based on their experiences, experts recommended that (1) the adaptation team is multiprofessional, digitally competent, and culturally sensitive; (2) DHI users and (3) all other relevant stakeholders are continuously involved; and (4) the adaptations incorporate evaluations and knowledge exchange. They further emphasized that culturally adapted DHIs must be understandable, relatable, appealing, and easy to adhere to, ensuring that health technology and content reflect the target population's lived experiences, sociodemographic characteristics, and digital literacy. When asked which elements of cultural DHI adaptations, the most common responses were language, lived experience, and technology. Responses revealed five common DHI-relevant challenges, including (1) technology, (2) uncertainty, (3) user involvement, (4) communication, and (5) evaluation and sustainability.

The cultural adaptation of DHIs was described as an iterative, often unstructured, and resource-intensive process that requires careful justification and a solid understanding of the culture and the specific cultural group for which it is implemented. Our interviews confirmed the absence of technology-specific frameworks to guide the cultural adaptations of DHIs. Based on our findings, such a framework should guide the choice of the correct definition of culture and the criteria for assessing the need to adapt. It should also offer tools to drive stakeholder engagement, prioritize adaptation elements, and address common challenges.