Table 4 Stage 1 recommendations to improve the cultural appropriateness of the CGI

Language

- The CGI manual, research materials, and outcome measures were translated into Arabic.

- An option for low literacy participants to complete outcome measures verbally (data collection staff and group facilitator read the items) was implemented.

- Names, idioms, and other language was deemed appropriate.

- Group facilitators were Iraqi nationals that spoke Arabic.

Persons

- Group facilitators were selected by the MSF-OCA team – one male, one female.

- It was determined that a female group would be appropriate, partly based on cultural norms (as females would be shy and embarrassed to sit with males) and partly based on the availability of female caregivers during working hours when the group was able to run.

- In the context of Al-Abbasi participant age, parental status, ethnicity, race and religion were not deemed to need special consideration.

- On collecting socio-demographic information from participants the category ‘Muslim’, rather than ‘Sunni’ or ‘Shia’ was used under religion. This was deemed more appropriate given that MSF is an international organisation collecting data which could potentially raise suspicion.

Metaphors

- The metaphor of ‘refill your cup’ was used instead of ‘recharge your battery’, as recharge your battery has sexual innuendo in the area. New text and illustration were produced to support this metaphor.

- Clothing (including headscarves for all adult women), objects and hairstyles in the illustrations were deemed appropriate.

Content

- No changes required.

Concepts

- No changes required. The explanatory theory of illness in the model, which emphasises environmental, biological, and psychological factors was deemed appropriate.

Goals

- No changes required.

Methods

- No changes required.

Context

- No changes required.