Cultural adaptation of compensatory cognitive training for Nigerian mental health services: a participatory approach balancing fidelity and contextual fit.

Abstract

Background: Cognitive impairment substantially constrains functional recovery in psychosis, persisting despite adequate symptom control. Although Compensatory Cognitive Training (CCT) demonstrates efficacy in high-income contexts, its direct transfer to resource-constrained settings encounters multiple barriers: linguistic complexity, cultural distance, extended session requirements, and specialist workforce dependencies. This study documents a systematic cultural adaptation process through which CCT was reconfigured for Nigerian mental health services whilst preserving core therapeutic mechanisms.

Methods: A ten-day participatory workshop convened 28 multistakeholder participants (clinicians, researchers, service users, implementation scientists, designers, and language specialists) organised into four interlinked committees. The adaptation drew upon layered theoretical frameworks, including the Ecological Validity Framework, Framework for Reporting Adaptations and Modifications-Enhanced, and principles balancing fidelity against contextual responsiveness. Modified Delphi procedures (80% consensus threshold) governed decisions according to hierarchical criteria: preserve cognitive principles, enhance accessibility, ensure feasibility. Post-adaptation assessment employed a five-domain fidelity matrix examining core model preservation, content validity, structural integrity, cultural fit, and implementation feasibility. Independent stakeholder validation involved both service users (n = 10) and mental health providers (n = 13) who had not participated in the adaptation process.

Results: The adapted twelve-session Nigerian CCT manuals retained all five cognitive domains and compensatory philosophy whilst incorporating extensive modifications: linguistic simplification with strategic Nigerian Pidgin integration, contextually grounded examples reflecting Nigerian daily life, session condensation (90-120 min to 60 min), complete visual redesign, and comprehensive task-shifting supports. Fidelity assessment suggested strong preservation of essential intervention features (overall M = 4.76/5.0). Stakeholder validation yielded exceptional ratings for language clarity (M = 4.9/5.0), cultural relevance (M = 4.9/5.0), and acceptability (M = 4.8/5.0). All service users expressed willingness to participate; 92% of providers endorsed sixty-minute session deliverability. Implementation barriers appeared predominantly structural, concerning space (54%) and staffing (46%), rather than content-related.

Conclusions: Theory-informed participatory adaptation appears capable of preserving intervention fidelity whilst enhancing both cultural appropriateness and implementation feasibility. The adapted CCT-Nigeria materials demonstrate content readiness for pilot implementation, though successful scale-up will likely require health system strengthening that addresses infrastructure, workforce capacity, and resource constraints. This methodology may offer a replicable framework for complex intervention adaptation across resource-constrained settings.

Trial registration: Not applicable.