TY - JOUR

T1 - Assessing the Cultural Fit of a Digital Sleep Intervention for Refugees in Germany: Qualitative Study

AU - Blomenkamp, Maja

AU - Kiesel, Andrea

AU - Baumeister, Harald

AU - Lehr, Dirk

AU - Unterrainer, Josef

AU - Sander, Lasse B

AU - Spanhel, Kerstin

PY - 2025/4/3

Y1 - 2025/4/3

N2 - Background Digital interventions have been suggested to facilitate access to mental health care for refugees, who experience structural, linguistic, and cultural barriers to mental health care. Sleep-e, a digital sleep intervention originally developed for German teachers, has been culturally adapted for refugees in Germany mainly coming from African and Middle East countries. With the increasing number of refugees from Ukraine and the associated diversity of cultural backgrounds among refugees in Germany, it is essential to assess whether existing digital interventions are culturally appropriate for this target group as well. Objective The study aimed to investigate the perceived cultural appropriateness of Sleep-e in both its original and culturally adapted versions among refugees in Germany, hereby exploring and possibly contrasting the needs of refugees coming from Ukraine and other countries of origin. Methods Overall, 13 refugees (6 from Ukraine, 23-66 years old; and 7 from other countries, 26-41 years old) participated in the study. Each participant went through parts of the original or culturally adapted version of the digital sleep intervention, with 5 participants going through both versions. A total of 17 semistructured interviews (11 for the adapted, 6 for the nonadapted intervention version) and 9 think-aloud sessions (6 for the adapted, 3 for the nonadapted intervention version) were conducted to assess cultural appropriateness, suggestions for adaptations, and perceived relevance. Data were transcribed, categorized, and analyzed using structured qualitative content analysis. Results The findings showed key differences in the perceived appropriateness and identification between the 2 refugee groups and the 2 intervention versions. Ukrainian participants expressed positive (n=70) and negative (n=56) feedback on the adapted intervention version, which revealed identity conflicts, as the adapted intervention version was targeted at a refugee population with whom they could not fully identify (18 negative feedback quotes concerning the refugee example characters). Whereas they identified with the European context in the original version, they found the problems described less relevant to their experiences. In contrast, participating refugees from other countries found the culturally adapted version more comprehensible and culturally appropriate (55 positive and 5 negative feedback quotes). No significant usability issues were reported, but several participants highlighted the need for an individualization of the intervention content. Conclusions Neither the original nor culturally adapted version of the digital sleep intervention fully met the needs of all refugee groups, highlighting the complexity of culturally adapting digital interventions for this population. Particularly, the identity conflict of participating Ukrainian refugees regarding the refugee context suggests that adaptation should go beyond regional considerations and consider the dynamics of social identity. These findings emphasize the relevance of including co-design processes with different refugee populations to ensure broad identification and, herewith, cultural appropriateness of digital interventions. Trial Registration German Clinical Trials Register DRKS00036484; https://drks.de/search/de/trial/DRKS00036484

AB - Background Digital interventions have been suggested to facilitate access to mental health care for refugees, who experience structural, linguistic, and cultural barriers to mental health care. Sleep-e, a digital sleep intervention originally developed for German teachers, has been culturally adapted for refugees in Germany mainly coming from African and Middle East countries. With the increasing number of refugees from Ukraine and the associated diversity of cultural backgrounds among refugees in Germany, it is essential to assess whether existing digital interventions are culturally appropriate for this target group as well. Objective The study aimed to investigate the perceived cultural appropriateness of Sleep-e in both its original and culturally adapted versions among refugees in Germany, hereby exploring and possibly contrasting the needs of refugees coming from Ukraine and other countries of origin. Methods Overall, 13 refugees (6 from Ukraine, 23-66 years old; and 7 from other countries, 26-41 years old) participated in the study. Each participant went through parts of the original or culturally adapted version of the digital sleep intervention, with 5 participants going through both versions. A total of 17 semistructured interviews (11 for the adapted, 6 for the nonadapted intervention version) and 9 think-aloud sessions (6 for the adapted, 3 for the nonadapted intervention version) were conducted to assess cultural appropriateness, suggestions for adaptations, and perceived relevance. Data were transcribed, categorized, and analyzed using structured qualitative content analysis. Results The findings showed key differences in the perceived appropriateness and identification between the 2 refugee groups and the 2 intervention versions. Ukrainian participants expressed positive (n=70) and negative (n=56) feedback on the adapted intervention version, which revealed identity conflicts, as the adapted intervention version was targeted at a refugee population with whom they could not fully identify (18 negative feedback quotes concerning the refugee example characters). Whereas they identified with the European context in the original version, they found the problems described less relevant to their experiences. In contrast, participating refugees from other countries found the culturally adapted version more comprehensible and culturally appropriate (55 positive and 5 negative feedback quotes). No significant usability issues were reported, but several participants highlighted the need for an individualization of the intervention content. Conclusions Neither the original nor culturally adapted version of the digital sleep intervention fully met the needs of all refugee groups, highlighting the complexity of culturally adapting digital interventions for this population. Particularly, the identity conflict of participating Ukrainian refugees regarding the refugee context suggests that adaptation should go beyond regional considerations and consider the dynamics of social identity. These findings emphasize the relevance of including co-design processes with different refugee populations to ensure broad identification and, herewith, cultural appropriateness of digital interventions. Trial Registration German Clinical Trials Register DRKS00036484; https://drks.de/search/de/trial/DRKS00036484

KW - Ukraine

KW - eHealth

KW - sleep disturbances

KW - low-threshold treatment

KW - culturally sensitive treatment

KW - refugee

KW - digital sleep

KW - Germany

KW - digital intervention

KW - interview

KW - content analysis

KW - qualitative study

KW - mental burden

KW - mental health care

KW - electronic health

KW - digital health

KW - Psychology

U2 - 10.2196/65412

DO - 10.2196/65412

M3 - Journal articles

C2 - 40179371

VL - 9

JO - JMIR Formative Research

JF - JMIR Formative Research

SN - 2561-326X

M1 - e65412

ER -