Culturally Adapted Cognitive Behaviour Therapy (CaCBT) to Improve Community Mental Health Services for Canadians of South Asian Origin: A Qualitative Study

Abstract

French

Background

South Asian (SA) Canadians are disproportionately affected by higher rates of mood and anxiety disorders. SA Canadians with depression report significant barriers to accessing mental health care and the highest proportion of unmet mental health needs. The Mental Health Commission of Canada (MHCC) advocates for culturally and linguistically relevant services for SA Canadians. Culturally adapted cognitive behavior therapy (CaCBT) has shown to be more effective than standard cognitive behavior therapy (CBT). Adapting CBT for the growing SA population in Canada will ensure equitable access to effective, culturally-appropriate mental health interventions.

Method

The study used a qualitative design to elicit stakeholder consultation via in-depth interviews. This study is reported using the criteria included in Consolidated Criteria for Reporting Qualitative Studies (COREQ). The analysis follows an ethnographic approach and was informed by the principles of emergent design.

Results

Five themes were identified from the analysis, (i) Awareness and preparation: factors that impact the individual's understanding of therapy and mental illness. (ii) Access and provision: SA Canadians’ perception of barriers, facilitators, and access to treatment. (iii) Assessment and engagement: experiences of receiving helpful treatment. (iv) Adjustments to therapy: modifications and suggestions to standard CBT. (v) Ideology and ambiguity: racism, immigration, discrimination, and other socio-political factors.

Conclusions

Mainstream mental health services need to be culturally appropriate to better serve SA Canadians experiencing depression and anxiety. Services must understand the family dynamics, cultural values and socio-political factors that impact SA Canadians to reduce attrition rates in therapy.

Keywords

depression anxiety behavioral culturally adapted CBT CBT South Asian qualitative research

Background

SA origin are the largest racialized group in Canada. The three largest racialized groups in Canada represent 16.1% of Canada's total population (SA: 2.6 million people; 7.1%; Chinese: 1.7 million; 4.7%; and Black individuals: 1.5 million; 4.3%), with each population topping 1 million.¹ In 2016, these groups represented 13.6% of Canada's total population, which indicates the rapid population growth of visible minority groups in the country.² SA Canadians are disproportionately affected by higher rates of mood and anxiety disorders compared to Caucasian Canadians.³ In addition, SAs who immigrated to Canada at the age of 17 or younger experience higher anxiety and other psychological symptoms compared to individuals from elsewhere who immigrated to Canada at the same age.^4,5 Furthermore, Canadians of SA origin are significantly impacted by the social determinants of health, including unemployment, low income, language barriers, low education, low literacy and migration stress.¹ These factors can negatively impact mental health and decrease access to care, thereby increasing mental health inequities.⁶ Compared to other ethno-cultural groups, SA Canadians with a major depression report significant barriers to accessing mental health care (33%) and the highest proportion of unmet mental health care needs (48%).⁷ SA Canadians that experience major depression are 85% less likely to seek treatment than their White counterparts.⁶ The lower use of mental health services by SA Canadians indicate inequities in accessing appropriate care for these populations.^6‐9 The MHCC recommends improving Canadian mental health care to serve diverse populations with equitable, timely access to appropriate, effective, and evidence-based treatments that meet unique sociocultural needs.^10,11 The MHCC Case for Diversity report highlights the necessity for culturally and linguistically appropriate services particularly for immigrant, refugee, ethno-cultural and racialized populations, including SA Canadians.^6,12

CBT is considered the gold standard psychotherapy¹³ for the treatment of several mental health conditions and is endorsed by international treatment guidelines including National Institute for Health and Care Excellence (NICE) and American Psychological Association (APA).^14,15 The effectiveness of CaCBT has been tested in a Randomized Controlled Trial (RCT) targeting 50 Chinese American adults experiencing major depression.¹⁶ Completion of twelve sessions demonstrated a more significant decrease in depressive symptoms among CaCBT groups compared to standard CBT. Additionally, the dropout rate was lower when patients were receiving the culturally adapted CBT intervention in comparison to standard CBT.¹⁶

Adaptation of therapy in many cultural setting is not a new phenomenon, as Interpersonal Psychotherapy (IPT) has been used with efficacy and effectiveness¹⁷ with many adaptations of IPT in various cultural settings.¹⁷ CBT in its available format does not always meet the needs of non-Western groups due to pre-existing differences in cultural values.^18‐20 To address these issues, CBT needs to be culturally adapted for individuals who are from different ethnic backgrounds and needs to be established as an operational, evidence-based intervention.^21‐25 CaCBT has shown to be more effective and has shown a reduction drop-out rates when compared with standard CBT.^16,26 CaCBT is crucial to increase access to mental healthcare and improve outcomes for immigrant, refugee, ethno-cultural, and racialized populations.^27‐29 Adapting CBT for the growing SA population in Canada will ensure equitable access to effective, culturally-appropriate mental health interventions.

The purpose of this study was to create a CaCBT manual for the SA Canadian population living with anxiety and depression. To culturally adapt CBT, and explore participants’ understanding of mental health, their experiences with mental illness, access to mental healthcare, and to elicit the recommendations to improve treatment for this group.

Method

This qualitative study is reported using the criteria included in Consolidated Criteria for Reporting Qualitative Studies (COREQ), a 32-item checklist reporting guidance for qualitative research.³⁰ COREQ checklist was used to report important aspects of the research team, study methods, context of the study, findings, analysis and interpretations.³⁰ The analysis was undertaken using an ethnographic approach³¹ and informed by the principles of emergent design.³² The emergent design denotes the ability to acclimatize new ideas, conceptions, or results that ascend through conducting the research. The emergent approach is embedded within every stage from conception to publication.³² This method allowed for any unanticipated information to be generated, therefore contributing to the richness of the data.

The aim of the study was to engage various stakeholders, living in the Greater Toronto Area (GTA) (municipalities of Halton, Peel, York, Toronto and Durham), Vancouver and Ottawa to inform the development of CaCBT guidelines for depression and anxiety, building on our research teams previously developed qualitative methodology.^33‐36

Ethics

This study was approved by the Centre for Addiction and Mental Health's (CAMH) REB (#071/2019). All participants provided written informed consent to participate in the study.

Data Collection

Semi-structured, in-depth interviews were conducted and the interviewees were encouraged to talk freely about specific pre-determined topics.^37,38 This approach allowed the interviewers to pursue in-depth information on the topics of interest by asking or probing with follow-up questions to gain greater understanding of the cultural context and treatment.^37,38

Eligible participants provided consent were then invited to participate in semi-structured interviews in the languages they were most comfortable speaking. Interviews lasted 30–60 min, they were conducted using videoconferencing software and were audio recorded. Field notes were taken during these sessions, noting non-verbal communication and behaviours to triangulate with the interview data.³⁹ NS, FS, and MM conducted semi-structured interviews using an interview guide for each target group (see in Appendix A). The three research assistants received regular supervision from the research team. Each interview recording was transcribed verbatim and checked for accuracy by the research team. A random selection of interviews was assessed by study principal investigator (FN) in the research team for transcription accuracy, themes were rechecked by NK.

Recruitment

A purposive sampling method was used to recruit individuals from four different target groups through our partnering agencies within the target local community: (a) SA individuals with depression and/or anxiety, (b) caregivers and family members of SA individuals affected by depression and anxiety (c) mental health professionals’ and (d) SA community opinion leaders. Snowball sampling was used to facilitate recruitment and individuals self-identified in the above groups.³⁷ Therefore, SA community opinion leaders could also include individuals that were professionals. Interested individuals were invited to complete an inclusion questionnaire to determine their eligibility to participate in the study. The inclusion criteria for the four groups are described below. Recruitment materials were developed in various SA languages to engage individuals whose first language was not English.

Inclusion Criteria

SA Clients

Self-identification as SA or of SA origin,

Between the ages of 18–65, and currently diagnosed/previously diagnosed as having depression and/or anxiety or show the symptoms of these disorders.

Who identified as South Asian

Ages 18–64

Had access to an electronic device

A Hospital Anxiety and Depression Scale (HADS) score of 8 or higher

Caregivers and Family Members of SA Individuals Affected by Anxiety and Depression

Parents / relatives / guardians of a SA individual who had been diagnosed with depression and/or anxiety or had shown the symptoms of these disorders.

Mental Health Professionals

Mental health workers or clinicians who have worked directly with Canadian SA client populations who had been diagnosed with depression and/or anxiety or had shown the symptoms of these disorders.

MHP participants were Registered Psychotherapists, Registered Social Workers, Counsellors and Recreation Therapists.

SA Community Opinion Leaders

Self-identification as SA or of SA origin and are involved in Canadian SA communities.

Data Analysis

NVivo 12 software⁴⁰ was used to analyze the data. Identifying information was removed from the transcripts and was analyzed for systematic content and themes.⁴¹ The analysis was undertaken with the research team who collected the data and under supervision of the FN. The data was triangulated by comparing themes from different participant groups across sites.³⁹ The analysis was approached by making notes of first impressions and thoughts. For the initial analysis process, labels were created for codes that emerged. These came directly from the text and were used as the initial coding scheme. The codes were sorted into categories based on how different codes were related, overlapped, and linked. The evolving categories were used to organize and cluster codes into meaningful groups and final themes.^31,42

Results

Forty-two participants were interviewed, which included thirteen individuals with depression and/or anxiety, nine caregivers and/or family members, ten community leaders and ten mental health professionals (MHPs). Sixteen participants were situated in Vancouver, twenty-one participants were interviewed from the Greater Toronto Area and five in Ottawa. Participant demographic data is summarized below (See Table 1).

Table 1.

Participant Demographic Information.

	Individual with Anxiety/Depression (n = 13)	Caregiver/Family Member (n = 9)	Community Leader (n = 10)	Mental Health Professional (n = 10)	TOTAL (n = 42)
	Count	Count	Count	Count	Count
MEAN AGE
Mean (SD)	36 (11.5)	42 (11.0)	35 (10.3)	39 (6.4)	38 (10.1)
GENDER
Female	11 (84.6%)	8 (88.9%)	9 (90%)	8 (80%)	36 (85.7%)
Male	2 (15.4%)	1 (11.1%)	1 (10%)	2 (20%)	6 (14.3%)
MARITAL STATUS
Single	7 (53.8%)	4 (44.4%)	4 (40%)	3 (30%)	18 (42.9%)
Married	6 (46.2%)	4 (44.4%)	6 (60%)	5 (50%)	21 (50%)
Divorced	0	1 (11.1%)	0	2 (20%)	3 (7.1%)
Born in Canada
Yes	7 (54%)	3 (33.3%)	7 (70%)	4 (40%)	21 (50%)
No	6 (46%)	6 (66.7%)	3 (30%)	6 (60%)	21 (50%)
DISABILITY^b
Chronic Illness	2 (15.4%)	2 (22.2%)	2 (20%)	1 (10%)	7 (16.7%)
Mental Illness	7 (53.8%)	1 (11.1%)	2 (20%)	1 (10%)	11 (26.2%)
Developmental Disability	1 (7.7%)	0	0	0	1 (2.4%)
Learning Disability	0	0	1 (10%)	0	1 (2.4%)
Other	1^c (7.7%)	0	0	0	1 (2.4%)
None	4 (30.8%)	6 (67.7%)	6 (60%)	8 (80%)	24 (57.1%)
^bQuestion allowed for multiple responses ^cOther disability reported: chronic anxiety and ADHD
EDUCATION
Graduated from high school	1 (7.7%)	0	0	0	1 (2.4%)
Attended college but did not complete	0	1 (11.1%)	0	0	1 (2.4%)
Completed a college diploma	3 (23.1%)	0	0	0	3 (7.1%)
Completed a Bachelor's degree	5 (38.4%)	3 (33.3%)	3 (30%)	1 (10%)	12 (28.6%)
Completed a Master's degree	3 (23.1%)	5 (55.6%)	7 (70%)	8 (80%)	23 (54.8%)
Completed a Doctoral or Professional degree	1 (7.7%)	0	0	0	1 (2.4%)
No Response	0	0	0	1 (10%)	1 (2.4%)
TOTAL HOUSEHOLD INCOME
$30,000—$39,999	2 (15.4%)	0	0	1 (10.0%)	3 (7.1%)
$40,000—$59,999	4 (30.8%)	0	1 (10.0%)	1 (10.0%)	6 (14.3%)
$60,000 or more	5 (38.5%)	7 (77.8%)	6 (60.0%)	6 (60.0%)	24 (57.1%)
Do Not Know/Prefer Not to Answer	2 (15.4%)	2 (22.2%)	3 (30.0%)	2 (20.0%)	9 (21.4%)

Using the emergent characteristic, which were an important part of the grounded theory, five themes were identified from the analysis (See Fig. 1), (i) Awareness and preparation: factors that impact the individual's understanding of therapy and mental illness. (ii) Access and provision: SA Canadians’ perception of barriers, facilitators, and access to treatment. (iii) Assessment and engagement: experiences of receiving helpful treatment. (iv) Adjustments to therapy: modifications and suggestions to standard CBT (this included both individual and community level suggestions). (v) Ideology and ambiguity: racism, immigration, discrimination, and other socio-political factors that individuals’ felt they did not have control over but predisposed to mental health issues and illness.

(i) Awareness and preparation: factors that impact the individual's perception of therapy and mental illness

Figure 1.

Five themes identified in the analysis.

Participants’ recognition and ownership of their own understanding of mental health included; experience of the signs, symptoms, causes and information about acceptable treatment options (Table 2). Our findings indicated that the family system played a major role in shaping the individual's perception of mental ill health and the understanding around what was adequate treatment. Suggesting that a collectivistic approach might be more helpful and that the SA communities required services to include a role where the importance of a family unit was necessarily included because data showed this was intrinsically linked to and seen as a resilient part of their identity.

(ii) Access and provision: SA Canadians’ perception of barriers, facilitators and access to treatment

Table 2.

Awareness and Recognition.

Theme	Sub theme	Quotation
Awareness and recognition	Awareness of mental illness: While some SAs living in Canada have a basic understanding of mental illness, such as depression and anxiety, an overall lack of understanding of mental health in SA culture was reported.	“Like you can treat a broken arm with a you know a sling and going to the doctor and getting medication, but when someone can’t get out of bed or is having an outburst because of their anxiety and fearful of something that's unknown there's no-like you can’t really give it a treatment like go to the hospital and get your arm fixed, right? So, there's-there's no understanding first of all coming from why an individual is experiencing things like this that can’t just be treated with you know going to a hospital. So, there's never been that understanding in the South Asian culture.” (Individual with anxiety/depression, GTA)
	The awareness of mental health among the SA population was influenced by their sociocultural and religious values. ‘Spiritual’ or ‘traditional’ beliefs linked to South Asian idioms of distress were commonly cited during interviews.	“So like, being paranoid, or, you know, like, we have a lot of superstitions in our culture, and so like, you know, people really like give power to like the evil eye, or that people are out to get you or they are doing magic on you or this or that.” (Caregiver, Vancouver)
	All groups reported a better understanding of the impact of mental health on their daily life.	“You know, depression, anxiety has huge effects on people's lives, especially if it's undiagnosed or untreated. It can, you know, affect your performance, it affects your ability to function at times. It can affect your relationships. Definitely affects your work, your you know, your daily life. Like for me, personally, I know that you know, having dealing with both thing, depression and anxiety like oftentimes I feel like I’m unable to like do things.” (Individual with anxiety/depression, Ottawa)

The theme ‘accessing treatment’ identified the barriers SA individuals had to face when in need of mental health services and treatment. The types of barriers that prevented access to treatment were related to immigration and settlement, financial difficulties, language and interpreters, poor level of acculturation and a lack of awareness about what mental health services could offer (see Table 3). Moreover, there were issues such as long waitlists for mental health treatments and lack of culturally competent services and/or therapists to really understand the SA trajectory and cultural context. Mental health services were further experienced as complex systems that were difficult to navigate.

Table 3.

Access and Provision.

Theme	Sub theme	Quotation
	Lack of culturally competent services and/or therapists:A lack of culturally competent therapists and services in Canada further impedes access to therapy for the SA Canadian population. Study participants reported that people feel disconnected when they see a therapist they perceive as outside their own culture, because they have no idea whether the therapist would be culturally sensitive or appropriately trained to understand them, despite the therapists’ background.	“…I don’t think people would understand how hard it was for that individual to seek out help and not having the support at home because it's not a physical illness, its mental health. And I don’t think the therapist would understand how hard it is, that added layer of simply just being East Indian. I just don’t think they fully would grasp how hard it would be for a particularly a woman who may be also a victim of abuse and you just can’t just leave - I don’t think they would understand that. Like this is- this is your future, and “oh my god, he's, we better not tell anybody,” kinda thing, I don’t think they understand any of that. I don’t know if-if a therapist would fully grasp the magnitude of the pressure that's on this poor individual that's seeking out support and being Indian.”(Community leader, Ottawa)“I saw a man and he was a, you know, a white heterosexual male who has absolutely no idea what goes on in Indian family, and like talking to him absolutely it was ridiculous, like, made me even more stressful, because I'm like, he has no idea what the hell I'm talking about, he will never understand what I'm talking about.” (Individual with depression/anxiety, Vancouver)
	Waitlists:Free services were unavailable, due to the long waitlist.	“You’re on a waitlist for psychiatrist for very, very long period of time before you can actually get the treatment for free and even if you are getting that treatment you’ve now gotten to a point when you’re in an extreme situation because your symptoms and your diagnosis and your illnesses probably progress so much more…….because you waited for so long to get that treatment that you needed.” (Community leader, GTA)
	Findings also suggested that when SA individuals seek therapy, they often drop out due to the perpetuating stigma associated with mental health.	“In South Asian culture, often seeking treatment doesn’t happen, because the taboo and the stigma around it so often people are left suffering in silence, and, and not getting the help that they need.” (Individual with depression/anxiety, Vancouver)
	Stigma:Participants reported that there is still a stigma associated with mental illness influencing their ability to seek treatment.	“How can I express my feelings when they’re so shameful or they’re so embarrassing? What if I get attacked for them?” (Caregiver, GTA)
	Stigma was rooted in the cultural implications of exhibiting certain emotions such as anger, fear and sadness in a socially appropriate manner.	“And because of that, oftentimes, many people don't go and seek help. And myself included, for a very long time didn't go and seek any assistance from therapy or counseling, even knowing that there were stuff out there, knowing that we had school counselors never went because I was scared that ‘oh my God, what if my parents find out?….. or, you know, and then it's like, that fear of being judged and that fear of being like, ‘why do you need therapy? And ‘why are you stressed, you have everything you need, why would you need to go to a therapist?”(Individual with anxiety/depression, Vancouver)
	Participants, were afraid of being judged and ridiculed in society if they went to therapy.	“I think there would be an even greater stigma on men……so, going to a therapist would mean that they don’t have control or they don’t know what they’re doing and they need additional help. So they aren’t…… doing a good job as man of the house and then again like somebody else telling them what to do or how to do something better would be a major issue for them too.” (Caregiver, Vancouver)
	Virtual care reduced the impact of stigma	“But I think due to the stigma and just people feeling uncomfortable accessing services on site, I wasn't getting a lot of clients, but then when I start offering on the phone or video, more people start contacting just because there was, I guess, less embarrassment around getting mental health support.” (Mental health Professional, GTA)
Access and provision	Family:Family plays a significant role in decision making and whether individuals will access therapy	“The other thing with South Asian households is like sometimes there's a lot of people living in the same house…… if somebody manages to go to therapy or thinks that he should go they might not get the support that they need from everyone in the house. So in that case. I don’t know if like family involvement might hinder it “(Mental health professional, GTA)

Financial resources:

SA Canadians could not afford therapy as it was not covered under their medical health care plan. In cases where extended insurance was provided for therapy sessions, many noted that it was not sufficient to address their needs due to limited number of sessions offered. Findings indicate secrecy and denial existed of mental illness, to protect against stigma.

“It's expensive that's for sure [laughs] it's very expensive and unfortunately a lot of the South Asian population–for those who are coming to Canada especially they work in the labor- labor department you know like they– some of the work that they do it's not a well-paid job so, if you’re charging- if you’re going to see a psychologist for CBT for your depression they’re probably going to charge you like a hundred dollars an hour or something right. So that can probably deter you from wanting to go seek treatment because it's so expensive. And unfortunately, some of the registered psychotherapy is expensive when you go through like a private, when you try to seek it out privately. So it is expensive. Quite expensive actually” (Mental health professional, GTA)

Language:

Many participants found it difficult to express their needs in English. As noted by many participants, cultural nuances are lost in translation, and this made it difficult for many individuals to fully explain their mental health difficulties.

“We have huge number of population here, here with us who don’t speak or read or write English language in South Asian community specially the parents those who are here. So I’ll appreciate if we can get something in Urdu, Hindi, Punjabi, the, the worksheets or anything, information, pamphlets, anything. I’ll really appreciate because most of my clients they, they – when we do CBT we cannot bring it, bring in CBT worksheets at all because of the language barrier. So I do provide therapy them in Urdu language and Hindi language, in Punjabi as well, so it's all oral, and the homework, they cannot write anything because of the language barrier. But I give them still, you know, the, that open, and that, “okay, you can write on the plain paper what you’re thinking.” But still it is something in the language, oh wow, that will help our clients a lot. So this is another huge barrier.” (Mental health professional, GTA)

Need for a translator:

“People who are coming here English is not their first language, are not able to communicate with therapist unless the therapist speak their language. If they do communicate with the therapist they have to have a translator there. And if the translator's there they might not feel comfortable sharing their most personal intimate details with a third person who – some, in most cases when a grandparent goes to a doctor they’re taking their grandchild with them or their kid with them, right? So they might not wanna share all those details if they have problems with their own family members, they’re not go and say that to a translator or their child who then tells the therapist what the problem is. You don’t know – so many messages are lost in translation that way.” (Community leader, GTA)

(iii) Assessment and engagement: experience of receiving helpful treatment

Psychotherapists reported they applied therapies based on clients’ needs. All the interviewed therapists identified ‘active listening’ as a primary component while treating clients. The process involved open-ended questions, identifying clients’ negative thoughts and the changes clients want to see in their life, followed by goal setting, and finally, engaging the client in the care plan during therapy (see Table 4).

(iv) Adjustments to therapy: modifications to standard CBT

Table 4.

Assessment and Engagement.

Theme	Sub theme	Quotation
Assessment and engagement	Steps in psychotherapy:Most of the psychotherapists highlighted applying a holistic approach, such as breathing and muscle relaxation exercises, mindfulness-based practices, healthy eating, psychoeducation, stress management, solution-focused techniques, harm reduction strategies, behavioral activation techniques, and trauma informed therapies.	“Starting with active listening and encouraging [them] more, so applying talk therapy, helping them processing the pain, open-ended questions, then depending where they are stuck, elaborate on that issue, so there I apply trauma therapy techniques, then it reaches into stress-management, by the end of every session I suggest them or teach them about deep breathing exercises, mindfulness-based practices, some kind of physical exercises, it could be simple yoga or simple walk anything whatever they are able to do.” (Mental Health Professional, Vancouver)
	Five out of ten mental health professionals reported “journaling” an important tool for tracking thought records which helps patients with depression and anxiety to act on their thoughts.	“Then I bring in journaling. So once they start journaling, they can see that, ok, their behaviour diaries, emotional diaries, and so, so cognitive diaries. And then they will – I will bring them in later on, after journaling to the, the cognitive restructuring or bal-balancing thoughts.” (Mental Health Professional, GTA)
	Patient-therapist relationship:Therapists from Western cultures who lacked an understanding of SA cultures, values and norms, were thought to lack understanding of SA clients. However, we acknowledge that South Asian therapists can also misunderstand South Asian cultures. There are many SA cultures and belief systems and SA therapists may make erroneous assumptions about individual's values. Also, training in a model of Western psychology, could influence SA therapists work.	So, I can say from someone who has accessed help, before I knew of any South Asian organizations that exist today, a barrier for me was yes I could speak the language, but my therapist who was white did not understand my culture. So, there was a […] block in my treatment always. In that form of understanding which is deeply rooted in my culture for me. Even though I’m born here, I’m very connected to my culture. So that […] I think my mental health really suffered in the begging when I first started to access services for my mental health because I wasn’t connecting to someone that was giving me a […] wholesome approach of you know, understanding me, who I am as a human being as a South Asian woman, my culture. (Individual with anxiety/depression, GTA) However, […] even a South Asian individual that seeks South Asian therapists may find that as a barrier because we’re taught within our community that you don’t speak about these things within your community, so you know that's a barrier as well. Going with [laughs], with the therapist from the same community because there's so much shame linked to depression and anxiety because it's […] there's such a stigma within our community having you know open dialogue about it. (Individual with anxiety/depression, GTA)
	Factors that impaired engagement):According to the mental health professionals, there is a misalignment between expectations of therapy and what therapy actually offers in the SA community.	“I feel […] they’re coming in for an answer, or a solution. Many times I’ve read, I’ve seen clients “ok, are you gonna help me get out of this? What should I do?” So I think they don’t have a complete understanding of psychotherapy for sure.” (Mental Health Professional, Vancouver)
	Mental Health professionals from a different culture who did not understand the SA culture contributed to disengagement from treatment.	“I was helping some person, a lady, who was undergoing therapy, with a Western therapist. And she had, she had been abused in her childhood, and the therapist was trying to get her to say that it was her parents fault and they failed to protect her…. this woman, being from Southeast Asian culture, stopped going to therapy because there is no way she is going to blame her parents…..there is no way we are going to blame our parents in any way. And we might not even seek help if that is what it involves, right?” (Community leader, GTA)
	Some participants identified a resistance to therapy:Mental health and recovery was seen to be interlinked with religion and belief in god.Therefore ill health, was part of a ‘test’ and if you belief was strong then it would result in recovery otherwise it was karma.	“Oh, well I think in our culture, people defer to religion for everything, just pray and it will go away, just praying you will feel better. If you just believe in God, it will get better […].I think that sometimes if you want to pursue therapy, there is resistance against it because, you know, this is your karma and you have to work through it […] what is therapy gonna do for that, like, I think there is definitely like that kind of resistance towards it.” (Caregiver, Vancouver)
	Influences that improved engagement:Educating the community in a culturally sensitive manner and making information visible in the community was identified as a factor that would improve engagement.	“If a therapist describes how prevalent mental illness is in South Asian families like statistically or if they talk about— Like I think talking about Hindu mythological beings and like you know finding some sort of overlap between the mentally ill people or mental illness and how it's represented or displayed in like Hindu scriptures and like I, I think that sort of thing would make people feel a lot more comfortable and on board like as oppose to feeling like they’re doing something really wrong by going to the therapist.”(Caregiver, GTA)“Or like, or have a good understanding of the transgenerational trauma that's passed down and being presented, or just like the hard conversations or like the lack of boundaries cause it's, it's, it's really funny when like a counsellor tells me, “oh maybe you just need to put in boundaries with your parents” like that's really hard to do with, with South Asian parents like putting boundaries [laughs] is hard with South Asian parents, and so, having someone who understands that, I think will be the biggest, access to treatment where it could be like improved.”(Individual with depression/anxiety, Vancouver)

Participants identified adjustments that would improve the overall therapy and for culturally appropriation, to improve its acceptability and impact. These included strategies MHPs had used affectively.

What worked in therapy: Providers need to consider the collectivistic SA culture.

“I think CBT, or just any types of therapy for it to be more effective I think they need to take like a cultural, cultural perspective with it and so like, a cultural perspective acknowledging that there's like transgenerational trauma, and acknowledging that the trauma that your client has now it could be rooted from the trauma that their parents had, or, or, or what their grandparents had and that it can be passed down.” (Individual with depression/anxiety, Vancouver)

Ineffective Techniques

Participants identified techniques that were not culturally applicable for the SA community. Particularly, asking SA clients to go against their cultural beliefs and values for favorable results in therapy.

“it's really funny when like a counsellor tells me, “oh maybe you just need to put in boundaries with your parents” like that's really hard to do with, with South Asian parents like putting boundaries [laughs] is hard with South Asian parents” (Individual with depression/anxiety, Vancouver)

“Like for a Southeast Asian woman, if you tell her, just like go party, enjoy yourself, go to a bar […] Or if you tell a Southeast man that from today you are going to cook, clean, do everything that your wife does, and that’ll make you happy, it's not going to happen. So, you cannot modify the behaviour just because of their culture. Cognitive-behavioural therapy depends on modifying the behaviour of a person and if it is not culturally appropriate it will just not work.” (Community leader, GTA)

(v) Ideology and ambiguity: racism, immigration, discrimination and other socio-political factors that individuals’ felt they did not have control over but made them susceptible to mental health issues and illness.

Study participants cited socio-political factors that are beyond one's control but nevertheless have a substantial impact on an individual's identity, their role in society and their mental health (Table 5).

Table 5.

Ideology and Ambiguity.

Theme	Sub theme	Quotation
Ideology and ambiguity	Awareness and reflection:Findings suggested that it was important for therapists to understand their own inherent biases and consider factors that are beyond a patient's control, that are impacting their mental health.	“There's that whole race issue as well that we have to look at. And it has become very prominent in our in, in the Western society right now, […] we have to keep in mind that there is, inherently, there is bias. And there's bias in therapies and there's bias in systems, and there's bias in people who control these systems [sigh]. They’re not aware of it or even if they’re, there’re in denial of these, these biases that are, that are so wrapped within these systems. And these biases will definitely impact the way therapies are delivered to people who are marginalized, and people who’re disadvantaged, people who belong to equity seeking groups.” (Caregiver, GTA)
	Poverty, cultural barriers and access to health services;Play a significant role in exacerbating the symptoms associated with depression and anxiety.	“My parents faced extreme poverty because their education from back home was not recognized in-in Canada, so they had to resort to jobs that were below their education status, things that they never thought they would ever do, but they had to, to provide for you know their household. Just the whole continuum of health of you know, not having access, living in a low income neighborhood, so not having access to services- health services, not having access to good food, so being in you know- again low income neighborhoods, they don’t have a lot of you know fresh food markets, so you rely on fast food, because it's cheap. And then you know just-just more and more cultural barriers, and then when you have children in-in-in a country that's not-that's not you know from-from your cultural background then you further start to have differences with your children around cultural differences and wanting to keep that sol-sense of identity, which then leads to I think you know the children really feeling the effects of their parents mental health, which-which they’re-they’re facing. So, it's like a- it's like a ripple effect I feel like from the parents to the children because of the-the lack of yeah just-just resources and-and a path to settlement being more easier in this country for them.” (Individual with anxiety/depression, GTA)
	Beyond therapeutic interventions:Participants alluded to an improvement in socio-political factors in the community would have a significant impact on individuals’ mental health.	“No racism and better social systems, and things like that, but I do think that's kind of the most effective way to drive like actual positive mental health. Like universal basic income and things like that, I think those support mental wellbeing a lot more than like CBT in the five sessions that your insurance covers.” (Caregiver, GTA)

Discussion

To our knowledge this is the first study to qualitatively explore stakeholder attitudes and beliefs to inform cultural adaptation of CBT to the needs of the Canadian SA population. Our aim was to ultimately enhance the acceptability of CBT to the Canadian SA population to improve engagement and reduce health inequality. The present study was the first phase of a three-stage mixed methods trial of culturally adapted CBT. The qualitative research reported in this article is the analysis from phase one of a three-phased mixed-methods trial. The trial was the first mixed method study to investigate the need for a CaCBT intervention for the Canadian SA population to increase the value of CBT intervention in that group.

The analysis of the forty-two interviews indicated that participants reported a lack of understanding from therapists because CBT did not include SA cultural values and norms, leading to implications that such clients could not access or engage with these treatments. For instance, Li et al., demonstrated that culturally adapted CBT for patients who were living with psychosis led to an increase in efficiency, accessibility, and acceptability of the therapy.³³ Forty-five semi structured interviews revealed the need for awareness of patients’ cultural and spiritual values, adaptation of language instead of simply translating verbatim, and adjustments in therapy, specifically, involvement of family in treatment approaches.³³ Anik et al., analyzed culturally adapted psychotherapies for depressed adults, looking at data on the process of adaptations using thematic analysis and treatment efficacy was assessed through meta-analysis of Randomized Controlled Trials. This study showed that culturally adapted psychotherapies were confirmed to be more efficacious than control treatments.⁴³

There is still a gap existing in services to incorporate SA cultural values and norms into CBT therapies. Yet, our results point to the fact that if therapy is to be useful for these communities and for it to impact client outcomes positively, there is a dire need to include them in such interventions. This was an important finding that suggests that there is a need for CaCBT and is a key reason for why such interventions may likely have not worked in the past and prevented many SA clients from accessing treatments or help. While this is the first study that specifically focuses on the SA Canadian population, similar research shows that culturally adapting CBT to treat mental health conditions yields positive results in treating mental health conditions and improving retention to therapy for minority groups.^16,19,44,45

Compared to a previous study which described the process of adaptation and the areas that need to be focused on to adapt CBT to a given culture, we found that racism, immigration, discrimination and other socio-political factors weighed heavily on the SA groups, causing direct and ‘consequential distress’ that individuals’ narrated as linked to having decreased control to change for positive outcomes.⁴⁶

SA communities often rely on friends and family suggestions for what treatments are acceptable or useful. If there is a precedent set for an acceptable intervention within a community or family circle, then this acceptance/recommendation will be shared in the group. Participants suggested that educating family members and the general SA community to ‘brand’ the intervention ‘allowable,’ and for therapists and services to become familiar with the patients cultural and religious context could improve patients’ engagement in therapy. Therefore, working with a collectivist approach to include the ideas of family during engagement phase could increase the acceptability of interventions as they become familiar and can be endorsed by others in the family and community circles.

Congruent with these findings, participants were highly aware that there was a sense of incompetency in service intervention for SA groups and overall a shortage of culturally appropriate services. They reported that accessing services that were operating in languages other than which they spoke was very difficult to navigate especially when there was already complexity around navigating complex health systems when the language wasn’t a barrier. Interventions that cannot be fully understood or carried out due to a lack of understanding, in both directions (from client to therapist and vice versa) were of little use or ineffective from the start to end. Where intervention could be useful, individuals reported financial costs as a barrier to accessing a therapist. Migration and low-income were the most prevalent and dominant factors that was linked to anxiety and depression in this group. Poverty in racialized communities is a growing problem in Canada. For example, 207,380 SA Canadians in Ontario live in poverty and that is approximately 18% of the SA population of Ontario.⁴⁷ Studies also show that racialized communities, including SA communities, are more likely to fall into poverty because of systemic barriers, such as racism.⁴⁷ Consequently, findings also alluded to therapists accepting their own inherent biases and sympathetically considering such factors that were beyond a clients’ control, and which was impacting their mental health negatively. They were also acutely aware of racism and cited socio-political factors suggesting helplessness as they were experienced as ‘beyond one's control’ but still having a substantial impact on an individual's identity, their role in society and their mental health.

There are limited number of qualitative studies on CaCBT, however our findings are comparable with our previous qualitative studies conducted in different settings by our team. This research shows that CaCBT has a significant impact on improving therapeutic outcomes for Sa Canadians.^19,44,48 CaCBT has not been employed for SA Canadians formerly, our findings suggest that understanding patients’ cultural values and incorporating them in therapy is an effective treatment that can reduce dropout rates.

Limitations and Strengths

A sample size of over 40 participants in the present study allowed for a rich set of data and content to analyze. Analysis of the transcripts revealed a repetition and consensus of themes across our four target groups, achieving cross validation from the groups. There were fewer male participants than females. There were also fewer participants from the Ottawa region, though the demographics of this region explain the number of South Asian individuals compared to Vancouver and the GTA. Our study was limited to the adult population and we did not capture data from the child, adolescent and senior populations, small urban or rural populations, Quebec and the Maritime Provinces, which may have distinct cultural and linguistic influences.

Conclusions and Recommendations of Mental Health Support

This study sought to demonstrate the usefulness of culturally adapted cognitive behavioural therapy (CaCBT) for SA populations living in Canada. Based on the findings of this research, we have recorded a number of considerations for providing mental health support for SA Canadians with depression and anxiety disorders, including the necessity of adaptations to existing CBT interventions in mental health services to meet the needs of diverse communities, see recommendations of support below.

Recommendations of Support

(i) Awareness and recognition: factors that impact the individual's understanding of therapy and mental illness	More information to understand mental illness, such as depression and anxiety, Services to work with the information that mental health among the SA population will be influenced by their family, sociocultural and religious values. Take or integrate a collectivist approach that is tolerable to the SA communities, for example include the importance of the role of a family unit which was important to the individuals.
(ii) Increase access to treatment through working on factors related to immigration and settlement, financial difficulties, using appropriate language and interpreters, and increase awareness about what mental health services and interventions can offer.	Mental health treatments and services to move towards culturally competent services and/or where therapists can understand the SA trajectory and context. Mental health services are experienced as complex systems that were difficult to navigate. For example, information regarding health systems navigation and their work would likely make individuals who might never hear of use a service, even if it was free or at subsidized cost access it.
(iii) Assessment and engagement: experience of receiving helpful treatment	Therapists to use “active listening” as a mechanism for understanding the client and their context. Using open-ended questioning to identify clients’ negative thoughts. Eliciting the changes that clients want to see in their lives, To use techniques to set achievable and context relevant goals, and Engaging the client in the care plan during therapy.
(iv) Adjustments to therapy: modifications and suggestions to standard CBT	Providers to accept and work with the wider family of the individual using the service, by including the collectivistic SA culture. Techniques that are not effective; therapist being aware not to request SA clients to undertake tasks that are not realistic and place them in conflict with their cultural beliefs and values for favorable results in therapy.
(v) Ideology and ambiguity:	Services to acknowledge racism, immigration, discrimination and other socio-political factors that made clients susceptible to mental health issues and mental illness, Were experienced as not controlled or reduced with service intervention, as services took no responsibility to alleviate the distress and impact they had on mental health of SA clients Important for therapists to understand intrinsic biases and consider factors that are beyond a patient's control.

As Provinces and Territories are currently considering ways to expand access to publicly funded psychotherapies like CBT, both Ontario and Quebec have announced funding for structured psychotherapy programs, yet in both instances it is not clear how they plan to address issues of equity for immigrant, refugee, ethno-cultural or racialized (IRER) populations. This research has provided policy makers and service planners with evidence-based tools and a strong case for investment in the implementation of CaCBT for SA populations living in Canada.

Supplemental Material

sj-docx-1-cpa-10.1177_07067437231178958 - Supplemental material for Culturally Adapted Cognitive Behaviour Therapy (CaCBT) to Improve Community Mental Health Services for Canadians of South Asian Origin: A Qualitative Study

Supplemental material, sj-docx-1-cpa-10.1177_07067437231178958 for Culturally Adapted Cognitive Behaviour Therapy (CaCBT) to Improve Community Mental Health Services for Canadians of South Asian Origin: A Qualitative Study by Farooq Naeem, MBBS, MSc, FRCPsych, PhD, Nagina Khan, BHSc, PGCert, PhD, Nazia Sohani, MSc, Farhana Safa, RSW, MBBS, MPH, MScCH, Mehreen Masud, MACP, RCC, Sarah Ahmed, MSc, Gary Thandi, MSW, RSW, Baldev Mutta, SSW, Azaad Kasaam, MD FRCPC, Kamlesh Tello, MSc, Muhammad Ishrat Husain, MBBS, MD(Res.), MRCPsych, Muhammad Omair Husain, MBBS, MRCPsych, Sean A. Kidd, PhD, CPsych and Kwame McKenzie, BM, FRCPysch in The Canadian Journal of Psychiatry

Footnotes

Abbreviations

Acknowledgements

We extend our immense gratitude to the research participants who graciously shared their experiences and perspectives surrounding SA mental health through interviews. Their direct contributions have made the development of this work and this research possible. We would like to thank the Mental Health Commission of Canada, Somerset West Community Health Centre and Ottawa Newcomer Health Centre, Punjabi Community Health Services, and Moving Forward Family Services for their continual support. We would like to acknowledge Nina Flora for the organization, oversight and support during the data collection and analysis of this research. We also thank Bertina Jebanesan and Wishah Khan for their support in the organization of this research.

Author Contributions

F.N, K.M, conceptualized the research question, design and methodology. F.N, K.M, supervised the group N.S, F.S, M.M and S.A. who acquired, analyzed and interpreted the data, with support from all authors. F.N provided supervision throughout. N.K. verified the analysis and interpreted the data, drafted the manuscript, with input and critical review from all authors. All authors read and approved the final manuscript.

Data Availability

Data are available on reasonable request.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics

This study was approved by the Centre for Addiction and Mental Health's REB (#071/2019). All participants consented to participate in the study.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Health Canada.

ORCID iDs

Nagina Khan

Sean A. Kidd

Muhammad Ishrat Husain

Supplementary Material

The supplemental material for this article is available online.

References

Statistics Canada. The Canadian census: A rich portrait of the country’s religious and ethnocultural diversity. https://www150.statcan.gc.ca/n1/daily-quotidien/221026/dq221026b-eng.htm (2021).

Government of Canada. Federal Proposal to Strengthen Health Care for Canadians. (2016).

Grace

Tan

Cribbie

, et al. The mental health status of ethnocultural minorities in Ontario and their mental health care. BMC Psychiatry. 2016;16:Arte Number: 47. doi:10.1186/s12888-016-0759-z

Islam

Khanlou

Tamim

. South Asian populations in Canada: migration and mental health. BMC Psychiatry. 2014;14(1):1‐13.

Lai

DWL

Surood

. Predictors of depression in aging South Asian Canadians. J Cross Cult Gerontol. 2008;23:57‐75.

McKenzie

Milton

Smith

Ouellette-Kuntz

. Systematic review of the prevalence and incidence of intellectual disabilities: current trends and issues. Curr Dev Disord Reports. 2016;3:104‐115.

Gadalla

. Ethnicity and seeking treatment for depression: a Canadian national study. Can Ethn Stud. 2010;41:233‐245.

Chiu

Amartey

Wang

Kurdyak

. Ethnic differences in mental health status and service utilization: a population-based study in Ontario, Canada. Can J Psychiatry. 2018;63:481‐491.

Tiwari

Wang

. Ethnic differences in mental health service use among White, Chinese, South Asian and South East Asian populations living in Canada. Soc Psychiatry Psychiatr Epidemiol. 2008;43(11):866‐871.

10.

Comission de la santé mentale du Canada. Making the case for investing in mental health in Canada. Ment Heal Commison Canada. 2010:1‐27.

11.

Bartram

Chodos

. Changer les orientations, changer des vies : strategie en matiere de sante mentale pour le Canada Appel a une reflexion critique sur la mise en oeuvre. Can J Community Ment Heal. 2013;32:1‐8.

12.

Mental Health Commission of Canada. The case for diversity: Building the case to improve mental health services for immigrant, refugee, ethno-cultural and racialized populations. 1–59 (2016).

13.

David

Cristea

Hofmann

. Why cognitive behavioral therapy is the current gold standard of psychotherapy. Front Psychiatry. 2018;9.

14.

Association

. Clinical practice guideline for the treatment of depression across three age cohorts. Am Psychol Assoc. 2019.

15.

NICE. About the Quality and Outcomes Framework. Quality and Outcomes Framework (2014).

16.

Hwang

Myers

Chiu

, et al. Culturally adapted cognitive-behavioral therapy for Chinese Americans with depression: a randomized controlled trial. Psychiatr Serv. 2015;66(10):1035‐1042.

17.

Stuart

Pereira

Chung

JPY

. Transcultural adaptation of interpersonal psychotherapy in Asia. Asia Pac Psychiatry 2021;13:e12439. doi:10.1111/appy.12439

18.

Laungani

. Asian perspectives in counselling and psychotherapy. Asian Perspect Couns Psychother. 2004:1‐261. doi:10.4324/9780203697085

19.

Naeem

Phiri

Munshi

, et al. An evidence-based framework for cultural adaptation of cognitive behaviour therapy: process, methodology and foci of adaptation. World Cult Psychiatry Res Rev. 2016;112:61‐70.

20.

Scorzelli

Reinke-Scorzelli

. Cultural sensitivity and cognitive therapy in India. Couns Psychol. 1994;22:603‐610.

21.

Alavi

Hirji

Sutton

Naeem

. Online CBT is effective in overcoming cultural and language barriers in patients with depression. J Psychiatr Pract. 2016;22:2‐8.

22.

Husain

Chaudhry

Fatima

, et al. Antidepressant and group psychosocial treatment for depression: a rater blind exploratory RCT from a low income country. Behav Cogn Psychother. 2014;42(6):693‐705.

23.

McKenzie

Khenti

Vidal

. Cognitive behavioural Therapy for English speaking people of Carribean origin. (2011).

24.

Naeem

Saeed

Irfan

, et al. Brief culturally adapted CBT for psychosis (CaCBTp): a randomized controlled trial from a low income country. Schizophr Res. 2015;164(1-3):143‐148.

25.

Rathod

Phiri

Harris

, et al. Cognitive behaviour therapy for psychosis can be adapted for minority ethnic groups: a randomised controlled trial. Schizophr Res. 2013;143(2-3):319‐326.

26.

Kohn

Oden

Munoz

Robinson

Leavitt

. Brief report : Adapted cognitive behavioral group therapy for depressed low-i … Library (Lond). (2002).

27.

Hall

GCN

. Psychotherapy research with ethnic minorities: empirical, ethical, and conceptual issues. J Consult Clin Psychol. 2001;69:502‐510.

28.

Fung

. Culturally competent psychotherapy. Can J Psychiatry. 2003;48:161‐170.

29.

Rathod

Kingdon

. Case for cultural adaptation of psychological interventions for mental healthcare in low and middle income countries. Br Med J 2014;349. doi:10.1136/bmj.g7636

30.

Tong

Sainsbury

Craig

. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Heal Care. 2007;19(6):349‐357.

31.

Atkinson

Coffey

Delamont

Lofland

. Handbook of ethnography. Handb Ethnogr. 2012. doi:10.4135/9781848608337

32.

Creswell

. Qualitative, quantitative, and mixed methods approaches. Res Des. 2013:1‐26.

33.

Zhang

Luo

, et al. A qualitative study to explore views of patients’, carers’ and mental health professionals’ to inform cultural adaptation of CBT for psychosis (CBTp) in China. BMC Psychiatry. 2017;17(1).

34.

Naeem

Ayub

Kingdon

Gobbi

. Views of depressed patients in Pakistan concerning their illness, its causes, and treatments. Qual Health Res. 2012;22:1083‐1093.

35.

Naeem

Gobbi

Ayub

Kingdon

. University students’ views about compatibility of cognitive behaviour therapy (CBT) with their personal, social and religious values (a study from Pakistan). Ment Health Relig Cult. 2009;12:847‐855.

36.

El Rhermoul

Naeem

Kingdon

Hansen

Toufiq

. A qualitative study to explore views of patients, carers and mental health professionals’ views on depression in Moroccan women. Int J Cult Ment Health. 2018;11:178‐193.

37.

Gill

Stewart

Treasure

Chadwick

. Methods of data collection in qualitative research: interviews and focus groups. Br Dent J. 2008;204:291‐295.

38.

Flinders

. Interviews: an introduction to qualitative research interviewing. Eval Program Plann. 1997;20:287‐288.

39.

Carter

Bryant-Lukosius

Dicenso

Blythe

Neville

. The use of triangulation in qualitative research. Oncol Nurs Forum 2014;41:545‐547. https://doi.org/10.1188/14.ONF.545-547

40.

QSR. Nvivo11: QSR International Pty Ltd. NVivo (Version 12), (2016).

41.

Hsieh

H-F

Shannon

. Three approaches to qualitative content analysis. Qual Health Res. 2005;15:1277‐1288.

42.

Patton

. Qualitative Research and Evaluation Methods. Thousand Oaks, CA: Sage Publications; 2002).

43.

Anik

West

Cardno

Mir

. Culturally adapted psychotherapies for depressed adults: a systematic review and meta-analysis. J Affect Disord. 2021;278. doi:10.1016/j.jad.2020.09.051

44.

Naeem

Gul

Ifan

, et al. Brief culturally adapted CBT (CaCBT) for depression: a randomized controlled trial from Pakistan. J Affect Disord. 2015;177:101‐107.

45.

Algahtani

HMS

Almulhim

AlNajjar

, et al. Cultural adaptation of cognitive behavioural therapy (CBT) for patients with depression and anxiety in Saudi Arabia and Bahrain: a qualitative study exploring views of patients, carers, and mental health professionals. Cogn Behav Ther. 2019. doi:10.1017/S1754470X1900028X

46.

Naeem

Phiri

Rathod

Ayub

. Cultural adaptation of cognitive–behavioural therapy. BJPsych Adv. 2019;25:387‐395.

47.

Council of Agencies Serving South Asians, South Asian Legal Clinic of Ontario & South Asian Women’s Rights Organization. The impact of COVID-19 on South Asians in Canada. CASSA Rep. 2020:1‐3.

48.

Rathod

Gega

Degnan

, et al. The current status of culturally adapted mental health interventions: a practice-focused review of meta-analyses. Neuropsychiatr Dis Treat. 2018;14:165‐178. doi:10.2147/NDT.S138430

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.14 MB