The need for mental health services far outweighs the capacity of service providers all over the world [1]. Access to adequate-quality mental health care is also limited for many populations but is particularly limited for vulnerable groups such as the elderly and youth populations, racial and ethnic minorities, the socioeconomically disadvantaged, and rural populations [2]. Limited access to services is of particular concern for young people, as it is well established that 75% of the serious mental diseases and substance use problems emerge before 25 years of age [3]. When young people do seek and receive help, timely and evidence-based treatments are encountered by only a small proportion; in some low- and middle-income countries, the treatment gap can be as high as 90% [4].

Populations who do not speak English in English-speaking countries are less likely to receive mental health care [5]. In Latino populations with mental health problems, the lack of English proficiency is one of the biggest barriers when accessing services [6]. In Australia, non–English-speaking migrant populations struggle to access and understand the local health care system [7]. Language proficiency has been identified as a true barrier for migrant men when using services [8].

Australia is a popular study destination for students around the world. Most of Australia’s international students are enrolled in the higher education sector (44%), followed by the vocational education and training sector (27%), and English-language intensive courses for overseas students (19%) [9]. Studying abroad can be one of the most remarkable and rewarding experiences, but it can also be a source of great distress. The way migration is experienced by each individual highly depends on the push and pull factors that precipitated the migration [10]. In the case of international students, a high motivation to study in a different country can act as a protective factor, but the cultural distance of the host country, the lack of social support, and academic pressure can be powerful stressors. Consequently, several studies have shown increased rates of mental health problems in this population [10-12].

In Australia, international students have been identified to be disadvantaged compared with their peers; have weaker social support networks; have higher rates of psychological distress [13]; and are at higher risk of experiencing an adjustment disorder or other mental health problems [14]. The “International Student Welfare in Australia” report suggested that Australia does not adequately protect international students’ human rights and highlights mental health as a key area of concern [15]. Recently, awareness of these issues has been covered by Australian mass media due to 27 suicides in the international student population between 2009 and 2015; sadly, all were reportedly associated with low help-seeking behaviors (22%) [16]. As international students are less likely to receive mental health care, the previously mentioned report encourages institutions to provide information, including available services and increased research in this area. However, most of the research has been focused on tertiary education students and none or very little has been dedicated to language students.

This scenario is acquiring a significant relevance in Australia, where the Spanish-speaking (including Latino) international student migration is rapidly growing. In 2016-2017, language student visa grants (subclass 570) increased by 16.8%, where 3 Spanish-speaking countries (Colombia, Spain, and Chile) were situated in the top 10 countries of applications logged outside Australia [17].

The internet and new and emerging technologies hold enormous promise for significantly expanding the reach of adequate-quality mental health care by addressing several barriers [18]. Interventions delivered through these technologies have the potential to reach a wide geographic area via remote delivery of care [19]; decrease costs in delivering self-help and social networking interventions; and allow for relatively rapid, centralized scaling up of interventions to a public health dissemination level [20]. English-language, Web-based mental health interventions have proven to be effective for self-screening and referral [6], reducing symptoms and delivering effective treatment for major mental health disorders [21]. A large number of studies, including randomized controlled trials, have also demonstrated the effectiveness of various internet-delivered interventions, such as psychotherapy and psychoeducation [22], treating problematic health behaviors [23], and delivering prevention and treatment programs [24]. Other population-based studies have reported that Web-based tools can enhance the delivery of mental health care in primary care settings [25] and support training and supervision for providers [26]. The number of programs available is growing rapidly [27]. Although positive results are seen from the use of self-directed electronic health interventions, increased effectiveness has been reported if they are used as part of a stepped-care model [28], with the support of a trained health professional [29] or as an adjunct to face-to-face treatment [30].

Despite the growth of such technologies in high-income countries, these technologies are still lacking in low- and middle-income countries and, more specifically, in the Spanish language [31]. Traditional telemedicine has supported the cooperation between developed and developing countries to deliver care across borders by linking professionals rather than providing direct connection between professionals and patients [32]. Telepsychiatry has been used to deliver mental health care to individuals requiring attention, not only locally [33-35], but also internationally, as a means to deliver care to Spanish-speaking individuals residing in a different country [32,36,37]. This type of care is a more efficient alternative, as it doesn’t require the use of interpreters and is culturally sensitive [38]. Successful Spanish-language health information technology (HIT) interventions have been applied in several fields, such as cancer; diabetes; and child, infant, or maternal health [39]. Despite this, the HITs available for mental health are scarce. Initial reports have demonstrated their potential utility in the screening of mental health problems [40], as well as in the treatment of depression [31,41,42], anxiety [43], and substance use disorders [44].

Although the development of HITs in Spanish is recent, their usability and retainability among users is of concern [31]. Experience in other languages (mostly English) has demonstrated that participatory design research methodologies that involve stakeholders and end users in the design and development of these systems at all stages could finally increase user engagement and system usability [45-48]. A close collaboration with end users ensures the appropriateness of these systems for culturally and linguistically diverse populations [49]. Therefore, incorporating participatory design research methodologies that puts end users at the center of the design and development process is greatly needed for Spanish-language–based HITs.

The University of Sydney’s Brain and Mind Centre (Sydney, Australia) is a leader in the development of youth-specific mental health services [50,51] and evidence-based electronic health technologies to engage young people in their own care [52]. The Mental Health eClinic (MHeC) [48,53] was a prototypic Web-based tool designed and developed through a partnership between the Young and Well Cooperative Research Centre and the Brain and Mind Centre. The MHeC aimed to deliver best-practice clinical services to young people experiencing mental health problems by making clinical care accessible, affordable, and available to young people whenever and wherever they need it most. The original MHeC had 5 main elements: a home page with a visible triage system for those requiring urgent help; a comprehensive online physical and mental health self-report assessment; a detailed dashboard of results; a booking and videoconferencing system to enable video visits; and the generation of a personalized well-being plan that included links to evidence-based, young person–suggested, health professional–recommended apps and e-tools [53]. We hypothesized that having a Spanish version of the MHeC (MHeC-S) could greatly benefit young people who are native Spanish speakers living in Australia and who are actively seeking help.

Using a research and development cycle (including several participatory design phases) with end users (young people aged 16 to 30 years, supportive others [such as family, friends, caregivers, coaches, teachers, or community members], and health professionals) as a framework, in this study we aimed to (1) conduct co-design workshops with end users to co-design and culturally adapt the MHeC for Spanish-speaking young people based in Australia; (2) inform the development of the alpha prototype of the MHeC-S; (3) test the usability of the alpha prototype of the MHeC-S; (4) translate, culturally adapt, and face-validate the self-report assessment to a Spanish-speaking population based in Australia; and (5) collect information to inform the beta prototype of the MHeC-S.

Participants included community-based young people aged 16 to 30 years; native Spanish speakers living in Australia; and native Spanish-speaking young people attending headspace Camperdown and headspace Campbelltown (headspace Australia’s National Youth Mental Health Foundation provides early intervention mental health services and assistance in enhancing young peoples’ [aged 12-25 years] well-being; Camperdown and Campbelltown are 2 sociodemographic areas of Sydney, Australia). Additionally, native Spanish-speaking health professionals and supportive others participated. Participants were required to have regular access to a smartphone (with the iOS or Android operating system) and the internet.

The University of Sydney’s Human Research Ethics Committee approved the study (Protocol No. 2014/689 for the co-design workshops and Protocol No. 2016/487 for the user testing sessions). Participants were provided with the relevant information about the study (participant information statement) before providing their consent and participating in the study. We also obtained parental consent for participants under 18 years of age. Young people received gift vouchers to thank them for their time and expertise when they attended the co-design workshops and the user testing sessions.

The recruitment strategy included the identification of potential participants through headspace Camperdown and headspace Campbelltown; poster and postcard advertisements displayed in community organizations; Facebook advertisements and a study-specific Facebook page; use of organizational social media channels; universities, institutes of technical and further education, language schools, and vocational and training institutes; and cooperation with Spanish-speaking consulates in Australia.

We based the participatory design research methodology on the Young and Well Cooperative Research Centre’s guide Participatory Design of Evidence-Based Online Youth Mental Health Promotion, Intervention and Treatment [54]. The research and development cycle used our previously established phases for co-design and build of the original version of the prototypic MHeC [53]. The process encompasses several participatory design phases: co-design workshops (phase 1); knowledge translation (phase 2); language translation and cultural adaptation (phase 3); rapid prototyping of the alpha prototype and user testing (phase 4); rapid prototyping and user (acceptance) testing of the beta prototype (phase 5); and real-world trialing of the final prototype (phase 6). This paper reports the initial 4 phases; we will report phase 5 and phase 6 separately (Figure 1).

We held co-design workshops in 2 stages with a maximum of 10 participants per workshop; we ran these with young people and health professionals separately. We did not use technology in the workshops; instead, we conducted the following design activities to facilitate the process: we used design testing using mockups and end user sketching (Figure 2) to obtain information for the content, functionality, and the look and feel of the prototype.

The topics covered in each workshop included defining the advantages and disadvantages of having a Spanish version of the MHeC; defining the barriers of having an MHeC-S; assessing the 5 main elements of the MHeC; and defining the functionality and the user interface. At the end of each workshop, the knowledge translation team analyzed and synthetized the information.

The knowledge translation team independently analyzed the diagrams and notes taken from the previous phase (or workshop), then compared and discussed observations until they reached an agreement. They then synthesized the information by creating wireframes that would be used in the subsequent phase.

Phase 4 involved user testing with end users: young people, health professionals, and supportive others. Sessions used laptops, tablets, and smartphones (with the iOS or Android operating system), where participants had access to the alpha prototype of the MHeC-S. In each 90-minute one-on-one user testing session, a researcher was paired with an end user. Using a think-aloud protocol [56], participants were observed as they navigated the prototype and responses were recorded to questions posed by the researcher about the main elements of the MHeC-S. A total of 4 usability tasks were completed in the session: (1) create an account and log in, (2) find the Need Help Now button, (3) explore the dashboard of results, and (4) book an appointment. Task completion (yes/no) and task difficulty were measured using the Single Ease Question (SEQ; responses ranged from “very difficult” to “very easy,” rated from 1 to 7) [57]. User testing also explored the prototype’s utility and the users’ inclination to use the MHeC-S, overall comments, and naming of the prototype. Interviews and observations were transcribed. No instructions or clues were provided, and all responses and observations (eg, nonverbal cues) were transcribed.

We simultaneously collected and analyzed data at the end of each phase in order to facilitate the process. Hence, we explored preliminary findings in the following phase. We determined interrater reliability and analyzed task difficulty using IBM SPSS Statistics for Mac 22.0 (IBM Corporation). We uploaded and analyzed source documents (workshop discussion notes, artifacts [mockups and end user sketches] and user testing notes) using thematic analysis techniques [58] in NVivo 11 for Mac (QSR International) [59]. The thematic analysis framework involved both inductive and deductive coding. Acknowledging that one of the biggest challenges in this project was the translation and cultural adaptation of the MHeC-S, in the deductive code framework we considered the adaptation of the prototype in 4 dimensions: technology platform, functionality, content, and user interface. As defined by Valdez et al in their culturally informed design framework [60], “technology platform” refers to the different types of hardware, “functionality” indicates the actions that can be performed, “content” refers to the message that is transmitted, and “user interface (design)” refers to the visual presentation of the content and functionality. We also enriched this type of coding with our previously established [53] codes (general elements of the MHeC; general look and feel; privacy and data sharing; and interaction of the MHeC with social networks).

Data collection and qualitative analysis were done in Spanish. To facilitate reporting, we provide quotes translated from the original data. Multimedia Appendix 1 shows the original quotes in Spanish.

One researcher coded all the material (coder A: LOP) and a second coder (coder B: not involved in the publication of this paper) reviewed half of the collected documents in order to assess the reliability, assess consistency, and reduce potential bias [61]. We calculated interrater agreement for each theme using the Cohen kappa statistic on a binomial distribution (category present vs category not present) for each of the themes [62] and interpreted the obtained values using Viera and Garrett’s criteria: kappa range .01 to .20 indicates slight agreement, kappa range .21 to .40 indicates fair agreement, kappa range .41 to .60 indicates moderate agreement, kappa range .61 to .80 indicates substantial agreement, and kappa range .81 to .99 indicates almost perfect agreement [63].

In May 2015, we conducted 1 full-day co-design workshop with Spanish-speaking young people based in Australia and 1 full-day co-design workshop with Spanish-speaking health professionals based in Australia. In total, we conducted 3 knowledge translation sessions immediately after each workshop and at the end of the usability testing. The general-content translation process started in June 2015, and the self-report assessment literature review and translation process started in January 2016 and lasted until the end of the same year. We conducted 15 one-on-one user testing sessions between March and November 2017.

A total of 10 young people participated in the co-design workshops; 8 were female and their ages ranged from 17 to 29 years (median age 24 years). Of the young participants, 8 were Colombian and 2 were Chilean. A total of 7 health professionals participated in the workshops; 6 were female and their ages ranged from 22 to 34 years (median age 28 years). Of the health professionals, 3 were from Colombia, 2 were from Chile, and 2 were from Spain.

A total of 15 participants participated in the one-on-one user testing sessions: 7 young people with ages ranging from 19 to 30 years (median age 26 years); 5 health professionals with ages ranging from 27 to 74 years (median age 35 years); and 3 supportive others with ages ranging from 30 to 57 years (median age 30 years). Of these participants, 10 were female and 12 were Colombian, while the rest were from Argentina, Spain, and Venezuela.

We collected and analyzed a total of 225 source documents (2 workshop discussion notes and 208 artifacts produced by participants were collected in the co-design workshops plus 15 user testing notes) during the entire process.

Our study used a comprehensive research and development approach to co-design and culturally adapt a prototypic Web-based mental health clinic (MHeC) for Spanish-speaking young people based in Australia (MHeC-S). Thematic analysis resulted in adequate acceptability of the 5 main elements of the alpha prototype (a home page and triage system; a comprehensive online physical and mental health self-report assessment; a dashboard of results and progress report; a booking and videoconferencing system to enable video visits; and the generation of a personalized well-being plan that includes links to evidence-based, young person–suggested, health professional–recommended apps and e-tools). The data also revealed gaps in the alpha prototype, such as the need for tailored assessment tools and a greater integration with Spanish-speaking services and communities; a lack of Spanish-language apps and e-tools, and of online mental health information was noted. As a consequence, the development of new features included the addition of cultural adjustment items in the online self-report assessment, creation of specific algorithms, and development of several videos and factsheets (Multimedia Appendix 2). In the future, the beta prototype should additionally include refinements of language; explanations of specific medical terminology; and minor changes in layout and navigation.

Migrants and newly arrived residents have been identified as populations who are difficult to recruit, and then to involve and maintain in research [113], yet this is a population in critical need of support. The research and development cycle that we employed in this study is an optimal methodology to engage, retain, and work more efficiently with hard-to-reach populations. We selected various participatory design methodologies to enhance the generation of new ideas and improve the feedback process. The nature of the research and development cycle and the use of diverse methodologies enabled the research to be conducted and completed in a time-efficient manner.

Previous research has highlighted the need to tailor HIT interventions beyond content and language, by including culture [39]. One of the strengths of this study was the incorporation of the cultural framework as a cornerstone of the research and development cycle. As a consequence, we obtained information about the participants’ cultural preferences for the prototype’s interface and functionality, as well as the development of culturally appropriate content and features. Performing data collection and analysis in the original language reduced the risk of losing relevant information (or meaning), and decreased research time and costs [114]. Other advantages of this study were the variety of origin of participants (Argentina, Chile, Colombia, Spain, and Venezuela) and the research team (Australia, Chile, Colombia, and Venezuela). Furthermore, this research united all relevant stakeholders (young people, supportive others, and health professionals) in a common goal of adapting this prototype to a population in need.

Although Spanish is the second most common language spoken worldwide and HIT is a growing field, Spanish-speaking populations (including migrants and those residing in low- and middle-income countries) are at risk of experiencing not only physical but also technological social health inequalities [115]. This body of research aims to breach this gap by creating a widely available MHeC-S that works across devices. The participation of end users in the design process ensured that the prototype was accessible to individuals of varying literacy levels with a range of cultural differences. Furthermore, the MHeC-S has the potential to be configured and adapted for use in Spanish-speaking countries and in other multicultural countries with Spanish-speaking migrant populations.

International education in Australia has grown dramatically and is its third largest export industry, contributing Aus $32.4 billion to the Australian economy [116]. It highlights a significant bilateral exchange (Aus $755 million in 2012) between Latin America and Australia, which is increasingly recognized as an important destination for the English education of Latin Americans [117]. In 2017, the Latin American Spanish-speaking international student population had reportedly increased to more than 21,000 [17]. Our study highlighted a critical concern in the community in relation to a shortage of mental health services targeting the well-being of these students. This is vital, as these students are at higher risk of developing adaptational problems and being socially and linguistically isolated [118]. Participants generally expressed a lack of understanding of the Australian health system, particularly service providers and insurance agencies, resulting in an important barrier for students’ help-seeking process. Even for those who do know how to navigate the health system, a reduced English competence could impair the care they do obtain. Protecting, caring for, and enhancing positive experiences for international students is Australia’s best strategy to protect and grow this industry.

New and emerging technologies present a solution, as they have changed the way young people communicate, connect, and engage with each other and with society. With the introduction of smartphones, information, services, and resources provided online or via mobile apps can be accessed privately and at any time. This can be empowering for individuals who are marginalized or geographically or socially isolated. It could also help to address the need for Spanish-speaking mental health professionals and interpreters. Having an MHeC-S could greatly benefit young people who are native Spanish speakers living in Australia and who are actively seeking help. This study is the first step toward providing a technology-enabled solution to improve this population’s mental health and well-being in Australia. To the best of our knowledge, there has been no research to date in this field.

Further research is needed to understand the psychometric properties of the online self-report assessment (eg, criterion validity) and the integration of the MHeC-S with other apps or e-tools. Importantly, additional steps are needed to evaluate the engagement, efficacy, and effectiveness of the MHeC-S in real-world settings. The MHeC-S shares the same elements and functionality of the original version of the MHeC. Its main difference relies on interaction with face-to-face services. The original MHeC was designed to work with primary care mental health services; however, in the case of the MHeC-S, in Australia it could be used additionally by language schools and Overseas Student Health Cover providers. To the best of our knowledge, this study is the first to explore mental health care barriers and facilitators, and potential technology solutions in a language student population; additional research is needed to expand the knowledge on this topic.