Materials and methods

A qualitative mixed-method approach was undertaken in this study to assess the judgmental validity of the Manohari module. The judgmental validity was assessed using the modified Delphi method [20] with subject experts to achieve consensus on the module content and using focus group discussions (FGDs) [21] conducted with a group of students to explore their perceptions of and acceptability of the module.

A purposive sample of six experts was recruited to participate in the modified Delphi process for content validation, while six students were recruited for an FGD to assess the module's clarity, acceptability, and cultural relevance. As this was an initial qualitative validation study, the sample size was considered adequate for obtaining in-depth feedback; however, the relatively small sample size may limit the generalizability of the findings and should be considered when interpreting the results.

Development of Manohari modules

Manohari is a community-based MHPSS programme developed collaboratively by the Directorate of Mental Health, Ministry of Health, Sri Lanka, and the WHO. The term "Manohari," derived from Sanskrit, denotes "stealing the heart or mind" (captivating), reflecting the programme's focus on engaging and positively influencing the hearts and minds of individuals to enhance mental well-being within the community.

The programme was designed to address the root causes of psychosocial distress and conflict at the community level through ten structured modules, which were developed by a multidisciplinary resource team of experienced MHPSS professionals [22]. These modules are structured as a life skills-based developmental package, incorporating interactive and activity-based sessions that address key domains relevant to psychosocial development. These include communication skills, emotional intelligence, problem-solving, decision-making, time management, stress management, and interpersonal relationships, aiming to enhance adaptive coping and overall mental well-being.

Initially, 10 drama therapy-based training modules were developed in collaboration with the WHO, with an additional four modules later incorporated, comprising activities such as storytelling, dialogues, role-playing, and interactive discussions focused on emotional regulation, coping skills, positive behavioral change, and improving understanding and non-violent responses in stressful situations. The modules are based on Panchatantra stories, Jataka tales, or similar scripts using animals as characters. The use of animal characters provides symbolic representations of human behaviors and emotions, enabling adolescents to discuss values, relationships, and coping strategies with reduced personal defensiveness while maintaining engagement through familiar cultural narratives. The facilitator presents the story to the participants and then encourages them to act it out. The programme consists of several topics, such as understanding emotions, rage, taking responsibility for one's feelings and changing behaviors, shyness, envy, peer pressure, keeping children safe and happy, recognizing the emotions of others and responding to them, and communicating needs effectively. This module is feasible for delivery in low-resource settings and can be implemented by non-mental health professionals. The programme was piloted across multiple districts in Sri Lanka, including Mullaitivu, Kilinochchi, Mannar, Vavuniya, Monaragala, Badulla, Gampaha, Hambantota, Kalutara, Kandy, Matara, and Ratnapura, targeting frontline mental health staff, MHPSS workers, and community leaders [17].

Experts review using the modified Delphi approach

An expert review using a modified Delphi approach, derived from the original method developed by Dalkey and Helmer [20], was used to evaluate the validity of the module. This method was used to systematically gather and synthesize expert opinions in a structured manner to facilitate consensus.

Experts were selected based on the following criteria to ensure their relevance and suitability for the study. Experts were required to: (i) hold recognized professional qualifications in their respective fields (psychiatry, community medicine, public health, or educational administration); (ii) have a minimum of five years of professional experience in their respective fields in Sri Lanka; (iii) demonstrate active involvement in public health and adolescent health programmes; and (iv) have prior experience in mental health programme development.

The panel of experts included two Zonal Directors of Education (ZDEs), two Consultant Psychiatrists, and two Consultant Community Physicians.

The expert panel reviewed the Manohari module to assess face and content validity, along with overall consensus. During the initial review, each expert was contacted via email and provided with information outlining the study and its objectives, along with the Manohari module. Experts were requested to assess the clarity and relevance of the module content.

A structured evaluation form, developed based on the literature [23,24], was used for this purpose. The form consisted of eight core items applicable to all the experts, rated on a five-point Likert scale (strongly agree, agree, neutral, disagree, and strongly disagree) to assess agreement and relevance. In addition, subject-specific items were included according to the expertise of the panel members. ZDEs received six additional subject-specific items. Consultant psychiatrists and community physicians received three common subject-specific items; consultant psychiatrists were given three further subject-specific items, while Community Physicians received one additional item. ZDEs and consultant psychiatrists each received 14 evaluation items, while Community Physicians received 12 evaluation items for the judgmental validation of the module. The evaluation form also included open-ended questions to obtain qualitative feedback and suggestions for improvement.

Following the initial round, responses were compiled and summarized, and the anonymized feedback was shared with the expert panel. Experts were then encouraged to review the summary and refine their opinions through continued email communication until consensus on the module's validity was achieved. As no further rating rounds or predefined consensus criteria were applied, this study represents an expert review using a modified Delphi approach rather than a formal Delphi validation.

Ethical approval for the study was obtained from the Ethics Review Committee, Faculty of Medicine, University of Jaffna (approval no. J/ERC/24/160/NDR/0320).

Data analysis involved deriving the percentage of agreement for each item, defined as the proportion of experts selecting either "strongly agree" or "agree." Items with less than 65% agreement were subjected to further review and revision based on the experts' feedback.

Student FGDs

In addition to expert feedback, students' perspectives were obtained to assess the face and content validity of the module. Six Grade 12 students were recruited from a secondary school outside Jaffna using convenience sampling. Following approval from the school administration, eligible students were invited to participate voluntarily in the study. To ensure equal representation, participants were selected to maintain an equal male-to-female ratio (1:1). The FGD, with a duration of approximately two hours, was facilitated by the principal investigator of the study. The FGD explored students' overall impressions of the module across several key dimensions, including the clarity of language, the reliability of characters and situations, cultural appropriateness, the portrayal of mental health, understanding of life skills, usefulness for real-life situations, and the quality of illustrations. Students were encouraged to share their perspectives openly.

The qualitative data from the FGD were analyzed using thematic analysis. The discussion notes were read several times to achieve familiarity with the data. Meaningful statements related to participants' perceptions of the module were identified and coded. Similar codes were then grouped into categories, from which overarching themes were developed through an iterative review process. The identified themes represented participants' views on the strengths of the module and areas requiring improvement.

The findings from the FGDs were used to further refine the module. By combining feedback from both the expert panel and the student participants, the module was comprehensively reviewed and improved to ensure clarity, relevance, and alignment with the intended objectives of the life skills training programme.