Results

Overall expert agreement on the content of the Manohari module

For the purpose of content validation, experts were defined as professionals with specialized knowledge and practical experience relevant to the module content, comprising two consultant community physicians, two consultant psychiatrists, and two ZDEs.

The overall agreement regarding the module content is presented in Table 1. The findings indicate a generally positive evaluation by the expert panel, with most responses falling within the "agree" and "strongly agree" categories, as five out of eight core items achieved an overall agreement above 65%.

No. | Assessment items (statements) | Agreement - n (%)
1 | The topics covered are relevant to the adolescent population. (Statement_1) | 4 (66.67)
2 | The module aligns with the current understanding of adolescent mental health in Sri Lanka. (Statement_2) | 4 (66.67)
3 | The learning activities are practical and easily understandable for non-health professionals delivering the module. (Statement_3) | 4 (66.67)
4 | The module adequately covers key life skills needed for mental health promotion. (Statement_4) | 5 (83.33)
5 | The examples, scenarios, and language used are culturally sensitive and appropriate for Sri Lankan adolescents. (Statement_5) | 3 (50)
6 | The module considers the diverse cultural, religious, and socioeconomic backgrounds of adolescents in Sri Lanka. (Statement_6) | 4 (66.67)
7 | The activities and exercises are engaging and developmentally appropriate. (Statement_7) | 3 (50)
8 | The module addresses the pressure from academic expectations and familial expectations. (Statement_8) | 3 (50)

A majority of the experts (83.33%) agreed that the module adequately covers key life skills needed for mental health promotion. Four experts (66.67%) agreed that the topics covered in the module are related to the adolescent population and align with the current understanding of adolescent mental health in Sri Lanka. However, qualitative feedback from the consultant psychiatrist indicated that only some topics are more applicable to late childhood and early adolescence, with limited relevance to late adolescence, and that the overall coverage of adolescent mental health issues remains insufficient.

Similarly, four experts (66.67%) also agreed that the learning activities are practical and easily understandable for non-health professionals delivering the module. The consultant psychiatrist noted that while the activities are highly practical for grassroots or community-level workers, the level of comprehension may vary. The consultant community physician emphasized the need for additional simplification of the learning activities.

Regarding cultural appropriateness, four experts (66.67%) agreed that the module considers the diverse cultural, religious, and socioeconomic backgrounds of adolescents in Sri Lanka. Nevertheless, the consultant psychiatrists highlighted that these aspects are not specifically tailored to adolescent populations.

Lower levels of agreement were observed for items related to the cultural sensitivity of examples, scenarios, and language used, as well as their appropriateness for Sri Lankan adolescents, with three experts (50%) expressing agreement. The consultant psychiatrist indicated that although these are not specifically adolescent-focused, they are generally applicable within the Sri Lankan context and recommended further simplification of the language.

Additionally, three experts (50%) agreed that the activities and exercises are engaging and developmentally appropriate. The consultant psychiatrist questioned whether these are more developmentally appropriate for parents than for adolescents, while the consultant community physician indicated that further explanations are needed. Finally, three experts (50%) agreed that the module addresses the pressures related to academic and familial expectations, with the consultant psychiatrist noting that these issues are reasonably addressed through selected case scenarios, stories, and discussion.

Agreement among experts on assessment items pertaining to clinical and public health perspectives was assessed by consultant community physicians and consultant psychiatrists. Three experts (75%) agreed that the coping strategies and interventions presented are effective and feasible within the Sri Lankan context. Qualitative feedback from the consultant psychiatrist supported the practical and contextual relevance of the strategies used in the module; however, it was emphasized that their effectiveness should be confirmed through implementation and outcome evaluation.

Experts’ agreement on assessment items for clinical and public health perspectives

Regarding whether the module addresses the most pressing mental health concerns among adolescents in Sri Lanka, two experts (50%) agreed. Qualitative feedback from the consultant psychiatrists indicated that the module does not directly address clinical mental health conditions but instead functions as a preventive, parent-focused mental health promotion tool. Similarly, two experts (50%) agreed that the mental health disorders and symptoms are described in a culturally understandable and non-stigmatizing manner within the Sri Lankan context. However, the consultant psychiatrist disagreed with this statement, noting that the module content predominantly addressed emotional and behavioral issues or disturbances rather than clinically defined mental health disorders (Table 2).

No. | Assessment items (statements) | Agreement - n (%)
1 | The module addresses the most pressing mental health concerns among adolescents in Sri Lanka. (Statement_9) | 2 (50)
2 | The mental health disorders and symptoms are described in a way that is culturally understandable and not stigmatizing within the Sri Lankan context. (Statement_10) | 2 (50)
3 | The coping strategies and interventions presented are effective and feasible within the Sri Lankan context. (Statement_11) | 3 (75)

Subject-specific assessment of Manohari module content by consultant psychiatrist (n = 2)

Both psychiatrists (100%) agreed that the module adequately addresses issues such as stigma, help-seeking, and access to mental health services. However, qualitative feedback revealed nuanced differences: one psychiatrist acknowledged that these issues are adequately covered, whereas the other noted that access to mental health services is not sufficiently discussed, suggesting variability in the perceived comprehensiveness of the module (Figure 1).

Figure 1: Ratings of the Manohari module content across subject-specific assessment items by consultant psychiatrists

In contrast, opinions diverged regarding the clinical soundness of the module from the perspective of mental health professionals (psychiatrists, psychologists, and counselors) in Sri Lanka. One psychiatrist (50%) agreed that the module is clinically sound, while the other (50%) strongly disagreed. The dissenting view emphasized that the module is better conceptualized as a mental health promotion or prevention tool rather than a clinically oriented intervention for treatment.

Regarding alignment with the current Sri Lankan national mental health policies, both psychiatrists (100%) provided neutral responses. Qualitative comments indicated uncertainty in this domain; one psychiatrist suggested that while the module may contribute to mental health promotion, it does not demonstrate clear alignment with broader adolescent mental health aspects.

Subject-specific assessment of Manohari module content by ZDE (n = 2)

The responses to the subject-specific assessment items of the ZDEs indicate a high level of consensus across several domains, with some areas of neutrality (Figure 2).

Figure 2: Ratings of the Manohari module content across subject-specific assessment items by Zonal Directors of Education (ZDE)

Both ZDEs (100%) agreed that the visuals and supplementary materials used in the module are helpful and easy to understand. Similarly, both experts (100%) agreed that the module can help families support their adolescents' mental health and that teachers and school counsellors in Sri Lanka would find the module practical and applicable in educational settings. In addition, both ZDEs (100%) agreed that the module is compatible with the existing school curriculum and available resources, indicating strong alignment with the educational context.

However, both ZDEs (100%) provided neutral responses regarding whether community leaders and family members would find the module helpful and culturally appropriate, as well as whether the language and complexity of the content are suitable for the cognitive development of adolescents. This neutrality indicates a level of uncertainty and highlights the need for further contextual validation in these areas.

Qualitative feedback from the experts

Qualitative feedback from the experts provided additional depth to the judgmental validation findings, highlighting both strengths and areas requiring refinement.

The psychiatrist identified a few adolescent-specific issues that need more attention within the module, including predominant reliance on knowledge-based content rather than skill-based development, limited coverage of digital challenges and cyber risks, and insufficient exploration of the generation gap between traditional beliefs and modern adolescent aspirations. The inclusion of components focusing on resilience and empowerment was also recommended. Despite these concerns, the psychiatrist acknowledged that the modules are innovative, practical, and culturally aligned. However, it was noted that the translation of these perceived benefits into measurable outcomes remains uncertain, given the potential influence of multiple factors on implementation.

Community physicians highlighted several practical and content-related limitations. It was noted that exercises could be explained more clearly, with greater emphasis on key follow-up issues such as parental attitudes (e.g., comparing children with others) and the prevention of adolescent substance use. Additionally, concerns were raised regarding the limited coverage of mental health disorders and symptoms, with recommendations to include these aspects to enhance the comprehensiveness of the module. Further feedback emphasized the need to better incorporate context-specific challenges faced by adolescents in Sri Lanka. In particular, the significant pressure arising from high parental expectations regarding academic achievement was identified as a major contributor to sustained stress among adolescents.

Moreover, the community physician highlighted important issues such as the relatively high rates of adolescent suicide in the Northern Province, often linked to academic pressure from parents and teachers, interpersonal conflicts, and relationship-related stresses. Road traffic injuries and fatalities among late adolescents were identified as a neglected area. In addition, the importance of addressing adolescents' understanding of sexual and emotional experiences, as well as supporting informed decision-making while balancing academic demands, was emphasized.

FGD findings

The thematic analysis of the FGD identified eight major themes related to the adolescents' perceptions of the Manohari module: (i) overall appeal of the module, (ii) relatability of characters and situations, (iii) understanding and application of life skills, (iv) language and clarity, (v) cultural appropriateness, (vi) portrayal of mental health, (vii) illustrations and visual appeal, and (viii) peer acceptability and recommendations.

Overall, participants expressed positive impressions of the module, describing the stories as interesting, engaging, and enjoyable to read. Several students highlighted that the variety of situations presented helped maintain their attention. However, some suggested that certain story titles could be improved to better reflect the content and recommended incorporating more humor to enhance engagement and age-appropriateness.

In terms of relatability of characters and situations, participants agreed that the characters and situations were realistic and reflective of their daily experiences. They noted that the problems depicted were similar to those encountered in their own lives. However, students preferred the use of real-life human characters (e.g., parents, siblings, and friends) rather than animals, reflecting a preference for real-life relevance.

Participants demonstrated a strong understanding of the life skills embedded in the stories, particularly in areas such as decision-making, emotional regulation, and communication. They reported that these concepts were clearly conveyed through the narratives. Furthermore, most students agreed that the life skills presented were applicable to real-life situations. When asked to rate the influence of the stories on their understanding or behavior (on a scale of 1-10), the majority rated it as 6/10, suggesting a moderate impact, which they attributed to insufficient motivational elements within the module.

Regarding language and clarity, students consistently reported that the content was simple, clear, and easy to understand, with minimal use of complex vocabulary. This enabled them to complete the reading within a relatively short time (approximately 30 minutes).

The module was also perceived as culturally appropriate, with participants noting that the family dynamics and peer interactions reflected typical Sri Lankan contexts. However, some students pointed out that certain character names were not culturally suitable, suggesting the need for minor adjustments.

In relation to the portrayal of mental health, participants responded positively, indicating that emotional experiences were presented in a non-judgmental and normalized manner. They suggested that incorporating more humor and explanatory elements could further enhance emotional engagement and potentially contribute to stress relief and improved emotional well-being.

Feedback on illustrations was generally favorable, with students noting that visuals supported their understanding of the stories. However, they recommended including more illustrations, particularly cartoon-style images with humorous elements, to increase engagement.

Finally, there was strong consensus regarding the module’s peer appeal and acceptability. Participants indicated that the stories were relatable and did not feel like additional academic work. All students expressed willingness to recommend the module to their peers, suggesting high acceptability within the target group.

Overall, the FGD findings indicate that the module is engaging, culturally relevant, and understandable, with opportunities for improvement in areas such as motivation, humor, character representation, and contextual refinement.