Discussion

The study assessed the content validity and cultural relevance of the Manohari module to support its implementation among adolescents in Sri Lanka using a mixed-method approach. Overall, the findings indicate that the module is acceptable and culturally relevant while highlighting several areas requiring refinement to improve its effectiveness and applicability.

The positive expert appraisal of the module’s content, cultural appropriateness, and practicality for delivery by non-health professionals supports its potential as a scalable intervention. This is consistent with established evidence that life skills-based mental health promotion interventions can be effectively implemented in low- and middle-income settings when delivered by trained lay facilitators, thereby increasing scalability and accessibility [14,25].

However, the qualitative feedback highlights several critical areas for refinement. Notably, concerns were raised regarding the developmental appropriateness of the content, particularly its limited relevance to late adolescence. This is consistent with existing literature indicating that adolescence comprises distinct developmental stages, including early, middle, and late adolescence, each characterized by differences in cognitive, emotional, and social functioning [26], thereby underscoring the importance of interventions that are appropriately tailored to these developmental variations. Overall, while the module demonstrates strong foundational potential as a practical tool for school-level mental health promotion, further refinement in terms of developmental targeting is essential to enhance its relevance, acceptability, and effectiveness among Sri Lankan adolescents.

A notable finding of this study was the lack of consensus between the two psychiatrists regarding the clinical soundness of the Manohari module. While one psychiatrist considered the module to be clinically sound, the other strongly disagreed, indicating that consensus was not achieved on an important aspect of the module. This difference in expert opinion highlights the need for continued refinement and further validation of the module by a larger multidisciplinary expert panel.

The variation in expert agreement regarding clinical relevance also underscores the importance of clearly positioning the module within a preventive and promotive framework. As indicated by the experts, the module’s primary focus on emotional and behavioral competencies, rather than clinically defined mental health disorders, aligns with existing literature indicating that adolescent health interventions are intersectoral and multi-component, incorporating school- and community-based approaches and are associated with improvements in psychosocial functioning and well-being [2,23,27]. This suggests that while the module is appropriate as a mental health promotion resource, its role should be clearly positioned within a preventive framework and not as a substitute for clinical mental health care.

From an implementation perspective, the views of ZDEs regarding the module’s practicality, clarity of visuals, and compatibility with the existing school curriculum suggest strong potential for integration within the educational system. However, the neutrality expressed regarding cultural appropriateness for broader community stakeholders highlights the need for further contextual validation.

The findings from the FGDs indicate that the module is highly acceptable, engaging, and understandable from the perspective of adolescents, supporting its potential as a youth-friendly mental health promotion tool. The positive reception of the stories, particularly their relatability and alignment with real-life experiences, highlights the importance of interventions being acceptable and perceived as relevant by participants in order to promote engagement [28]. Participants’ preferences for realistic human characters over symbolic representations further highlight the importance of authenticity and contextual relevance in adolescent-focused interventions. The strong understanding of life skills such as decision-making, emotional regulation, and communication suggests that the module effectively conveys key competencies, aligning with the principles of life skills education promoted by WHO, which emphasize experiential and relatable learning approaches. However, the moderate self-reported impact (mean rating 6/10) and suggestions for increased humor, motivation, and illustrative content indicate that while the module is informative, its capacity to influence behavior change may be limited without stronger engagement strategies. Overall, these findings suggest that while the module is well-designed in terms of content clarity, cultural alignment, and acceptability, incorporating more engaging and motivational components could enhance its effectiveness in promoting meaningful behavioral and emotional change among adolescents.

While the above findings highlight the relevance and acceptability of the Manohari module within the Sri Lankan context, several limitations should be considered when interpreting the results. A key limitation of this study is the relatively small number of participants included in both the expert panel and the FGD, which may limit the generalizability of the findings. Although participants were selected based on their expertise and involvement in adolescent mental health, the sample may not fully represent the diversity of perspectives across different regions and professional groups in Sri Lanka.

In addition, the study relied primarily on subjective perceptions and self-reported feedback to evaluate the module. Such approaches are inherently susceptible to response bias, which may have influenced the assessment outcomes. Moreover, inter-rater reliability was not formally assessed using statistical measures such as Cohen’s kappa, Fleiss’ kappa, or the intraclass correlation coefficient (ICC). Although the level of agreement among experts was reported using raw agreement percentages, this approach does not account for agreement occurring by chance and provides a less robust assessment of consensus compared with established reliability statistics.

Furthermore, a potential conflict of interest may exist due to the involvement of the developer of the instrument as a co-author of the study. This dual role may have introduced the possibility of bias during the evaluation or interpretation of findings. Although efforts were made to maintain objectivity through expert review and systematic evaluation procedures, future studies should consider involving independent researchers without direct involvement in the process to enhance transparency and reduce potential bias. Beyond this, the study did not incorporate objective measures to assess the effectiveness of the module, such as pre- and post-intervention evaluations among adolescents. As a result, the findings are limited to perceived relevance and acceptability rather than demonstrable impact. Future research involving larger and more diverse samples, as well as the inclusion of objective outcome measures, would be valuable in strengthening the evidence base and supporting wider implementation of the module.