Table 5 Thematic analysis of semi-structured interviews (N = 6) to evaluate implementation EASE intervention in public schools of Pakistan

Acceptability to adolescents

Better able to cope with distress

“Previously, I used to get angry at my sister but yesterday I practiced slow breathing exercise when I felt anger at my sister and it helped me to control my anger.” (Youth)

“Whenever my heart beat goes up, I practice breathing exercise and feel relaxed.” (Youth)

“I fought with my friend, and felt sad after some time. Then I used the ‘tree exercise’ to resolve the problem.” (Youth)

Helpful strategies to resolve daily life problems

“I used to get late for school and I was having difficulty in managing time but after learning problem solving strategy in session and applying it, my problems has been resolved.” (Youth)

“These sessions/strategies helped me in my school work.” (Youth)

“If I ever receive a chance to be a part of these sessions again, I would be willing to attend this program.” (Youth)

Ensuring confidentiality

“As you (non-specialist facilitators) keep my confidentiality intact, so I feel comfortable in sharing my personal problems with you.” (Youth)

“It is good that our conversations will stay within this group.” (Youth)

Relatable story

“I really like to hear Noor’s Story from you as I find it quite relatable to my daily life problems and it gives me confidence that I can solve my problems too.” (Youth)

“Noor’s story is really interesting.” (Youth)

“I like the example in which Noor spots birds.” (Youth)

Peer pressure

“Other students say to me that you are missing out your studies because of these sessions and these sessions are useless.” (Youth)

“Some students in the van pressurize me into sharing all about the sessions, and I was not comfortable with it.” (Youth)

“The other day one of my class fellows wanted to see my workbook, but I did not want to show it to him.” (Youth)

Acceptability to caregivers

Increase in knowledge about parenting

“It is very helpful to learn useful strategies from them (non-specialist facilitators) and I really want to thank them for coming here for us and our children. I would like to attend such sessions in future as well.” (Caregiver)

“Previously I didn’t praise my child as it might spoil him but after attending this session I realized the importance of praise and I even praise him for his small efforts.” (Caregivers)

“My child felt very happy when I actively listened to him.” (Caregiver)

Welcoming session environment

“We really like to come here for our children and you welcome us so nicely.” (Caregiver)

“It is great to see that you care for our children, and engage us too.” (Caregiver)

“Your positive behavior motivates me to attend the session.” (Caregiver)

Group learning

“I have learnt a lot from the experiences of others (parents) in the group.” (Caregiver)

“The group sessions have helped me better understand my child’s problems.” (Caregiver)

“It was difficult for me to understand the components of praising the child, but with the support of this I was able to learn this.” (Caregiver)

Traveling issue

“We get late in the sessions because it is challenging to find a transport at this time and we have to travel a long distance.” (Caregiver)

“I cannot travel alone and need someone to accompany me for the session. I came with my daughter today therefore I couldn’t send her to school.” (Caregiver)

“Since I have a health problem, it is not easy for me to cover long distance on foot.” (Caregiver)

Personal commitment

“It is hard to attend session along with household activities.” (Caregiver)

“My working hours are being compromised because of attending the session.” (Caregiver)

“Normally I am supposed to complete my household chores around this time.” (Caregiver)

Language Barrier

“We were unable to understand the intervention strategies completely, would it be possible for you to deliver the key concepts in our local language?” (Caregiver)

“It will be easy for us to participate in discussion in our local language.” (Caregiver)

Acceptability to non-specialist facilitators

Helpful strategies for adolescents

“At the beginning, it was challenging for the children to open-up however, with the passage of time we developed a trustful relationship and children were more comfortable in sharing their stressful experiences with us.” (non-specialist facilitators)

“Children were able to practice slow breathing exercise to manage their difficult feelings due to repeated demonstration of this strategy during the session.” (non- specialist facilitators)

“It was satisfying to see the children feel comfortable sharing their thoughts and problems in group settings.” (non-specialist facilitators)

Cooperation from schools

“School staff was very cooperative in terms of providing proper venue and ensuring the availability of children for the sessions and they coordinated with the parents as well.” (non-specialist facilitator)

“Well, the school administration was quite aware of the President’s Mental Health Program, and they welcomed us wholeheartedly.” (non-specialist facilitators)

“Some of the school principals showed great interest in our work with children and had post-session discussions with non- specialist facilitators to discuss how best children can be supported in their development and academics.” (non-specialist facilitators)