Qualitative findings
Disruptive
The qualitative analysis identified five overarching themes: (i) Overall positive experiences of EASE; (ii) Acceptability and feasibility of intervention components; (iii) Impact of EASE on adolescents and caregivers; (iv) Facilitators and barriers to participant adherence and attendance; (v) Scale-up and integration into community. There was positive feedback about the intervention and the impact it had on adolescent behaviour and emotions, and relationships in the family and outside. Participants reported that adolescents benefited directly from EASE strategies as well as increased support from caregivers. One boy reported improvements in his own behaviour: Intervention content was generally reported to be understandable, relevant, and useful. The strategies of slow breathing, problem solving and noticing strengths were most positively received. Some challenges were noted with understanding the psychoeducation about the vicious cycle of inactivity, and related activity planning / behavioural activation strategies. Facilitators and trainers noted that repetition of content helped with learning, but was also a source of boredom. Participants reported that there was a lack of interactive activities, and the storybook, which forms the core of the sessions, was not engaging enough for adolescents in this study. Disruptive behaviour in sessions was common and was a reported concern for facilitators and for other adolescents, who felt it disturbed their experience. Trainers and facilitators reported that the intervention often assumed adolescents and caregivers could read and write, while this was commonly not the case. Furthermore, caregiver sessions were perceived as too dense and long.There was some dissatisfaction among caregivers that ‘Outreach and engagement were noted to be challenging, with one trainer mentioning: “Facilitators reported that the training was comprehensive and appreciated the active role-plays and feedback, along with anticipating and learning how to respond to challenging situations. They reported feeling overwhelmed with the amount of new content at first, but soon mastered it through implementation. Supervisors noted that additional support was required in managing difficult in-session behaviour, explaining complex strategies to participants to enable application to their own situation, and presenting strategies in engaging ways for adolescents. Results indicated that EASE facilitators were deemed acceptable delivery agents and perceived as competent by all stakeholder groups. Trainers attributed this success to 1) training and supervision were comprehensive; 2) recruited facilitators had significant experience prior to training in EASE; 3) a supportive and sharing environment between team members. Additionally, facilitators cited multiple motivations to stay in the intervention, in contrast to previous task-shifting interventions where low facilitator motivation has been a barrier to implementation. While financial incentives were mentioned, non-financial incentives such as the promise of a certificate, personal skill development, willingness to help, and perceived value of the intervention were all important factors. After several rounds of implementation, supervision sessions were perceived as being repetitive and there was a recommendation to make them more active.