Table 1 Key adaptations to group interpersonal therapy using the Ecological Validity Framework

Context

Increase accessibility; enhance feasibility, acceptability and compliance

Integrate group IPT into the government secondary education system.

Parents are more likely to trust an intervention if it is linked to their children’s school. There are also private rooms available in schools to hold the sessions, and supportive staff to help organise sessions and recruit adolescents. Most adolescents in the study area are in school and so it will be convenient for them to attend. Out of school adolescents said they do not have a problem attending sessions held in schools. (Qualitative study)

In rural Nepal there are more schools than health posts. Locating the intervention in government schools ensures an equitable and sustainable delivery platform, and avoids potential stigma associated with visiting health services for treatment. Previous mental health interventions in Nepal have been successfully delivered through schools. (Desk review)

Groups should be single gender but can include adolescents from different caste/ethnic groups, and younger and older, in and out of school, and married and unmarried adolescents. The preferred group size is six to 10.

Group composition: Adolescents feel embarrassed to talk about heart-mind problems in front of members of other genders but are comfortable to join groups with adolescents from different socio-economic backgrounds. (Qualitative study)

Group size: A group of six to 10 adolescents is large enough for some adolescents to be absent from sessions without leaving those attending feeling exposed. It is also manageable for two facilitators. (Trainer practice groups) This number is in line with the WHO Group IPT Manual and an adaptation of group IPT for adolescents in Uganda. (Desk review)

Persons

Engaging non-mental health professionals and promoting the therapist-patient relationship

Recruit and train school nurses to facilitate IPT. Male facilitators will also be recruited from the local community.

The One School, One Nurse government policy seeks to appoint a nurse at every government school. The role of these nurses could be expanded to include facilitation of IPT groups. In Nepal most nurses are female however, adolescents prefer a facilitator of the same gender hence male facilitators must also be recruited from the local community. (Qualitative study)

Facilitators work in pairs

Two facilitators are needed to manage the documents and assessments and ensure all session content is covered. (Trainer and facilitator practice groups)

Goals

Clarifying and extending goals; identifying goals relevant to adolescents in Nepal

Include aims for each phase of group sessions (Table 2)

Aims are missing from the WHO Manual and it would be helpful to clarify these to focus the sessions and support facilitators. (Read-through and workshop with the project team)

Developmental

Accounting for abrupt changes in mental state and high reactivity among adolescents; engaging parents and caregivers; ensuring content is relevant for adolescent age group

Include a second pre-group session with the adolescent and their parent/caregiver, ideally at the adolescent’s home. The session will use a strengths-based approach and take on the following structure: describe group IPT as a life skills programme, explain how will it help and state that it does not involve money, tuition or medical care; highlight the importance of confidentiality and that the adolescent will not be able to discuss problems that others bring to the group with members of their family; obtain permission for the adolescent’s participation in the group; describe how the parent or caregiver can support the adolescent.

Parents were anxious about what was happening in the groups, unaware of the potential benefits, and not supporting their children to attend. Engaging parents early in the intervention will help to mobilise their support and reassure them. (Trainer practice groups)

Chapter 4, Middle group phase: Include a second meeting with parents or caregivers if the adolescent is absent for two consecutive group sessions. The aims of the meeting are to identify the barrier to adolescents attending sessions and to work together to find a solution.

Absenteeism can be an issue if the parent is not supportive of the adolescent’s participation. (Facilitator practice groups)

Chapter 4, Middle group phase: Addition of the Bhitri-Bahiri Bhawana (meaning inside/outside feelings) technique which prompts adolescents to differentiate between the feelings they project to others and their ‘true’ inner feelings.

Adolescents had difficulty expressing their emotions during group sessions. (Facilitator practice groups)

Chapter 4, Middle group phase: In the third group session each group member should develop a severe distress safety plan akin to a suicide safety plan. Facilitators should be reminded that suicide may be one of the first topics they have to discuss, possibly even in the pre-group sessions.

Due to potential abrupt changes in the mental state of adolescents, suicidality may present suddenly and adolescents should have a plan in place to help them manage such thoughts. Completing a severe distress safety plan as a group activity will help to ensure that all group members understand and are prepared. (Training of trainers)

Chapter 5, Strategies for disputes: The WHO Manual describes three stages of disputes: still negotiating, being stuck or ending the relationship. Where it is desirable for a relationship to end, the individual is encouraged to end it, mourn and move on. Among adolescents we should expand the definition of ‘ending the relationship’ to include shifting the caring responsibility (e.g. from a parent to an aunt) and accepting the situation and finding coping strategies.

Ending the relationship between adolescents and their parents may not be possible or appropriate, and other solutions are required. (Read-through and workshop with the project team)

Chapter 5, Strategies for disputes: Add a strategy to help adolescents manage anger. Ask the participant what they do when they are angry. Explain that anger is a natural emotion. Ask the participant if their anger had a positive or a negative effect. If negative, ask the group members for tips about how the participant can manage their anger so that it has a positive effect.. Use role-play to practice anger management. The Gestalt Empty Chair Technique can also be used. This involves participants imagining the person with whom they have a conflict and thinking about what they would say to them.

Managing anger is one of the main barriers adolescents face when trying to resolve disputes (Trainer practice groups)

Language

Ensuring translation is harmonious with Nepali language; use of local idioms of depression; replacement of technical terms with colloquialisms

Throughout the Manual, change the word depression to udas-chinta. Introduce udas-chinta as one type of heart-mind problem.

Although some adolescents understand the term depression, udas-chinta (meaning sadness-worry) is preferred because it: i) is Nepali, (ii) reflects the high prevalence of depression/anxiety comorbidity in this population, (iii) parents may link anxiety to the upcoming school exams and be more likely to support adolescents’ attendance. Heart-mind problem is a local, non-stigmatising term for psychosocial problems. (Qualitative study)

Chapter 2, Individual session: The facilitator discusses with the adolescent how to create an environment that will “help recovery from depression”. Change to “help you to improve your depression”.

‘Recovery’ is translated as ‘healing’ in Nepali which is an unrealistic therapeutic goal. (Clinical review of the WHO Manual)

Chapter 3, Initial Group Phase: The word ‘common’ is used to describe depression. Replace this word with the phrase “many people have depression - about one in four”.

Direct translation of ‘common’ in Nepali is ‘normal’. Whilst depression is common it is not considered ‘normal’. (Training of trainers)

Concepts

Using Nepali concepts of mental ill health, including somatic, social and religious concepts; addressing locally relevant stressors

Chapter 1, Introduction: In the explanation of the social isolation problem area, include local examples, e.g. an adolescent from the Dalit caste or a minority religion who is being excluded from friendship groups and school activities.

Social isolation is a concept that facilitators may find difficult to understand and explain. Local examples will aid understanding. (Desk review)

Chapter 1, Introduction: Add content to help facilitators to understand the consequences of depression for adolescents, specifically its effects on education friendships and relationships, as well as long term health, social and economic outcomes. Link depression to healthy development and child protection.

The WHO Manual lacks information about the relevance of depression for adolescents. Linking depression to educational outcomes will be a motivating factor for parents to send their child to the groups. Communities may not be aware of the health and social benefits of improving depression. (Read-through and workshop with the project team)

Chapter 2, Individual session: When inviting an adolescent to join the group, the facilitator should describe IPT as a life skills training programme

In the community adolescents are likely to experience stigma associated with accessing treatment for a mental health problem. Describing IPT as a training programme will be more acceptable to adolescents and their families and will help to promote recruitment. (Trainer practice groups)

Chapter 2, Individual session: Add an instruction to the facilitator to ask the adolescent if they are experiencing any kind of physical or sexual abuse. Give examples of how to ask about this. Remind facilitators that adolescents may not feel confident talking about abuse with facilitators when they first meet and that the facilitator should be prepared to enquire again in later sessions. Include a locally relevant plan in the Manual to manage abuse and provide focussed facilitator training on this.

In Nepal, violence against children and adolescents is common. IPT is unlikely to benefit adolescents who continue to live in violent homes and require additional input from e.g. child protection services. (Facilitator practice groups)

Chapter 5, Strategies for dealing with life changes: Identifying the old role and mourning its loss is a strategy for life changes. Elaborate on this metaphor of mourning a previous role. Add “What can you do that is like grieving to help you come to terms with the role change? Take the time to feel sad. It’s OK to feel sad.”

The metaphor may not be clear to participants or facilitators and requires further explanation. (Read-through and workshop with the project team)

Methods

Promoting adolescent engagement; adapting the intervention structure; adapting how depression is monitored; adapting IPT techniques and strategies

Increase the number of group sessions from eight to 12.

Two RCTs have evaluated group IPT for adolescents in LMICs involving 16 group sessions, however we expect an intervention of this duration to be unacceptable to adolescents in Sindhupalchowk and would incur high drop-out rates. Trainer practice groups suggested that adolescents take 4–5 session to get comfortable discussing openly in the groups and therefore eight sessions would be insufficient. (Trainer practice groups; Desk review)

Chapter 3, Initial group phase: As a warm-up exercise, begin each group session with the Prativa Dekhaune Kriyakalap (meaning share a talent) activity. Each session begins with a group member sharing their talent (e.g. singing, dancing, storytelling, telling jokes, talking about an interest, hobby or person who is important to them). The facilitator shares their talent in the first session and asks for volunteers for the next session.

Adolescents said they wanted fun games to play during the group sessions. This warm-up activity will also help adolescents to get to know each other (Qualitative study)

Chapter 3, Initial group phase: Add the Mero Mon (My Heart-Mind) game – The facilitator gives an example of a positive or negative event (e.g. mother is cooking your favourite food for dinner). Adolescents have a handout with different emoticons and point to the one that fits how they feel about the event (e.g. a happy, smiling emoticon). The facilitator then asks, how does the problem make you behave (e.g. running to reach home quickly in order to eat the food).

In practice groups adolescents were finding it difficult to link their mood to IPT problem areas. This is a fun activity designed to help with this (Trainer practice groups)

Chapter 3, Initial group phase: All group members are given a dainiki (diary) to help them review progress, record useful information from the group discussions and any tasks to do outside sessions, and provide contact information for facilitators and other relevant services. The dainiki should be colourful and engaging. Facilitators should also provide stickers and pens for adolescents to personalise their dainikis during the sessions.

Adolescents want an incentive to attend the groups and help to remember the timing and dates of group sessions (Qualitative study). Having a booklet where adolescents can keep all of the key information will empower them and provide them with something to refer to beyond the groups. (Trainer practice groups)

Chapter 4, Termination group phase: Celebrate the end of the group with the Mitho Samjhana (sweet, unforgettable memories) activity: each adolescent sticks a piece of paper to their back; adolescents take turns to write positive words on each other’s back.

Adolescents said they wanted fun games to play during the group sessions. (Qualitative study)

Metaphors and content

Using stories and local examples; incorporating local values, customs and practices into the Manual content

Chapter 6, Suggestions for Facilitators: Add additional content to help facilitators to address the following challenges/crises: argument between group members, disclosure of abuse, group member runs away from home, elopement, illness of group member or relative, and parents refusing to send adolescent to the session.

These are challenges that we expect facilitators will have to manage. (Facilitator practice groups)