Qualitative Process Evaluation of the Early Adolescent Skills for Emotions (EASE) Intervention in Mozambique: Research Protocol

This study is a qualitative process evaluation of the Early Adolescent Skills for Emotions (EASE) intervention, a brief group-based psychological program developed by the World Health Organization (WHO) for young adolescents (aged 10–15) experiencing internalizing problems such as anxiety and depression. EASE is delivered by trained non-specialist community providers and consists of seven weekly group sessions for adolescents and three complementary sessions for their caregivers, drawing on evidence-based cognitive-behavioral techniques including relaxation, behavioral activation, and problem-solving. The evaluation is conducted in Mozambique, where EASE is being piloted in humanitarian settings — including displacement-affected communities in Maputo, Inhambane, and Chimoio — to address a critical gap in adolescent mental health support in a low- and middle-income country (LMIC) context. The overarching purpose of this study is to generate a rich, contextually grounded understanding of how EASE was implemented in practice, for whom it worked and under what conditions, and what would be required to sustain and scale it within Mozambican systems. While randomized controlled trials may establish efficacy, they do not explain the mechanisms or contextual factors shaping real-world outcomes. This evaluation is specifically designed to fill that explanatory gap. The study is guided by two complementary theoretical frameworks. The Medical Research Council (MRC) Framework for Process Evaluations structures the inquiry around three core domains: implementation (fidelity, dosage, and reach), mechanisms of impact (how participants and providers engage with intervention components to produce change), and context (how local factors such as displacement, economic conditions, and cultural norms shape delivery and reception). The RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance) further supports analysis of the intervention's potential for broader public health impact and scalability. Data collection takes place over an intensive 10-day field mission structured in three phases: an orientation and planning phase to finalize tools and review monitoring data; a deep-dive data collection phase involving Focus Group Discussions (FGDs) with adolescent participants, caregivers, and EASE facilitators, as well as Key Informant Interviews (KIIs) with supervisors, trainers, community outreach workers, and local stakeholders; and a synthesis phase featuring a collaborative analysis workshop and the drafting of preliminary outputs. Where logistically possible, direct observation of an EASE session will be conducted using a structured fidelity checklist. The total sample is anticipated to comprise approximately 40–60 individuals per location, selected through purposive sampling to maximize diversity across gender, role, and level of program engagement. Triangulation across methods and informant groups will strengthen the credibility and depth of findings. The evaluation investigates four core domains. First, acceptability and cultural appropriateness — whether adolescents, caregivers, and facilitators find EASE relevant, engaging, and suitable to their lived context, including reactions to specific components such as the illustrated storybook, group format, and skill-building activities. Second, feasibility — the practical barriers and enablers to delivering and attending sessions, including logistical, economic, and scheduling challenges faced by both providers and participants. Third, fidelity and quality — the degree to which the intervention was delivered as intended, including the quality of facilitator training and supervision, adherence to the EASE manual, and any deliberate or emergent adaptations. Fourth, perceived impact and future scale-up — participant- and stakeholder-attributed changes in adolescent wellbeing, behavior, and coping, alongside stakeholder views on what would be needed to integrate EASE sustainably into local health, education, or protection systems. Data analysis will combine deductive and inductive thematic analysis, using a codebook grounded in the study frameworks while remaining open to emergent themes. Transcripts will be coded independently by two researchers and cross-checked for consistency. Findings will be triangulated across data sources, and process data will ultimately be interpreted in light of the quantitative outcomes of the pilot implementation to offer an integrated account of EASE's real-world performance. Expected outputs include a comprehensive process evaluation report with rich participant quotes and actionable recommendations, a stakeholder presentation for local and international audiences, and a concise recommendations brief for program implementers. Findings will be shared with the global mental health community through relevant humanitarian and academic forums, and coordinated with researchers from other EASE implementation sites (including Jordan, Uganda, Tanzania, Kenya, Zimbabwe, and Europe) to support cross-country learning. The study thereby aims to contribute directly to the optimization, adaptation, and responsible scale-up of EASE in humanitarian settings globally.