Impact statement
As global strategies seeking to address the mental health services gap through scalable mental health interventions become more widely adopted, there is a growing importance for cultural adaptation of psychosocial interventions to reflect local needs and contexts. This study, which reports on the cultural adaptation process of a World Health Organization (WHO) mental health intervention for youth and caregivers, Early Adolescent Skills for Emotions (EASE), is the first step towards implementing EASE in the United States and expanding mental health services for New York City (NYC) adolescents in economically marginalized communities of color. Through documenting the researchers’ close partnership with the local government, youth and caregivers, the study highlights the importance of centering community voices in intervention development, implementation, and dissemination. It also indicates the necessity of culturally sensitive approaches to co-create strategies that are acceptable, relevant, and engaging for underrepresented groups. The study’s findings are being used to inform the pilot implementation and evaluation of EASE in NYC in 2025. It may also guide community-based adaptation work in other contexts globally. Additionally, the study offers insights into how a novel strategy focused on community building and social and emotional learning may increase access to care for adolescents in need of mental health support.
Introduction
Despite the growing need for adolescent mental health services in the United States (US), there remain significant barriers to care, with access to treatment especially inequitable for people of color (Alegría et al., Reference Alegría, Canino, Shrout, Woo, Duan, Vila, Torres, Chen and Meng2008; Weersing et al., Reference Weersing, Gonzalez, Hatch and Lynch2022; Agency for Healthcare Research and Quality, 2023). Among those seeking care for depression, people of color are considerably less likely to receive adequate care (Alegría et al., Reference Alegría, Canino, Shrout, Woo, Duan, Vila, Torres, Chen and Meng2008). Studies have identified socioecological barriers that contribute to a number of disparities between adolescents of color and White adolescents. For example, stigma, caregiver attitudes, income and insurance have been found to play critical roles in access to care at the individual and structural levels (Alegria et al., Reference Alegria, Vallas and Pumariega2010; Planey et al., Reference Planey, Smith, Moore and Walker2019; Castro-Ramirez et al., Reference Castro-Ramirez, Al-Suwaidi, Garcia, Rankin, Ricard and Nock2021; Lu et al., Reference Lu, Todhunter-Reid, Mitsdarffer, Muñoz-Laboy, Yoon and Xu2021; Acker et al., Reference Acker, Aghaee, Mujahid, Deardorff and Kubo2023). The mental health burden and structural inequities faced by adolescents of color call for novel approaches that may bridge the services and treatment gap (Rothe et al., Reference Rothe, Fortuna, Tobon, Postlethwaite, Sanchez-Lacay and Anglero-Diaz2021).
One approach that is becoming increasingly studied globally to build increased access to mental health services is task-sharing (WHO, 2008). Task-sharing refers to the delivery of mental health interventions through trusted non-specialist community members, especially in underresourced settings and low- and middle-income countries (Hoeft et al., Reference Hoeft, Fortney, Patel and Unützer2018; Patel et al., Reference Patel, Saxena, Lund, Thornicroft, Baingana, Bolton, Chisholm, Collins, Cooper, Eaton, Herrman, Herzallah, Huang, Jordans, Kleinman, Medina-Mora, Morgan, Niaz, Omigbodun and UnÜtzer2018; Lange, Reference Lange2021). Importantly, a growing body of evidence is showing that scalable mental health interventions delivered by non-specialists are effective in reducing symptoms of distress and post-traumatic symptomatology across different populations and contexts at follow-up assessments (Tol et al., Reference Tol, Leku, Lakin, Carswell, Augustinavicius, Adaku, Au, Brown, Bryant, Garcia-Moreno, Musci, Ventevogel, White and van Ommeren2020; Zhang et al., Reference Zhang, Zhang, Lin and Huang2020; Jordans et al., Reference Jordans, Kohrt, Sangraula, Turner, Wang, Shrestha, Ghimire, Hof, Bryant, Dawson, Marahatta, Luitel and Ommeren2021; Purgato et al., Reference Purgato, Carswell, Tedeschi, Acarturk, Anttila, Au, Bajbouj, Baumgartner, Biondi, Churchill, Cuijpers, Koesters, Gastaldon, Ilkkursun, Lantta, Nosè, Ostuzzi, Papola, Popa and Barbui2021; Karyotaki et al., Reference Karyotaki, Araya, Kessler, Waqas, Bhana, Rahman, Matsuzaka, Miguel, Lund, Garman, Nakimuli-Mpungu, Petersen, Naslund, Schneider, Sikander, Jordans, Abas, Slade, Walters and Patel2022; Turrini et al., Reference Turrini, Purgato, Tedeschi, Acartürk, Anttila, Au, Carswell, Churchill, Cuijpers, Friedrich, Gastaldon, Klein, Kösters, Lantta, Nosè, Ostuzzi, Papola, Popa and Sijbrandij2022).
Although there is considerable work evaluating the potential benefits of task-sharing interventions globally, this approach is somewhat newer in the US. Nevertheless, burgeoning work in the US is beginning to demonstrate the feasibility and adaptability of such interventions with adults remotely (McBride et al., Reference McBride, Harrison, Mahata, Pfeffer, Cardamone, Ngigi, Kohrt, Pedersen, Greene, Viljoen, Muneghina and Brown2021; Pfeffer et al., Reference Pfeffer, Brown, Kohrt, Sangraula and Bakke2023). Other studies have found that peer-based interventions delivered by young adults were associated with significant reductions in depression, anxiety, and loneliness, as well as higher levels of happiness, self-esteem and positive coping (Huang et al., Reference Huang, Nigatu, Smail-Crevier, Zhang and Wang2018; Richard et al., Reference Richard, Rebinsky, Suresh, Kubic, Carter, Cunningham, Ker, Williams and Sorin2022).
With growing interest in and evidence for task-sharing interventions as a form of scalable culturally competent care, this report introduces Early Adolescent Skills for Emotions (EASE), a recently developed World Health Organization (WHO) psychological intervention for adolescents and caregivers, to the US context (WHO and UNICEF, 2023). EASE targets psychological distress in adolescents 10–15 years of age through seven 90-minute group sessions with adolescents and three group sessions with the adolescents’ caregivers (Dawson et al., Reference Dawson, Watts, Carswell, Shehadeh, Jordans, Bryant, Miller, Malik, Brown, Servili and van Ommeren2019). Through EASE, adolescents learn how to identify their emotions, distress-related physical arousal, slow breathing as a healthy coping strategy, behavioral activation to engage in meaningful activities, and problem-solving skills (Dawson et al., Reference Dawson, Watts, Carswell, Shehadeh, Jordans, Bryant, Miller, Malik, Brown, Servili and van Ommeren2019). Previous studies have found positive associations between emotion-focused strategies and youth mental well-being (Verzeletti et al., Reference Verzeletti, Zammuner, Galli and Agnoli2016; Fung et al., Reference Fung, Kim, Jin, Chen, Bear and Lau2019), and randomized controlled trials (RCTs) have indicated the scalability and efficacy of EASE in humanitarian settings (Bryant et al., Reference Bryant, Bawaneh, Awwad, Al-Hayek, Giardinelli, Whitney, Jordans, Cuijpers, Sijbrandij, Ventevogel, Dawson, Akhtar and Consortium2022a; Jordans et al., Reference Jordans, Brown, Kane, Taha, Steen, Ali, Elias, Meksassi, Aoun, Greene, Malik, Akhtar, van Ommeren, Sijbrandij and Bryant2023; Brown et al., Reference Brown, Taha, Steen, Kane, Gillman, Aoun, Malik, Bryant, Sijbrandij, El Chammay, Servili, van Ommeren, Akhtar, Zoghbi and Jordans2023).
The current study aimed to culturally adapt the intervention content, illustrations, and methods of implementation of EASE to center the experiences of adolescents of color in economically marginalized neighborhoods in Brooklyn, New York City (NYC). The cultural adaptation of mental health interventions recognizes the need for “systematic modification of an evidence-based treatment or intervention protocol to consider language, culture, and context in such a way that is compatible with the client’s cultural patterns, meanings, and values” (Bernal et al., Reference Bernal, Jiménez-Chafey and Domenech Rodríguez2009, p. 362). A number of studies have shown that culturally adapted interventions are more effective than nonadapted interventions for communities of color in the United States (Gonzales et al., Reference Gonzales, Lau, Murry, Pina, Barrera and Cicchetti2016; Hall et al., Reference Hall, Ibaraki, Huang, Marti and Stice2016; van Mourik et al., Reference van Mourik, Crone, de Wolff and Reis2017; Soto et al., Reference Soto, Smith, Griner, Domenech Rodríguez and Bernal2018).
The adaptation process was guided by established frameworks, such as the mental health Cultural Adaptation and Contextualization for Implementation (mhCACI), which was built on Bernal et al.’s (Reference Bernal, Bonilla and Bellido1995) ecological validity model to outline the steps for intervention content adaptation, scalability, and implementation (Sangraula et al., Reference Sangraula, Kohrt, Ghimire, Shrestha, Luitel, Hof, Dawson and Jordans2021). Additionally, documentation of the adaptation process followed the Reporting Cultural Adaptation in Psychological Trials (RECAPT) criteria, which provides guidelines for conducting deep and surface structure adaptations (Heim et al., Reference Heim, Mewes, Abi Ramia, Glaesmer, Hall, Harper Shehadeh, Ünlü, Kananian, Kohrt, Lechner-Meichsner, Lotzin, Moro, Radjack, Salamanca-Sanabria, Singla, Starck, Sturm, Tol, Weise and Knaevelsrud2021a). Moreover, we adopted the Community-Based Participatory Research (CBPR) framework, which is a collaborative research approach that recognizes the expertise and strengths of community members, along with researchers and other stakeholders (Wallerstein and Duran, Reference Wallerstein and Duran2010). In doing so, the adaptation process was a collaborative and iterative process between researchers at The New School Center for Global Mental Health, local government at the NYC Mayor’s Office for Community Mental Health, and three community-based organizations (CBOs), structured around feedback and input from adolescents and caregivers.
Through adapting the EASE intervention for underrepresented adolescents based in Brooklyn, NYC, the goal of the study was to create a version of EASE that is more accessible, relevant, and engaging for the local community and to empower mental health outcomes for underserved populations through a community-based model.
Methods
Participants
The NYC Mayor’s Office of Community Mental Health (OCMH) identified three CBOs based in Brooklyn, NYC, to participate in the adaptation process. The CBOs primarily serve Black, Hispanic, and Latino communities in economically marginalized neighborhoods. They recruited caregivers and adolescents from their existing services to contribute to the adaptation of a new community mental health program by participating in focus group discussions (FGDs).
Caregivers who had been recipients of services from the participating CBOs were invited to attend online adaptation sessions to provide feedback on EASE caregiver sessions. For the purpose of this adaptation, a caregiver was characterized as an adult, including parents and extended family members, who routinely provided care for at least one 10- to 15-year-old adolescent. Although some of the caregivers were related to the youth participating in the adaptation process, this was not a requirement for their own participation in the adaptation.
Adolescents, primarily between the ages of 10 and 15, were recruited from existing youth programs to participate in adaptation sessions held in-person and online. Older adolescents (ages 16 and 17) were also included to gain insights into mental health challenges that may emerge over time. The adolescent participants provided feedback on the seven adolescent sessions.
We also collected feedback about the community’s experiences of mental health from all adolescents and caregivers, and all participants were provided a stipend of $16 per hour for their time, as well as dinner during in-person sessions.
Materials
The EASE intervention materials included the main publication manual, adolescent and caregiver posters, caregiver handouts, the adolescent workbook, and the storybook (WHO and UNICEF, 2023). These materials were printed out during in-person FGDs and displayed with the share screen function on Zoom/Microsoft Powerpoint during virtual FGDs.
The in-person FGDs with the adolescents also involved the use of large poster boards, sticky notes, notebooks, and colored pencils and pens for adolescents to share their thoughts with the wider group. The research team also prepared extra materials, such as emoji stickers, as alternatives for some of the EASE strategies (WHO, 2024, p. 80).
Mural (https://mural.co/), an online visual collaboration tool that allows users to create and manipulate text and images, was used in all virtual FGDs. This tool allowed adolescents and caregivers to express their thoughts online in a format mirroring the poster board and sticky notes in-person.
Procedures
The cultural adaptation procedure was informed by the mhCACI framework (Sangraula et al., Reference Sangraula, Kohrt, Ghimire, Shrestha, Luitel, Hof, Dawson and Jordans2021) (Figure 1). The mhCACI framework is a 10-step process that guides the adaptation and implementation of evidence-based mental health interventions. It is divided into three phases. In phase I: pre-condition, investigators first familiarize themselves with the intervention goals and content, then they gather information on the population of interest and engagement and implementation practices to conceptualize how the intervention may be adapted. In phase II: preimplementation, investigators customize the adaptation prototype through consulting stakeholders such as intervention trainers, community members, and expert counselors. In phase III: implementation, investigators build on existing community partnerships and continue to refine the intervention as it is implemented and evaluated. As the current study focuses on documenting the process for EASE adaptation prior to pilot implementation, the last two steps of phase III: implementations (steps 9 and 10: implementation, supervision and process evaluation review) are omitted from this report.
Figure 1. Process of adaptation guided by the mhCACI framework (Sangraula et al., Reference Sangraula, Kohrt, Ghimire, Shrestha, Luitel, Hof, Dawson and Jordans2021).
Phase I: Precondition
Identify the key mechanisms of action
The key mechanisms of action refer to the core components of an intervention that lead to improved outcomes (i.e. distress reduction) and cannot be modified drastically (Sangraula et al., Reference Sangraula, Kohrt, Ghimire, Shrestha, Luitel, Hof, Dawson and Jordans2021). The first author and study principal investigator (PI) reviewed the intervention protocol and previous trials of EASE to identify five key mechanisms of action: (1) psychoeducation and identifying emotions, (2) coping strategies for stress management, (3) behavioral activation, (4) managing problems and (5) relapse prevention (Bryant et al., Reference Bryant, Bawaneh, Awwad, Al-Hayek, Giardinelli, Whitney, Jordans, Cuijpers, Sijbrandij, Ventevogel, Dawson, Akhtar and Consortium2022a; Jordans et al., Reference Jordans, Brown, Kane, Taha, Steen, Ali, Elias, Meksassi, Aoun, Greene, Malik, Akhtar, van Ommeren, Sijbrandij and Bryant2023; Brown et al., Reference Brown, Taha, Steen, Kane, Gillman, Aoun, Malik, Bryant, Sijbrandij, El Chammay, Servili, van Ommeren, Akhtar, Zoghbi and Jordans2023). In line with Sangraula et al. (Reference Sangraula, Kohrt, Ghimire, Shrestha, Luitel, Hof, Dawson and Jordans2021), we based subsequent adaptation changes on these key mechanisms.
In-depth literature review
A review was conducted of cultural adaptation frameworks, adaptation of low-intensity, scalable mental health interventions and the context of adolescents’ mental health globally, in the US, and in NYC. This involved searches in databases such as PubMed and PsychInfo, as well as policy briefs and annual reports from the NYC OCMH and the federal government. This step informed our understanding of the mental health barriers faced by underrepresented groups in the US.
The literature review suggested that task-sharing mental health interventions are lacking in the US and could be a way to bridge the services and treatment gap for underserved populations (Renn et al., Reference Renn, Casey, Raue, Areán and Ratzliff2023; O’Connell et al., Reference O’Connell, Renn, Areán, Raue and Ratzliff2024). Following the implementation of WHO task-sharing interventions in NYC CBOs, such as Problem Management Plus (PM+) for adult populations, it was determined that EASE may be a similarly viable and valuable resource catered to the city’s adolescents.
Phase II: Preimplementation
Training of trainers (ToT)
The first and second authors were trained as EASE trainers in the current study (see Supplemental File 1 for their demographic characteristics). The ToT process did not involve formal training conducted by EASE trainers from previous study sites, following Sangraula et al.’s (Reference Sangraula, Kohrt, Ghimire, Shrestha, Luitel, Hof, Dawson and Jordans2021) protocol; instead, the first and second authors conducted self-guided EASE training. The self-guided training involved reviewing the EASE manual in detail and discussing techniques to strengthen the key mechanisms of action. This self-guided training was approved by the WHO with ad hoc WHO technical support as needed due to the research center’s extensive experience with adapting and implementing PM+, a similar transdiagnostic intervention (Dawson et al., Reference Dawson, Watts, Carswell, Shehadeh, Jordans, Bryant, Miller, Malik, Brown, Servili and van Ommeren2019; Bryant et al., Reference Bryant, Malik, Aqel, Ghatasheh, Habashneh, Dawson, Watts, Jordans, Brown, Ommeren and Akhtar2022b; Pfeffer et al., Reference Pfeffer, Brown, Kohrt, Sangraula and Bakke2023; Kohrt et al., Reference Kohrt, Sangraula, Turner, Pfeffer, Best, Caracoglia, Cid-Vega, Gwaikolo, McEneaney, Platt, Shah, Sun, Wong, Ganesh, Assoudeh, Wong, van Heerden and Brown2025). The study PI, who is an experienced PM+ trainer, supported the EASE ToT process by helping trainees understand strategies shared by both interventions.
Training sessions were conducted prior to each corresponding FGD session so that iterative adaptation changes to the ways in which EASE activities were carried out could be made based on feedback from previous FGDs. Such changes focused on enhancing participant engagement or amplifying key mechanisms of action.
Translation of manual
Although many languages are spoken in NYC, this adaptation focused on English speakers, with 75% of the city proficient in the language (NYC Department of City Planning, 2025). Hence, we did not conduct any translations to the intervention material, which is in English. However the original intervention is in British English and contains language that does not align with the colloquial language of adolescents and caregivers in NYC. Thus, the research personnel discussed ways to provide explanations during FGDs using culturally relevant terminology that resonates with our target population.
Expert read-through and formative qualitative study
Steps 5 (expert read-through) and 6 (formative qualitative study) aim to gain information on the applicability of the intervention materials from experienced persons in the program site and understand the targeted community’s awareness of mental health, preexisting community mental health resources and barriers faced by the community (Sangraula et al., Reference Sangraula, Kohrt, Ghimire, Shrestha, Luitel, Hof, Dawson and Jordans2021).
To this end, we set up a Community Advisory Board (CAB) per CBPR guidelines (Newman et al., Reference Newman, Andrews, Magwood, Jenkins, Cox and Williamson2011) to collaborate with community and government-level stakeholders. The committee included the study’s PI, members of The New School’s Center for Global Mental Health (see Supplementary File 1), members of OCMH, and key staff members from the three CBOs in Brooklyn. The research team met with the CAB to plan for the FGDs. The CAB meeting involved CBO staff members (n = 5), an FGD caregiver participant (n = 1), OCMH members (n = 2), and members of the research team (n = 2). The first author took notes on the community stakeholders’ feedback. These notes were relayed back to the research team to devise the next steps of the adaptation process. Key observations and the subsequent adaptation changes are summarized later.
The CBO staff expressed that opportunities for adolescents to lead discussions would encourage active participation. As a result, FGDs were designed in blocks of intervention content and immediate feedback discussion on each section of the storybook, workbook, and strategy covered.
Adolescent FGDs were hosted in person and virtually to examine the feasibility of delivering EASE remotely. As suggested by the CAB, the first FGD session was designed as a virtual orientation with all participants to build rapport and introduce the study. Afterwards, the adolescents and caregivers were split into separate FGDs. The caregivers attended three additional virtual FGDs (1.5 hours each), whereas adolescents participated in seven additional FGDs, consisting of three in-person FGDs located at each of the three CBOs (3 hours each) and four virtual FGDs on Zoom (1.5 hours each). The all-virtual approach to caregiver FGDs was planned in accordance with the feasibility and preference of adults for virtual PM+ training (McBride et al., Reference McBride, Harrison, Mahata, Pfeffer, Cardamone, Ngigi, Kohrt, Pedersen, Greene, Viljoen, Muneghina and Brown2021), as well as CAB input that virtual sessions best complement busy caregiver schedules. All virtual sessions involved a technical facilitator to troubleshoot technological difficulties.
Based on input from CAB stakeholders, the adolescent FGDs were further divided into two sub-groups with younger and older adolescents (1) to encourage discussion and initiative-taking from the adolescents in smaller settings, (2) to keep each adolescent group size from 8 to 12 participants per WHO guidelines, and (3) to explore the suitability of EASE for adolescents in varied developmental stages.
Phase III: Implementation
Practice rounds
The FGDs were composed primarily of practice rounds, which refer to intervention delivery to the targeted population to obtain first-hand feedback about adaptation (Sangraula et al., Reference Sangraula, Kohrt, Ghimire, Shrestha, Luitel, Hof, Dawson and Jordans2021). In each FGD, two members of the research team served as facilitators leading intervention delivery and guiding group discussions, and two members served as notetakers. CBO staff also participated in the adolescent FGDs to help guide discussion. Following each practice round delivery of a core EASE component, participants engaged in extensive discussion focused on providing feedback. Cognitive interviews about the adolescents’ overall experience with EASE were also conducted during the final in-person FGD. The questions from the cognitive interviews can be found in Box 1 of Supplementary File 2.
Team adaptation workshops
Community sharebacks in June and October were conducted with the research team, CAB stakeholders, and adolescent and caregiver participants to review all intervention adaptations following the completion of practice rounds. In both sharebacks, the research team presented an overview of adaptation changes to date and obtained additional feedback from all stakeholders. The recommendations were then reviewed for final adjustments.
Data analysis
Data analysis was conducted on the four main components of the RECAPT criteria: (1) cultural concepts of distress; (2) community needs, stigma and context; (3) treatment components and (4) treatment delivery (Heim et al., Reference Heim, Mewes, Abi Ramia, Glaesmer, Hall, Harper Shehadeh, Ünlü, Kananian, Kohrt, Lechner-Meichsner, Lotzin, Moro, Radjack, Salamanca-Sanabria, Singla, Starck, Sturm, Tol, Weise and Knaevelsrud2021a). When mapping out FGD themes, we combined the deductive approach of the RECAPT criteria with an inductive approach based on participant feedback and research team observations.
As adolescents and caregivers were divided into FGD groups of six to seven participants, data from FGDs were manually coded by the research team. The FGD notetaker jotted down participants’ feedback and observations during the FGDs, and these notes were reviewed by the research team to identify themes. In addition, we collected participants’ immediate feedback via sticky notes during in-person sessions and via Mural during virtual sessions.
Data were extracted from the FGD notes, including responses from cognitive interviews. The team also conducted post-FGD debriefings to discuss the observations and feedback from all FGDs, with the goal of reaching a consensus on the key themes of observation and feedback from each FGD. Key points were summarized into themes based on the RECAPT criteria by the first two authors.
Results
Participant characteristics
As participants were recruited directly from the community programs of the partner CBOs, which serve Black, Hispanic, and Latino communities in economically marginalized neighborhoods in Brooklyn, NYC, the participant group reflects the communities and cultures that EASE aims to serve. The average age of the adolescents (n = 18) was 12.9, reflecting the EASE intervention’s targeted range. The group was relatively balanced in gender and was largely composed of adolescents who identified as Black or African American (72%), with the remaining identifying as Hispanic or Latino (22%) and American Indian (6%), as reported by participants in a questionnaire based on the racial and ethnic identity categories used by the US Census Bureau (2024). A number of adolescents were second generation immigrants (42%) or first generation immigrants (7%), and bilingual or multilingual (21%). The majority were in families receiving Medicaid (income-based health support) or SNAP (nutrition support) benefits (60%), and some adolescents had experienced homelessness (14%) (see Table 1). Twelve caregivers from the three partner CBOs participated in the study. Eight participants were caregivers of the adolescents enrolled in the study. Unfortunately, the demographic characteristics of the caregivers were not collected in the current study as caregivers were enrolled a couple weeks after adolescents and thus did not have a chance to complete demographic questionnaires.
Table 1. Sociodemographic characteristics of adolescents
Note: Not all participants responded to all of the questions about their lived experiences, hence the percentages reported only reflect the proportion of participants who responded.
Adaptation
This section highlights selected adaptation themes documented from the FGDs reported following the RECAPT criteria (Heim et al., Reference Heim, Mewes, Abi Ramia, Glaesmer, Hall, Harper Shehadeh, Ünlü, Kananian, Kohrt, Lechner-Meichsner, Lotzin, Moro, Radjack, Salamanca-Sanabria, Singla, Starck, Sturm, Tol, Weise and Knaevelsrud2021a), and can be seen in full in Supplemental File 1. Initially conceived to standardize and document the cultural adaptation process of mental health RCTs for refugees in Germany and reviewed by experts in cultural adaptation literature, the RECAPT consists of 11 criteria grouped under four stages (Heim et al., Reference Heim, Mewes, Abi Ramia, Glaesmer, Hall, Harper Shehadeh, Ünlü, Kananian, Kohrt, Lechner-Meichsner, Lotzin, Moro, Radjack, Salamanca-Sanabria, Singla, Starck, Sturm, Tol, Weise and Knaevelsrud2021a).
Stage A: A setup included documenting key characteristics about the target population and the researchers’ backgrounds (see Supplemental File 1).
Stage B: Formative research outlined the methods for the cultural adaptation process and reported on the target population’s mental health context and experiences, including (1) cultural concepts of distress; (2) community needs, stigma and context; (3) treatment components; and (4) treatment delivery.
Stage C: Intervention adaptation reported changes made to specific treatment elements based on the key mechanisms of action as well as surface adaptations aimed to improve intervention acceptability by our target population.
Stage D: Measuring outcomes and implementation includes criteria on reporting the questionnaires, clinical interviews and processes used during implementation (Heim et al., Reference Heim, Mewes, Abi Ramia, Glaesmer, Hall, Harper Shehadeh, Ünlü, Kananian, Kohrt, Lechner-Meichsner, Lotzin, Moro, Radjack, Salamanca-Sanabria, Singla, Starck, Sturm, Tol, Weise and Knaevelsrud2021a). These criteria are omitted in the current report as the study focuses on the adaptation of EASE prior to pilot implementation.
Cultural concepts of distress
Cultural concepts of distress refer to the ways in which the target population perceives and experiences distress. This category is subdivided into idioms of distress based on different symptoms (e.g. emotional, behavioral), explanations of distress, and beliefs about the distress (Heim et al., Reference Heim, Mewes, Abi Ramia, Glaesmer, Hall, Harper Shehadeh, Ünlü, Kananian, Kohrt, Lechner-Meichsner, Lotzin, Moro, Radjack, Salamanca-Sanabria, Singla, Starck, Sturm, Tol, Weise and Knaevelsrud2021c; Aeschlimann et al., Reference Aeschlimann, Heim, Hoxha, Triantafyllidou, Killikelly, Haji, Stöckli, Aebersold and Maercker2024). The current report focuses on the ways in which distress is conceptualized by our surveyed sample due to its influence on the subsequent adaptation changes.
Notable cultural explanations of distress included a lack of understanding of distressing emotions, lack of knowledge of how to respond to emotions, and the need to hide emotions. During the discussion about identifying feelings in the second FGD, adolescents shared their challenges with explicitly labeling their emotions. Adaptations were made based on these results to add a “Feelings Wheel,” which introduced a richer emotional vocabulary necessary for the identification and communication of nuanced feelings containing over 50 emotion words. This complemented and extended the original intervention’s “Feelings Chart” of 10 basic emotions as part of Adolescent Activity 1.5 (Understanding my feelings).
In the second FGD, adolescents cited that they sometimes felt controlled by their emotions in response to events that made them sad or angry. While the original activity focused on brainstorming problems and potential solutions, we added the concept and activity of a “Circle of Control” to Adolescent Activity 6.4 (Managing my problems with a new problem), which encourages adolescents to reflect on which aspects of a stressful situation are within their control and, thus, where to focus their energies in managing their emotions and efforts to change their external environments. Moreover, adolescents shared that they often conceal their emotions to appease societal expectations, especially among young men. In relation to this finding, some of the participants indicated that the “Feelings Pot” in Adolescent Activity 1.7 (Identifying personal feelings) may reinforce the idea of suppressing instead of learning to express one’s emotions. For example, when completing the activity, an 11-year-old said: “Why are we putting emotions into a pot? That’s just like bottling them up, but we’re supposed to learn how to express feelings.”Footnote 1 Thus, the Feelings Pot in the original intervention was changed to a Feelings Canvas to encourage emotional expression (see Figure 2). This modification was met with great enthusiasm by adolescents during the community shareback in June 2024.
Figure 2. Adaptation of Feelings Pot to Feelings Canvas in Adolescent Activity 1.7 (Identifying personal feelings). (A) Feelings Pot in the original manual. (B) Feelings Canvas, which is the adapted version of the Feelings Pot, in the current manual. These images are reproduced and adapted from Early Adolescent Skills for Emotions. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2023. License: CC BY-NC-SA 3.0 IGO. WHO is not responsible for the content or accuracy of this translation/adaptation.
Community needs, stigma and context
Community needs, stigma and context refer to the setting-specific information that influences mental wellbeing (Heim et al., Reference Heim, Mewes, Abi Ramia, Glaesmer, Hall, Harper Shehadeh, Ünlü, Kananian, Kohrt, Lechner-Meichsner, Lotzin, Moro, Radjack, Salamanca-Sanabria, Singla, Starck, Sturm, Tol, Weise and Knaevelsrud2021c). This includes factors such as the community’s understanding of mental health based on sociocultural determinants, openness to treatment, and access to mental health resources. This category is divided into two subcategories: attitudes toward mental health, which reflect how the community considers mental health aside from their perception of distress, and specific needs and other contextual information, which outlines social determinants that shape the current adaptation.
Attitudes toward mental health
Adolescents and caregivers’ attitudes toward mental health shared in FGDs included advocacy for inclusive and safe spaces when sharing mental health struggles; a desire for deeper knowledge-based explanations of psychological benefits; and building purpose, meaning, connection and identity.
Both adolescent and caregiver participants saw the promotion of inclusivity and sharing in safe spaces as important tenets of mental health. To that end, the original intervention’s “Body Map” poster of one male outline was expanded into five additional versions of outlined bodies that reflect different genders and body shapes (Adolescent Activity 2.3, Feelings and My Body). Associations of shame and physical punishment as parental discipline were also removed from the caregiver story (Caregiver Activity 2.5, Alternatives to harsh punishment). These adaptations aimed to reduce potential stigma and judgment such that participants could feel safer expressing themselves.
Moreover, the adolescents’ curiosity about the mind–body connection and the physiological basis of the coping strategies they were learning led to the addition of a Slow Breathing infographic in Adolescent Activity 2.4 (Calming my body) (see Figure 3). This infographic provides in-depth information about how the Slow Breathing strategy is connected with the nervous system. Variations to the strategy were also included to better connect it with the adolescents’ interest in somatic experiences. These adaptations aimed to promote engagement and relevance of the Slow Breathing activity.
Figure 3. Slow Breathing infographic in Adolescent Activity 2.4 (Calming my body). The infographic provides in-depth information about how the Slow Breathing strategy is connected with the nervous system.
Throughout the FGDs, adolescents expressed a strong desire to develop self-understanding and navigate purpose and meaning, particularly in relation to seeing how their personal identities might relate to the communities around them. These themes were mostly found in the fourth, fifth, and sixth FGDs, which covered behavioral activation and problem management strategies. For instance, when completing Adolescent Activity 3.4 (Changing my actions) and 5.4 (Managing my problems), adolescents questioned how they could identify a goal to work toward or how they could address a community-level concern based on their personal interests, strengths, and weaknesses. Thus, new activities were added to better connect EASE strategies to the adolescents’ personal lives and communities. For example, the concept and activity for a “Virtuous Cycle” was added to Adolescent Activity 4.3 (Changing my actions) to complement the original “Vicious Cycle.” The new activity encourages adolescents to explore how a self-reinforcing loop of fulfilling activities can motivate them. Similarly, the concept of the “Growth Mindset” and “Growth Zone” as opposed to the “Fixed Mindset” and “Comfort Zone” was included in Adolescent Activity 5.3 (Understanding common problems). This activity aims to help adolescents reframe challenges as learning opportunities. Furthermore, “Purpose Diagram” activities were included in Adolescent Activities 3.4 and 4.3 (Changing my actions) (see Figure 4). These initial activities prompt adolescents to consider what things they love doing, what things they are good at, and the intersection of these domains to identify their “passion.” The final Purpose Diagram activities are introduced in Adolescent Activities 6.5 (Completing the Purpose Diagram) and 7.3 (Brighter Futures) to explore “how I see the world,” “how I can make a difference,” and the intersecting components of “values,” “gifts” and “possibilities.” The Purpose Diagram activities aimed to guide adolescents in reflecting on how different aspects of their lives are interconnected and how they can form meaningful goals.
Figure 4. Purpose Diagram in Adolescent Activities 3.4 and 4.3 (Changing my actions); 6.5 (Completing the Purpose Diagram); and 7.3 (Brighter Futures). Through several Purpose Diagram activities, adolescents complete a full Purpose Diagram.
Specific needs and other relevant contextual information
Gender norms emerged as an important point of discussion during the caregiver FGDs. The caregivers felt that the original storyline emphasized the female caregiver’s homemaking responsibilities in comparison to the male caregiver but failed to discuss the emotional impact of this traditional gender norm equitably. To this end, a greater male caregiver presence was incorporated in the storyline, and we also included a discussion about caregiver responsibilities that could be influenced by gender roles in Caregiver Activity 3.4 (Gender roles in caregiving). We aimed to acknowledge the contributions of all caregivers and prompt discussion about ways to create a more supportive caregiving environment.
Furthermore, caregivers and adolescents expressed how digital technology could affect youth mental health positively and negatively throughout the FGDs. Thus, in the storybook adaptation, we portrayed the benefits of digital technology through the main character’s use of his phone to learn skateboarding skills and to connect with his friends. In contrast, the harms of digital technology are represented by cyberbullying, which the main character learned to address with the EASE skill of problem-solving.
In addition to cyberbullying, adolescents reported facing challenges from the economic pressures of NYC’s high living costs and peer pressure. We incorporated these findings in the adapted storybook to make it more relevant. For example, we included a scene of the main character struggling with pocket money when his friends wanted to go to a bodega together (Storybook text 19).
Regarding group dynamics, suggestions from the final FGD with adolescents emphasized the importance of bonding with facilitators and building trust among the group to encourage more honest and open expression. The older adolescents particularly appreciated how the CBO staff helper in their group shared personal experiences. This openness made the adolescents feel more comfortable sharing their own thoughts and feelings. Appropriate and genuine self-disclosure by EASE facilitators should be encouraged during training sessions. Although activities to build rapport within EASE groups exist in the original manual (e.g. Welcome activity at the beginning of all adolescent sessions), they were considered “too young” for the 10 to 15 year old age group in NYC. Thus, we replaced icebreaker suggestions like singing a song in the group with the use of multimedia, such as presenting pop culture video clips related to EASE topics for discussion. Similarly, roleplays were found to create awkward dynamics among adolescent groups, and adolescents were not actively engaged in them. For example, a 15-year-old commented that the roleplay activities were “weird, childish and not fun”Footnote 2 during the final FGD. As a result, we de-emphasized the use of roleplays throughout the adolescent sessions. For instance, the roleplay activity for “linking feelings and behaviors” in Adolescent Activity 4.3 (Changing my actions) was replaced by a visualization activity that served the same purpose: encouraging adolescents to be more emotionally aligned with their goal.
Treatment components
Treatment components refer to the ways in which the intervention is oriented and structured, taking into account the community’s understanding of distress, lived experiences, and access to mental health resources. Echoing Aeschlimann et al. (Reference Aeschlimann, Heim, Hoxha, Triantafyllidou, Killikelly, Haji, Stöckli, Aebersold and Maercker2024), the current study considers how the intervention goals are framed to address community mental health concerns. We found that it is crucial to clarify the framing of treatment goals when considering how to modify EASE treatment components. Two treatment goals were identified in the study: (1) developing social and emotional learning (SEL) and (2) community-building.
Framing treatment goals
As the current adaptation aims to create a version of EASE catered to urban adolescents and caregivers in NYC, we aimed to align the adaptation to programming by the Department of Youth & Community Development (DYCD) in NYC, which integrates SEL competencies identified by the Collaborative for Academic, Social and Emotional Learning (CASEL, 2015). CASEL addresses the five competencies of self-awareness, self-management, social awareness, relationship skills, and responsible decision-making (CASEL, 2015). We found that the CASEL competencies of self-awareness, self-management, and responsible decision-making seemed to be most salient in the original EASE activities, as evidenced by the adolescents’ feedback in the second FGD, which covered the EASE theme of identifying and understanding feelings, and the fifth and sixth FGDs, which covered the EASE theme of problem management. For instance, Adolescent Activity 1.7 (Identifying personal feelings) encouraged adolescents to use colors as a way of expressing emotions through the Feelings Pot. This activity prompts adolescents to better articulate their feelings, thus building their emotional regulation skills and competency for self-management: managing one’s emotions, thoughts and behaviors (CASEL, 2015). Moreover, Adolescent Activities 5.4 (Managing my problems) and 5.5 (Applying managing my problems), which introduced the Stop, Think, Go strategy to guide adolescents in brainstorming solutions for their problems, is related to the competency of responsible decision-making, which includes the ability of developing one’s critical thinking skills and making constructive choices (CASEL, 2015). However, these two competencies, as well as the competencies of self-awareness, social awareness, and relationship skills, could be more greatly emphasized in the current adaptation to better align EASE with DYCD programming.
The current adaptation’s Purpose Diagram activities (Adolescent Activities 3.4 and 4.3, Changing my actions; Adolescent Activity 6.5, Completing the Purpose Diagram; Adolescent Activity 7.3, Brighter Futures) target all of the CASEL competencies of SEL. Through activities that encourage adolescents to reflect on what they love and what they are good at, adolescents can improve their self-awareness through reflecting on their identities and strengths. Furthermore, through discussions about how they see the world and how they can make a difference, adolescents are guided to consider how they may contribute to their communities, thereby developing the competencies of social awareness, relationship skills, and responsible decision-making.
These new SEL-related additions to the program are supported by previous research that emphasizes the importance of SEL for adolescents in various contexts (Cherewick et al., Reference Cherewick, Lebu, Su, Richards, Njau and Dahl2021; Marsay et al., Reference Marsay, Atitsogbe, Ouedraogo, Nsubuga, Pari, Kossi, Park and Solberg2021; Gimbert et al., Reference Gimbert, Miller, Herman, Breedlove and Molina2023; Maloney et al., Reference Maloney, Whitehead, Long, Kaufmann, Oberle, Schonert-Reichl, Cianfrone, Gist and Samji2024; Martinez and Gomez, Reference Martinez and Gomez2024). Given existing literature highlighting the significance of mentalizing and emotional regulation to self-development (Pfeifer and Peake, Reference Pfeifer and Peake2012) and how SEL practices may benefit the development of ethnic-racial identity (Rivas-Drake et al., Reference Rivas-Drake, Lozada, Pinetta and Jagers2020), the Purpose Diagram activities aimed to further promote these areas of growth.
Community-building was identified as a second major treatment goal. This theme emerged throughout all the adolescent FGDs, and it is related to the previous finding on group dynamics. However, community-building goes beyond simply fostering rapport among adolescents and facilitators to encourage more open and honest sharing. We found that the treatment goals of SEL and community-building may complement each other. Notably, while reviewing the Slow Breathing home practice during the final FGD, a 14-year-old mentioned enjoying the activity with their friends, saying “Yeah we breathed together, they calmed me down, they’re real friends. Real friends breathe together!”Footnote 3
This finding was reinforced during team adaptation workshops, where CBO staff members emphasized that the original intervention’s group discussions and activities could create a safe space for adolescents to learn collaboratively. The CBO staff members also expressed that developing adolescents’ socioemotional skills could potentially improve community-building efforts by equipping them with the ability to establish and maintain healthy relationships. These findings point towards the importance of prioritizing community-building as a central goal of EASE. To this end, we added an EASE “yearbook” activity and expanded the graduation ceremony in Adolescent Activities 7.3 (Brighter futures) and 7.4 (Ending the intervention). Additionally, we are exploring the possibility of optional post-EASE drop-in sessions that can be integrated into existing community programs, such that adolescents can come together following the end of the official program to build relationships and continue practicing EASE skills. Through celebrating adolescents’ accomplishments in the EASE program, encouraging them to write and draw messages to future participants, and creating spaces for adolescents to continue learning from each other, we aim to promote community connectedness and program sustainability.
The importance of community-building in supporting adolescents’ socioemotional learning and growth aligns with previous studies indicating that adolescents responded to interviews and therapy more productively when interviewers and therapists offered self-disclosure or engaged in deliberate rapport-building (Brown et al., Reference Brown, Holloway, Akakpo and Aalsma2014; Dianiska et al., Reference Dianiska, Swanner, Brimbal and Meissner2021, Reference Dianiska, Simpson and Quas2024). In forming trusted connections with other participants and the EASE facilitators and CBO staff helpers, participants were more likely to share their thoughts and feelings honestly without fear of judgment. This is supported by past studies indicating how community-based approaches could enhance SEL programming for adolescents, caregivers, and educators (McKay-Jackson, Reference McKay-Jackson2014; Anziom et al., Reference Anziom, Strader, Sanou and Chew2021; Paik et al., Reference Paik, Duh, Rodriguez, Sung, Ha, Wilken and Lee2024; Speidel et al., Reference Speidel, Tsang, Day, DiSanto, Keel, Phu, Diaz, Miletic, Dhaliwal, Saldanha, Zhang and Malti2024).
Treatment delivery
Treatment delivery refers to how the intervention is implemented, including the format, method of communication, and the ways in which the key mechanisms of the intervention are portrayed to the community (Heim et al., Reference Heim, Mewes, Abi Ramia, Glaesmer, Hall, Harper Shehadeh, Ünlü, Kananian, Kohrt, Lechner-Meichsner, Lotzin, Moro, Radjack, Salamanca-Sanabria, Singla, Starck, Sturm, Tol, Weise and Knaevelsrud2021b, Reference Heim, Mewes, Abi Ramia, Glaesmer, Hall, Harper Shehadeh, Ünlü, Kananian, Kohrt, Lechner-Meichsner, Lotzin, Moro, Radjack, Salamanca-Sanabria, Singla, Starck, Sturm, Tol, Weise and Knaevelsrud2021c; Aeschlimann et al., Reference Aeschlimann, Heim, Hoxha, Triantafyllidou, Killikelly, Haji, Stöckli, Aebersold and Maercker2024). This category is subdivided into delivery format and surface adaptations, and the following sections outline findings and modifications made to improve the acceptability and engagement of EASE within the target community. Results regarding treatment delivery highlight issues and recommendations related to the delivery format, such as barriers to and advantages of use, promotion of use and key takeaways from surface adaptations.
Delivery format
Through the caregiver FGDs, we found that virtual meetings increased accessibility and convenience. The caregivers expressed preferences for virtual delivery, citing benefits of flexibility for their busy schedules. However, for adolescents, we observed more engagement, better focus and information absorption in in-person FGDs than in virtual FGDs; thus, we determined that in-person delivery is more suitable for adolescents. This result is in line with previous findings indicating that adolescents value forming connections with facilitators and other EASE group members, which helps them feel more comfortable sharing their thoughts and feelings, and aligns with the treatment goal of community-building.
In light of the community-building treatment goal, results indicated that the delivery of EASE could be integrated into existing adolescent groups within community organizations or after-school programs. The established relationships among members and trusted environments in these settings offer safe spaces that can support adolescents in honest self-expression and promote more effective SEL. These methods of delivery will inform the pilot implementation of EASE in the next phase of the study, where we aim to collaborate with DYCD to bring this adapted version of EASE to CBOs in NYC.
Surface adaptations
Throughout the FGDs, adolescents raised the critical point about not being able to identify with the characters and storyline in the EASE storybook. After reading storybook texts that involved the storybook main character encountering colorful, talking birds and engaging in birdwatching as a hobby, a 15-year-old said “In NYC, if you’re a kid, you’re probably walking to school alone, unless you take the bus or train to go to school in another area, but you can’t talk to birds in the subway or through the window. Seeing birds while walking on the sidewalks to school makes more sense, I guess, but it’s not a hobby.”Footnote 4 And a 13-year-old said, “Why is he still with the bird? Are the birds in his head?”Footnote 5 as the storybook main character continued developing his relationship with the birds. To make the main character more relatable to the adolescents, we modified the main character’s hobby to skateboarding, something that the adolescents expressed was a fun, enjoyable, and trendy activity. We removed the motif of the colorful talking birds and replaced it with an artist from a community center using different colors on his canvas to express emotions. This change aligns with the goal of Adolescent Activity 1.7 (Identifying personal feelings), which intended to use the birds to introduce adolescents to the concept of using colors to identify their feelings. Moreover, through incorporating themes such as gender norms, use of technology, economic pressure, and peer pressure in both the adolescent and caregiver storylines, we aimed to better reflect the challenges faced by adolescents and caregivers from the target community, and the storybook, poster and workbook illustrations were modified to be more representative of people in NYC (see Figure 5). These changes were highly endorsed by adolescents and caregivers during the community shareback in October 2024, with many participants sharing that the revised storyline and characters more accurately reflected their day-to-day experiences in NYC. Adolescents also expressed greater interest in this version of EASE because they could better identify with the main character’s journey of self-emotional exploration.
Figure 5. Adaptation of the Vicious Cycle Poster in Adolescent Activity 3.3 (Feelings and actions). (A) Vicious Cycle Poster in the original version. (B) Adapted version of the Vicious Cycle Poster in the current manual. These images are reproduced and adapted from Early Adolescent Skills for Emotions. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF), 2023. License: CC BY-NC-SA 3.0 IGO. WHO is not responsible for the content or accuracy of this translation/adaptation.
Finally, throughout the FGDs, the adolescents often proposed changes to phrases, idioms, and word use. In particular, both the younger and older adolescent groups expressed that the language used in the storybook seemed too formal. Many issues surrounding language were also related to the content of the adolescent storybook. For example, regarding storybook text 2, a 12-year-old said: “Who says ‘can we sing together’? It doesn’t sound New York at all. I’d ask if his sister would want to watch TV or play a game.”Footnote 6 Thus, local idioms and colloquial language were incorporated in the final text to make it more acceptable to the adolescents.
Activity ratings
In addition to collecting feedback based on the RECAPT criteria, we asked the adolescents to rank key elements (activities and posters) of the EASE intervention by (1) how helpful and (2) how engaging they found them out of 5. The average scores for these individual ratings, as well as the average scores across both ratings, can be found in Table 2.
Table 2. Average element ratings for core EASE elements
Note: The activities are presented in descending order of their overall score. Not all adolescents rated all of the activities, hence the scores reported do not reflect the averages for all participants.
* No engagement score is reported because the adolescents did not rate it.
1 Through drawing physical sensations associated with emotional experiences on body outlines, adolescents explore how their bodies may be affected by problems and feelings.
2 Through going through steps for problem management, adolescents learn to define a practical problem, explore possible solutions, choose the most helpful option, and plan to solve it.
3 Through filling in a plan for carrying out an enjoyable or meaningful activity, adolescents learn to break down their goals into small, manageable steps.
4 Through discussing coping strategies, adolescents learn to distinguish between helpful and unhelpful approaches.
5 Through writing potential solutions on the branches of a tree outline, adolescents practice brainstorming different ways to solve a problem.
6 Through discussing how the storybook main character is affected by a vicious cycle, adolescents learn how intense emotions can make one feel worse.
7 Through working together to find their way through a maze, adolescents learn the importance of trying out different options to solve a problem.
8 Through discussing the benefits of slow breathing and practicing it together, adolescents learn a skill to calm their bodies.
9 Through drawing feelings in the feelings pot, adolescents learn to express their emotions using creative means.
10 Through identifying the different feelings portrayed by characters in the feelings chart, adolescents learn to recognize and label emotions.
11 Through identifying features of a character portraying sadness, adolescents learn how feelings can be manifested in different ways.
Notably, the Body Map activity (Adolescent activity 2.3), the Stop, Think, Go activity (Adolescent activity 5.4), the Staircase activity (Adolescent activity 3.4) and the Solutions Tree activity (Adolescent activity 5.5) were in the top five highest rated elements for both how helpful and how engaging they were for the adolescents.
This feedback helped guide the adaptation of activities and illustrations, as some elements were found to be helpful but less engaging, suggesting that the elements could be made more relevant and appealing to NYC adolescents. For instance, the Slow Breathing strategy (Adolescent activity 2.4) was rated as fairly helpful (4.00) but less engaging as presented in the original manual (2.00). This finding echoed observations and quotations from the adolescents, as outlined in the previous section, indicating that the adolescents appreciated the strategy’s potential benefits but did not find it interesting. As a result, we added graphics and workshopped additional variations to the activity to make it more engaging.
Discussion
This paper presents findings of the community-based adaptation of EASE for underserved youth and caregivers in NYC. Through a series of FGDs with stakeholders such as youth, caregivers and CBO staff members, we obtained a range of valuable feedback regarding the areas of (1) cultural concepts of distress, (2) community needs, stigma and context, (3) treatment components and (4) treatment delivery. The feedback reflected the need for mental health resources and equitable access to mental health treatment for underrepresented groups in the US (Garland et al., Reference Garland, Lau, Yeh, McCabe, Hough and Landsverk2005; Alegría et al., Reference Alegría, Canino, Shrout, Woo, Duan, Vila, Torres, Chen and Meng2008; Martin et al., Reference Martin, Banaag, Riggs and Koehlmoos2021; Rothe et al., Reference Rothe, Fortuna, Tobon, Postlethwaite, Sanchez-Lacay and Anglero-Diaz2021; Chen et al., Reference Chen, Lui, Liu, Wright, Benson, Lin and Lau2022; Fan et al., Reference Fan, DuPont-Reyes, Hossain, Chen, Lueck and Ma2022; Rodgers et al., Reference Rodgers, Flores, Bassey, Augenblick and Cook2022; Weersing et al., Reference Weersing, Gonzalez, Hatch and Lynch2022).
We found that adaptation frameworks were essential for guiding our understanding of the intervention’s core elements, the target population and context, and the changes made. In particular, the RECAPT criteria enabled us to comprehensively assess community needs and treatment approaches (Heim et al., Reference Heim, Mewes, Abi Ramia, Glaesmer, Hall, Harper Shehadeh, Ünlü, Kananian, Kohrt, Lechner-Meichsner, Lotzin, Moro, Radjack, Salamanca-Sanabria, Singla, Starck, Sturm, Tol, Weise and Knaevelsrud2021a). Based on the RECAPT, we made deep adaptations that aligned the intervention’s components with SEL goals (CASEL, 2015) and emphasized its orientation to community-building. We also made surface adaptations to improve EASE’s acceptability, relevance, and engagement, such as altering the depiction of characters, incorporating community-specific day-to-day experiences and challenges, and using local idioms. The mhCACI framework, on the other hand, helped prepare us for future implementation and scaling. Its emphasis on adapting interventions within community settings and iterative processes has encouraged our ongoing collaboration with the OCMH, the three partnering CBOs, and participating adolescents and caregivers (Sangraula et al., Reference Sangraula, Kohrt, Ghimire, Shrestha, Luitel, Hof, Dawson and Jordans2021). Echoing existing literature, we found that the use of systematic frameworks streamlined the adaptation process and facilitated the integration of evidence-based knowledge, cultural contexts, and close partnership with community stakeholders (Wang et al., Reference Wang, Norris and Bero2018; Leung et al., Reference Leung, Sekar, Madrigal and Escoffery2024; Fernández et al., Reference Fernández, Baumann, Beg, Schneiderman, Revenson, Abraído-Lanza, Smith, Anderson, Antoni and Penedo2025).
Results preliminarily suggest that the process of culturally adapting EASE was an important first step toward its implementation. Although it is still to be determined, the steps taken to adapt EASE in collaboration with various stakeholders from the community may result in greater uptake and engagement, as these steps are in line with both international recommendations (Inter-Agency Standing Committee, 2007, as well as frameworks and proposals underscoring the importance of adaptation prior to implementation (Bennouna et al., Reference Bennouna, Ocampo, Cohen, Basir, Allaf, Wessells and Stark2019; Perera et al., Reference Perera, Salamanca-Sanabria, Caballero-Bernal, Feldman, Hansen, Bird, Hansen, Dinesen, Wiedemann and Vallières2020). Importantly, a burgeoning body of research has found that culturally and contextually adapted interventions are associated with factors such as greater fit, acceptability, relevance, and fidelity (Bernal et al., Reference Bernal, Bonilla and Bellido1995; Ferrer-Wreder et al., Reference Ferrer-Wreder, Sundell and Mansoory2012; Fernández et al., Reference Fernández, Baumann, Beg, Schneiderman, Revenson, Abraído-Lanza, Smith, Anderson, Antoni and Penedo2025).
Arguments in support of the potential benefits of adaptation towards implementation were also supported by feedback from stakeholders in our study. Throughout the FGDs, adolescents and caregivers indicated that the intervention strategies had to be relevant to community needs, the characters and scenes needed to be representative of their day-to-day experiences and the challenges, and coping strategies recommended in the EASE curriculum had to feel realistic in order for implementation to be successful. All stakeholders also expressed great enthusiasm during the community sharebacks, where we shared preliminary changes made to the intervention based on participants’ feedback.
Interestingly, another potential reason that this process may lead to greater implementation success may come from directly engaging adolescents in FGDs. Rather than simply relying on adults to guide potential implementation strategies, we prioritized youth perspectives to ensure that the adaptation would be more aligned with the actual realities of the young people it aims to serve. The inclusion of youth in the adaptation of interventions may be an important factor in implementation success, and it will be helpful to see how youth participation contributes to outcomes in various contexts (e.g. Galbraith et al., Reference Galbraith, Tarbox and Huey2023; Freeman et al., Reference Freeman, Desrosiers, Schafer, Kamara, Farrar, Akinsulure-Smith and Betancourt2024). Moreover, the adaptation processes may allow for greater implementation success as the FGDs were likely viewed as opportunities for community-building. Framing adaptation as a form of community-building builds on prior research that suggests the significance of leveraging relational factors to engage mental health non-specialists in co-designing and implementing community-based programs (Castro et al., Reference Castro, Barrera and Martinez2004; Marsiglia and Booth, Reference Marsiglia and Booth2015; Simpson et al., Reference Simpson, Ruru, Oetzel, Meha, Nock, Holmes, Adams, Akapita, Clark, Ngaia, Moses, Reddy and Hokowhitu2022; Norman et al., Reference Norman, Sedem, Ferrer-Wreder, Eninger and Hau2024).
Additionally, the results are supported by the qualitative rigor of data collection and analysis. For instance, purposive sampling was conducted to identify adolescents of color in economically marginalized neighborhoods in Brooklyn, NYC, through collaboration with local CBOs. This procedure ensured that the participants and contexts surveyed were most appropriate for meeting the research goals (Johnson et al., Reference Johnson, Adkins and Chauvin2020).
Furthermore, the study aimed to maintain a high degree of trustworthiness in its methods. Trustworthiness ensures result reliability through the credibility, transferability, dependability, and confirmability of qualitative findings (Stahl and King, Reference Stahl and King2020; Ahmed, Reference Ahmed2024). The current study established credibility via data triangulation, as we used several sources of information, such as the researchers’ observational feedback and interview notes, to identify patterns (Johnson et al., Reference Johnson, Adkins and Chauvin2020; Stahl and King, Reference Stahl and King2020). In addition, the study involved prolonged engagement, such that researchers gained familiarity with the participants and their cultures and contexts over the course of 2 months. This strategy enhanced result credibility and supported researcher reflexivity (Johnson et al., Reference Johnson, Adkins and Chauvin2020; Stahl and King, Reference Stahl and King2020). By discussing individual backgrounds and experiences (see Supplemental File 1), the team was better able to recognize potential research biases and report findings that more accurately represent participants’ perspectives. To establish confirmability, we conducted member checking and peer debriefing, which allowed participants and colleagues at the NYC Hall to review our work (Busetto et al., Reference Busetto, Wick and Gumbinger2020; Johnson et al., Reference Johnson, Adkins and Chauvin2020; Stahl and King, Reference Stahl and King2020; Ahmed, Reference Ahmed2024). Regarding transferability, Supplemental File 1 provides thick descriptions on the research procedures, contextual information, and decisions made based on the RECAPT criteria to provide insights into the applicability and relevance of our findings to other contexts (Stahl and King, Reference Stahl and King2020; Ahmed, Reference Ahmed2024). Our documentation of the adaptation process also ensures traceability for potential study replication, thus reaching the criterion of dependability (Johnson et al., Reference Johnson, Adkins and Chauvin2020; Ahmed, Reference Ahmed2024).
Limitations and future directions
As the current study is limited to reporting the adaptation process, future studies are needed to assess the adapted intervention within an implementation context to determine the significance of cultural adaptation towards effective implementation. As outlined above, we omitted steps 9 and 10 of the mhCACI framework in our methods; hence, the current study only provides a preliminary indication of how cultural adaptation could lead to more effective implementation. We decided to publish this report ahead of implementation for a more detailed documentation of the adaptation process, addressing the current gap in adaptation reports and contributing to the literature by illustrating how adaptations are conducted in practice (Escoffery et al., Reference Escoffery, Lebow-Skelley, Udelson, Böing, Wood, Fernandez and Mullen2019; Leung et al., Reference Leung, Sekar, Madrigal and Escoffery2024; Fernández et al., Reference Fernández, Baumann, Beg, Schneiderman, Revenson, Abraído-Lanza, Smith, Anderson, Antoni and Penedo2025). However, it is crucial to integrate cultural adaptation research with the field of implementation science to better translate research findings into routine care settings, sustainably reach underrepresented communities, and promote health equity (Sangraula et al., Reference Sangraula, Kohrt, Ghimire, Shrestha, Luitel, Hof, Dawson and Jordans2021; Lau et al., Reference Lau, Huey and Baumann2023). Through a single-arm pilot of the adapted intervention in 2025, we aim to further our understanding of how the intervention might be continuously adapted and implemented within community-based settings.
Another limitation of the current study is that it is unclear whether the adaptations made to the intervention would necessarily meet its goals of improving youth mental health outcomes and fostering SEL and identity development. Given existing adaptation literature on cultural and ethnic invariance (Huey et al., Reference Huey, Tilley, Jones and Smith2014; Jones et al., Reference Jones, Huey, Rubenson, Frisby and O’Donohue2018), it is critical to test the potential benefits of our adaptation. For example, what are the specific adaptations, such as SEL, identity development, and community-building for youth, that lead to more effective implementation and engagement? We also recommend comparing the effects of our adapted intervention with the original intervention through RCTs to explore whether our adaptations are causally related to improved mental health outcomes (Huey et al., Reference Huey, Tilley, Jones and Smith2014). Moreover, future research should also more critically examine the most effective adaptation strategies to meet the mental health needs of underrepresented groups (Park et al., Reference Park, Rith-Najarian, Saifan, Gellatly, Huey and Chorpita2023).
Further imitations of the current study include the small sample size and variations in adolescent and caregiver attendance. Due to scheduling limitations and technological difficulties, we did not always have the same number of participants in all the FGDs, and though we opened up the FGDs to newcomers to ensure we had a good number of participants in each session, the sample size was still limited to 18 adolescents and 12 caregivers. The small sample size may limit the generalizability of findings to other communities within or outside the US context. Despite these unavoidable logistical limitations, our sample size was consistent with similar adaptation studies (Garabiles et al., Reference Garabiles, Shehadeh and Hall2019; Sit et al., Reference Sit, Ling, Lam, Chen, Latkin and Hall2020; Tian et al., Reference Tian, Sun, Jiang, Guo, Huang, Wang, Rahman, Li and Yang2023), and we obtained valuable insights into the adaptation process. However, future work with large samples will be important for understanding the kinds of adaptations that are most important.
Finally, the study did not formally address saturation. Saturation refers to the point in qualitative data collection when no new, relevant information is found (Busetto et al., Reference Busetto, Wick and Gumbinger2020; Johnson et al., Reference Johnson, Adkins and Chauvin2020; Hennink and Kaiser, Reference Hennink and Kaiser2022). Saturation is typically assessed through counting the number of codes across transcripts until few or no more codes are identified (Hennink and Kaiser, Reference Hennink and Kaiser2022). Although we had an iterative process of reviewing notes from diverse data sources, discussing observational feedback and interview responses, and reaching a consensus on our results during regular team meetings, we did not establish a stopping criterion for saturation. This was primarily because we had a limited number of FGDs and participants. Despite this limitation, our sample size fell within the recommended range of interviews and FGDs for saturation (Namey et al., Reference Namey, Guest, McKenna and Chen2016; Hennink and Kaiser, Reference Hennink and Kaiser2022), indicating that our findings captured the depth of issues studied (Francis et al., Reference Francis, Johnston, Robertson, Glidewell, Entwistle, Eccles and Grimshaw2009).
Open peer review
To view the open peer review materials for this article, please visit http://doi.org/10.1017/gmh.2025.10045.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/gmh.2025.10045.
Data availability statement
The authors confirm that the data supporting the findings of this study are available within the article and its Supplementary Materials. The changes made to the EASE intervention as documented in this study are available from the corresponding authors, A.D.B. and J.W., upon reasonable request.
Acknowledgements
The authors would like to thank the following three CBOs and their affiliated members for their partnership and support in the adaptation FGDs through May to June 2024: El Puente, a Brooklyn and Puerto Rico-based center for adolescents organizing, activism and community-led action (El Puente caregiver: Celeste Liriano); The BRO (Brothers Redefining Opportunity) Experience, a safe space for young men of color to express their feelings, share ideas and cultivate character in Bedford-Stuyvesant, Brooklyn; and the Center for Community Alternatives (CCA) Seeds to Roots Youth Action Center, located in Brownsville, Brooklyn. CCA supports and builds power with people across New York State who have been affected by mass incarceration, criminalization and community disinvestment (EASE CCA Staff: Rhamgurav Robinson, Senior Director of Community Programs; Chenequa Rogers, Career Readiness Coordinator; and Christine Song, Operations Coordinator).
Author contribution
Conceptualization: J.W., T.X., J.C., N.G.I., A.D.B.; methodology: J.W., T.X., J.C., N.G.I., B.A.K., A.D.B.; formal analyses: J.W., T.X., J.C., A.D.B.; investigation: J.W., T.X., C.S., J.C., N.G.I., D.E.S., A.D.B.; resources: J.W., T.X., C.S., J.C., N.G.I., E.W., H.D., K.G., E.A.; data management: J.W., T.X., C.S., J.C., N.G.I.; writing – original draft: J.W., T.X.; writing – review and editing: C.S., L.M., J.C., N.G.I., K.P., D.E.S., A.H., E.W., H.D., K.G., E.A., B.A.K., A.D.B.; visualization: C.S., L.M.; supervision: B.A.K., A.D.B.; project administration: J.W., T.X., E.W., H.D., K.G., E.A., A.D.B.; funding acquisition: A.D.B.
Financial support
The adaptation of EASE is funded by a grant from the New York City Mayor’s Office of Community Mental Health (PI: A.D.B.).
Competing interests
All authors declare none.
Ethics statement
The New School University Institutional Review Board deemed this study Exempt from Human Subjects Research. However, all participating caregivers provided consent, while all participating adolescents provided minor assent. The caregivers of the participating adolescents also provided consent. The research team had resources available for participants should they be in need of referrals to manage distress. However, no referrals were needed in the current adaptation study.
Open access
Comments
Dear Professor Bass and Professor Chibanda,
My co-authors and I are writing to express our interest in submitting a manuscript to Cambridge Prisms: Global Mental Health.
We appreciate the opportunity to submit a manuscript for a recently completed study entitled, “Community-based adaptation of Early Adolescent Skills for Emotions for Urban Adolescents and Caregivers in New York City” co-authored by Janus Wong, Tina Xu, Cheenar Shah, Liam Miccoli, Josheka Chauhan, Nora Garbuno Iñigo, Kendall Pfeffer, Dana Ergas Slachevsky, Arian Holman, Eva Wong, Heather Day, Kala Ganesh, Eliot Assoudeh, Brandon A. Kohrt, and Adam D. Brown.
Despite the growing need for adolescent mental health services in the US, there remain significant barriers to care, with access to treatment especially inequitable for ethnic minorities (Agency for Healthcare Research and Quality, 2023; Alegría et al., 2008; Weersing, 2022). Globally, a growing volume of research has looked into how task-sharing interventions may be implemented to increase access to mental health services and build capacity in low-resourced settings (Jordans et al., 2021; Karyotaki et al., 2022; Purgato et al., 2021; Tol et al., 2020; Turrini et al., 2022; Zhang et al., 2020). However, this approach is somewhat newer in the US. Given the mental health burden and structural inequities faced by ethnically minoritized adolescents in the US, the current study aims to fill this services and treatment gap by introducing Early Adolescent Skills for Emotions (EASE), a recently-developed WHO psychological intervention for adolescents and caregivers, to the US context (WHO & UNICEF, 2023). As the first phase of a wider effort to implement and evaluate EASE in New York City (NYC), this manuscript reports on the cultural adaptation process of EASE. The adaptation process was a collaborative and iterative process between researchers at the New School for Social Research (NSSR), local government at the New York City Mayor’s Office for Community Mental Health (OCMH), three Brooklyn-based community organizations. Through a series of focus group discussions (FGDs) with adolescents (n=18) and caregivers (n=12) from the community organizations, the intervention was delivered by the NSSR research team, and feedback was collected from the stakeholders to inform subsequent intervention changes. We were guided by the mental health Cultural Adaptation and Contextualization for Implementation (mhCACI) framework (Sangraula et al., 2021) and the Reporting Cultural Adaptation in Psychological Trials (RECAPT) criteria (Heim et al., 2021), as well as Community-Based Participatory Research (CBPR) guidelines to recognize the expertise and strengths of community members.
The study found that both deep and surface adaptations were necessary to enhance EASE’s acceptability, relevance, and engagement for the NYC community. Notable cultural concepts of distress included a lack of understanding of distressing emotions, a lack of knowledge of how to respond to emotions, and the adolescents’ need to hide their emotions. We also identified community needs for inclusivity, knowledge-based explanation of psychological benefits, and building purpose and identity. Based on these findings, we made deep adaptation changes to the intervention, including the addition of activities such as the Purpose Diagram and a poster to emphasize the mind-body connection of the breathing strategy. Additionally, contextual information indicated the salience of NYC-specific themes such as gender norms, digital technology, and economic pressures, which were incorporated in the intervention’s storybook and guided discussions. We also aligned framing of the intervention to the goals of social and emotional learning and community-building, based on feedback from the FGDs and OCMH. Surface adaptations included changes to the storybook text and illustrations to be more representative of the spoken language and people in NYC. We also found that virtual sessions were more accessible for caregivers, and in-person sessions were more engaging for adolescents.
Thank you very much for your consideration. We sincerely look forward to hearing from you.
Best,
Janus Wong