Impact statement
Medical learners undergo considerable psychological stress in their training process, but the availability and contextually responsive mental health assistance in medical education is scarce. This research shows how culturally adapted Self-Help Plus (SH+) intervention can be reformulated to be more in line with medical training by substituting pre-recorded audio sessions in favor of the interactive, facilitator-led and peer-supported group format. The modified model provides a feasible solution for future physicians to enhance their resilience. It also helps them cope with their emotions by connecting the concepts of Acceptance and Commitment Therapy with common experiences, such as examinations, ward rotations and development of professional identity. The results indicate an acceptable and practical approach to the implementation of structured mental health support into medical education. On a larger scale, the research demonstrates the manner in which scalable psychological interventions can be culturally adjusted to professional training settings, with implications that can guide efforts to promote mental health among students and early-career professionals working in such settings across the globe.
Background
Mental health disorders represent a major public health burden in low- and middle-income countries (LMICs), including Pakistan. The National Psychiatric Morbidity Survey of Pakistan (2022) reported a lifetime prevalence of 38.1% and a current prevalence of 32.28% for mental disorders (Rahman et al., Reference Rahman, Sheehan, Javed, Ahmad, Shafiq, Kanwal, Afridi, Nizami, Rasool, Taj, Ansari, Naim, Farooq, Memon, Karim, Hana and Ayub2024). Despite this high burden, many conditions remain underdiagnosed and undertreated due to stigma, limited mental health literacy and restricted service availability, resulting in a substantial treatment gap.
Globally, the treatment gap for common mental disorders affects approximately 60% of individuals in high-income countries, 65% in upper-middle-income countries and over 80% in lower-middle-income countries (Alonso et al., Reference Alonso, Liu, Evans-Lacko, Sadikova, Sampson, Chatterji, Abdulmalik, Aguilar-Gaxiola, Al-Hamzawi, Andrade, Bruffaerts, Cardoso, Cia, Florescu, de Girolamo, Gureje, Haro, He and de Jonge2018). These disparities highlight the urgent need for accessible and culturally appropriate psychological interventions (Thornicroft et al., Reference Thornicroft, Chatterji, Evans-Lacko, Gruber, Sampson, Aguilar-Gaxiola, Al-Hamzawi, Alonso, Andrade, Borges, Bruffaerts, Bunting, de Almeida, Florescu, de Girolamo, Gureje, Haro and Hinkov2017).
Medical education is widely recognized as a demanding environment associated with considerable psychological strain. In Pakistan, undergraduate medical training typically spans five to six years and combines intensive academic demands with clinical exposure. While this training aims to develop professional competence, persistent academic pressure and psychosocial challenges may negatively affect students’ mental health. Evidence suggests that medical students in Pakistan experience higher levels of psychological distress than the general population (Azim et al., Reference Azim, Adnan, Azim, Nisar and Shamim2022). Depression, anxiety and stress are frequently reported among medical students in Pakistan and internationally, reflecting the psychological demands of medical training (Rehmani et al., Reference Rehmani, Q-ul-A and Fatima2018; Quek et al., Reference Quek, Tam, Tran, Zhang, Zhang, Ho and Ho2019; Rotenstein et al., Reference Rotenstein, Ramos, Torre, Segal, Peluso, Guille, Sen and Mata2016). This unresolved psychological distress can impair academic performance, professional behavior, and long-term career development (Haykal et al., Reference Haykal, Pereira, Power and Fournier2022). It has also been associated with substance misuse, attrition from medical training and reduced professionalism. Persistent psychological strain among medical trainees has further been linked to compromised patient safety and reduced quality of care (Carrieri et al., Reference Carrieri, Mattick, Pearson, Papoutsi, Briscoe, Wong and Jackson2020).
These difficulties often remain insufficiently addressed because medical students may delay or avoid help-seeking due to stigma, concerns about confidentiality, fear of academic or career consequences, and limited access to structured institutional mental health support (Berliant et al., 2022; Amin et al., Reference Amin, Wazeer, Imran, Rashid, Kiran and Haider2023; Bannatyne et al., Reference Bannatyne, Jones, Craig, Jones and Forrest2023; Zafar et al., Reference Zafar, Zaidi, Zaidi, Ahmed, Memon, Ahmed, Siddiqui, Fatima, Shahid, Hussain and Salam2024). In this context, a preventive, low-intensity intervention such as adapted Self-Help Plus (SH+) may offer an acceptable route for early support within medical education settings. SH+ is a stress-management and resilience-building intervention designed to reduce psychological distress and prevent progression to clinically significant mental disorders (WHO, 2021). However, the absence of accessible, preventive, and early-support interventions may allow distress to persist or worsen during training. SH+ is presented as potentially scalable intervention that may address this support gap after appropriate adaptation. Early intervention during training may therefore help reduce long-term psychiatric morbidity and professional burnout.
Medical students in LMICs are frequently exposed to chronic academic and psychosocial stressors that interact with individual vulnerabilities such as maladaptive coping styles, perfectionism and limited social support (Karim et al., Reference Karim, Ahmed and Akhter2022). In resource-constrained settings, restricted access to mental health services further exacerbates this risk. By enhancing psychological flexibility and adaptive coping strategies, SH+ offers a promising early intervention to mitigate distress.
The global treatment gap has prompted the World Health Organization and other research groups to prioritize scalable psychological interventions (WHO, 2017). Scalability refers to the capacity of interventions proven effective in controlled conditions to be expanded in real-world settings while maintaining effectiveness and reaching larger populations (Milat et al., Reference Milat, King, Bauman and Redman2013). However, successful implementation across diverse contexts requires cultural relevance.
Cultural adaptation involves systematic modification of evidence-based interventions to incorporate language, cultural values and contextual factors while preserving core therapeutic mechanisms (Bernal et al., Reference Bernal, Jiménez-Chafey and Domenech Rodríguez2009). Evidence consistently demonstrates that culturally adapted psychological interventions outperform non-adapted approaches (Harper Shehadeh et al., Reference Harper Shehadeh, Heim, Chowdhary, Maercker and Albanese2016). Meta-analyses have reported advantages for adapted interventions (Griner and Smith, Reference Griner and Smith2006; Smith et al., Reference Smith, Rodriguez and Bernal2011), with further evidence of benefits across populations (Benish et al., Reference Benish, Quintana and Wampold2011; Chowdhary et al., Reference Chowdhary, Jotheeswaran, Nadkarni, Hollon, King, Jordans, Rahman, Verdeli, Araya and Patel2014). These benefits are attributed to improved acceptability, comprehension and engagement (Ferrer-Wreder et al., Reference Ferrer-Wreder, Sundell and Mansoory2012), whereas lack of adaptation may reduce adherence and effectiveness (Cabassa and Baumann, Reference Cabassa and Baumann2013).
Given the high burden of psychological distress among medical students in Pakistan and the limited availability of preventive interventions, culturally adapting SH+ is essential. Therefore, in this study, SH+ was conceptualized as a low-intensity stress-management and early-support intervention rather than as treatment for severe mental disorder. Medical students often experience mild to moderate distress but may not seek specialist care because of stigma, academic pressure, or limited-service access. SH+ is therefore relevant as a preventive or indicated early-intervention approach that builds psychological flexibility and adaptive coping before distress progresses.
This study aimed to culturally and contextually adapt SH+ to enhance its relevance, acceptability, and feasibility while preserving its core ACT-based therapeutic mechanisms. For undergraduate medical students in Pakistan using Bernal’s Ecological Validity Framework (Bernal et al., Reference Bernal, Jiménez-Chafey and Domenech Rodríguez2009).
Procedures
This study reports the cultural and contextual adaptation of SH+ and does not evaluate clinical effectiveness. This adaptation of SH+ was conducted in two phases.
Phase I: Adaptation process of SH+.
Phase II: Field Testing.
Phase I: Adaptation process of SH+
In this phase, the SH+ manual was adapted to meet the needs of medical students.
SH+ was modified by removing the pre-recorded audio components from five 50-min sessions. In the standard SH+ protocol, core instructional content is delivered via pre-recorded audio, with facilitators providing discussion, examples, and clarification around it. In this adaptation, facilitators verbally delivered this instructional content themselves rather than playing the audio, while continuing to perform their standard supportive role. This change was made based on feedback from medical students who reported that passive listening was non-engaging, time-consuming, and did not effectively sustain attention. As facilitator training requirements, supervision structure, and overall resourcing are unchanged from the original SH+ protocol, we maintain that this adaptation does not increase the resource burden of the intervention and that it remains as scalable as the original WHO model. The adaptation process followed a structured cultural and contextual adaptation framework consistent with the ecological validity model proposed by Bernal and Sáez-Santiago (Reference Bernal and Sáez-Santiago2006) and updated implementation science guidance for psychological interventions (Movsisyan et al., Reference Movsisyan, Arnold, Evans, Hallingberg, Moore, O’Cathain, Pfadenhauer, Segrott and Rehfuess2019). These frameworks support systematic adaptation while maintaining fidelity to core therapeutic principles.
The expert group overseeing the adaptation consisted of:
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• Twenty medical students,
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• Two senior faculty members,
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• One medical educationist,
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• One clinical psychologist,
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• Three trained SH+ facilitators.
This multidisciplinary composition ensured contextual, pedagogical and psychological relevance while preserving the theoretical foundations of SH+. The 20 students participated as student co-creators during adaptation; they were not a representative or random sample of all medical students in Pakistan. They were purposively selected to provide information-rich feedback from the intended user group, and to take part in the cognitive walk-through/pre-testing of the adapted materials during the adaptation process. Two senior faculty members and a medical educationist were from the host institute. The three facilitators were also medical teachers but did not belong to the host institute and were not involved in participants’ teaching, learning or assessment of academic performance. One of the facilitators was also the main lead researcher of this study. No financial incentive was provided to any participant in this group.
The same multidisciplinary stakeholder group oversaw both the adaptation process and the pre-testing/field-testing stage, although their roles differed by stage. Professional experts reviewed fidelity, feasibility, and safety, while students provided end-user feedback on clarity, acceptability, relevance, and delivery format.
Pre-testing was conducted using a cognitive walkthrough to assess clarity, acceptability, feasibility and contextual relevance. It is widely used to refine health interventions to ensure comprehensibility and cultural appropriateness (Kushniruk & Patel, Reference Kushniruk and Patel2004; Nápoles et al., Reference Nápoles, Santoyo-Olsson and Karliner2018). This approach is increasingly recommended in adapting logical and behavioral interventions (Escoffery et al., Reference Escoffery, Lebow-Skelley, Haardoerfer, Boing, Udelson, Wood, Hartman, Fernandez and Mullen2018).
Adaptation by expert group
The expert group reviewed the SH+ materials to ensure:
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• Conceptual alignment with Acceptance and Commitment Therapy (ACT) principles underlying SH+,
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• Contextual relevance to medical students’ stressors (academic pressure, clinical workload, examination stress, professional identity formation),
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• Pedagogical suitability for adult learners in medical education and
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• Feasibility within institutional schedules.
Equivalence was achieved at both the technical level (clarity, abstraction, readability, academic tone) and the conceptual level (ensuring metaphors, experiential exercises and stress examples resonated with medical students). Particular emphasis was placed on replacing generic stress scenarios with medical training-specific contexts such as OSPE anxiety, ward rotations, night duties and performance expectations.
Relevant examples were added and refined to reflect authentic medical learning environments such as lecture halls, simulation laboratories and hospital wards, and to ensure culturally appropriate representation of medical students’ experiences and roles. The group also reviewed delivery conditions, recommending small-group facilitation (20–25 students) and interactive exercises instead of audio-led self-help delivery. This modification is consistent with emerging evidence suggesting that guided and interactive formats may enhance engagement and outcomes in student populations (Perera et al., Reference Perera, Salamanca-Sanabria, Caballero-Bernal, Feldman, Hansen, Bird, Hansen, Dinesen, Wiedemann and Vallières2020).
Pre-testing using cognitive walk-through
Following adaptation, a structured cognitive walk-through was conducted with twenty medical students representing different academic years. This approach was selected to evaluate usability, engagement, contextual relevance, and feasibility of the adapted SH+ intervention within the medical education setting. Cognitive walk-throughs are increasingly used in intervention research to assess step-by-step user interaction, identify barriers in comprehension and flow, and optimize intervention delivery before pilot testing (Kushniruk & Patel, Reference Kushniruk and Patel2004; Nápoles et al., Reference Nápoles, Santoyo-Olsson and Karliner2018).
During the walk-through sessions, participants progressed through selected segments of the adapted SH+ manual in a simulated delivery format. Facilitators observed participants’ responses, interaction patterns, and points of hesitation or confusion. Structured probing questions were used to explore; Comprehension of core Acceptance and Commitment Therapy (ACT) concepts (e.g., acceptance, cognitive defusion, values) (Hayes et al., Reference Hayes, Strosahl and Wilson2012; Öst, Reference Öst2014); Relevance of scenarios to medical training experiences (e.g., academic pressure, clinical responsibilities, performance expectations), (Slavin et al., Reference Slavin, Schindler and Chibnall2014); Emotional resonance of exercises and reflective activities, especially in relation to common stressors experienced by medical students (Radcliffe and Lester, Reference Radcliffe and Lester2003); Perceived feasibility within academic schedules and institutional constraints; Engagement with interactive components was introduced in place of pre-recorded audio materials (Carrieri et al., Reference Carrieri, Mattick, Pearson, Papoutsi, Briscoe, Wong and Jackson2020).
This process enabled the identification of barriers related to flow, session pacing, conceptual clarity, and activity burden. Feedback from participants informed refinements in language simplification, restructuring of experiential exercises, adjustment of session duration and alignment of examples with authentic medical student stressors.
The use of cognitive walk-through aligns with implementation science guidance for adapting complex psychosocial interventions to new contexts, particularly when delivery format and user interaction are modified (Movsisyan et al., Reference Movsisyan, Arnold, Evans, Hallingberg, Moore, O’Cathain, Pfadenhauer, Segrott and Rehfuess2019); Escoffery et al., Reference Escoffery, Lebow-Skelley, Haardoerfer, Boing, Udelson, Wood, Hartman, Fernandez and Mullen2018).
Documentation
Phase II – Field testing
Once the adaptation process was completed, the modified SH+ intervention was finalized for implementation. The program has been specifically tailored to meet the needs of medical students. As part of the adaptation, the original pre-recorded audio components were removed from all five sessions.
The adapted SH+ sessions were delivered face-to-face in small groups by trained facilitators within the medical college setting, using a tutorial room suitable for confidential discussion. Sessions were scheduled around academic timetables to minimize interference with teaching and assessment obligations and avoid extra burden on students’ commitments.
After the final session, structured feedback was gathered by the facilitators using a program survey with both fixed-choice and open-ended questions. Responses were collected from participating students and from the facilitators who delivered the intervention to capture a broad range of perspectives on its clarity, relevance, and acceptability.
This phase was conducted as a field test to assess acceptability, feasibility, and contextual fit rather than intervention effectiveness.
Setting and participants
This study was conducted in Islamabad, the capital city of Pakistan. Of the 1,630 medical students participating in the main study across the nine medical colleges in Islamabad, 91% responded. Out of these, 20 undergraduate medical students were selected for this particular cultural and contextual adaptation research.
Ethical safeguards and referral procedures
The research was conducted in accordance with the principles of the Declaration of Helsinki and received ethical approval from the Institutional Review Board of the Health Services Academy (No. 00009 IHSA/P/D-2022). Written informed consent was obtained from all participants, and confidentiality was strictly maintained throughout the study. Students who met the inclusion criteria were informed about the purpose and procedures of the study. Participants were informed at the beginning in the introductory session about voluntary participation, their right to withdraw without affecting their academics, attendance or any form of assessment. The facilitators had no role in teaching, grading, examination, or disciplinary decisions for participants. Confidentiality expectations were also explained, including respectful listening, sharing of information voluntarily, and not disclosing peers’ information with anyone outside the group. Emergency referral pathways were established, and participants were made aware of this but were not activated because no participant endorsed self-harm or suicidal ideation during screening.
For the field-testing phase, a purposive sample was selected that included medical students who received the intervention, faculty members, and trained facilitators involved in its delivery. Twenty selected participants, all early-year MBBS students, with equal representation from first and second year. Most students were aged 19–20 years (55%), followed by 21–22 years (35%). Most of the respondents were females (65%), while males made up 35%; this shows the national trend of sex ratio in medical education. In terms of residence, more students resided with their families (55%) compared to living in hostels (45%). Overall, the sample had a relatively balanced distribution across year of study, and age, gender and residential background were influential in understanding the needs for adaptation among early medical students. A detailed table on sociodemographic and Behavioral variables is available in the Supplementary Material.
Eligibility required students to score 5 or above on both the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7. After providing written informed consent, they were given SH+ materials, including the handbook and an illustrative guide. Group-based SH+ sessions were then conducted for these 20 students by the trained faculty members who had received prior training from an SH+ specialist.
A multidisciplinary expert group oversaw the adaptation process, comprising two senior faculty members serving as year coordinators, a senior medical educationist with extensive experience in undergraduate training, a clinical psychologist experienced in working with university students, and three trained SH+ facilitators (Professor, Assistant Professor, and Senior Lecturer). This panel ensured integration of both academic and psychological perspectives while maintaining relevance to medical students’ experiences.
Following the intervention, all individuals involved in delivering and implementing the program completed semi-structured questionnaires containing fixed-choice and open-ended items to evaluate acceptability, comprehensibility, and cultural relevance. Participants were encouraged to provide detailed feedback to inform further refinement. The field test aimed to obtain in-depth stakeholder perspectives on the contextual appropriateness and clarity of the adapted SH+ intervention. Participants were selected purposively as direct recipients or implementers of the program to reflect end-user perspectives. As this phase focused on experiential and implementation feedback, no formal power calculation was conducted.
Results
Adaptation phase
The SH+ intervention was largely culturally and contextually compatible with undergraduate medical students and required no major structural modifications. Details of the adaptations across framework domains are presented in Table 1.
Application of the Bernal framework to the adaptation of SH+ for medical students
Table 1. Long description
The table consists of three columns: Dimension, Operationalization in S H plus adaptation, and Examples of key adaptations in the present study. It contains eight rows.
* Row 1. Language: Operationalized as emotional expression and academic tone. Examples include simplifying A C T terminology like cognitive defusion and rephrasing metaphors to reflect academic stress like exam preparation.
* Row 2. Metaphors: Operationalized as symbols and experiential exercises. Examples include replacing generic stress metaphors with O S P E anxiety and ward rotations.
* Row 3. Content: Operationalized as alignment with academic culture. Examples include modifying scenarios to include academic overload, clinical hierarchies, and imposter syndrome.
* Row 4. Concepts: Operationalized as cultural interpretation of psychological constructs. Examples include framing A C T principles within resilience and professionalism.
* Row 5. Goals: Operationalized as alignment with learner needs. Examples include emphasizing burnout prevention and enhancing self-awareness during high-stakes assessments.
* Row 6. Educational context: Operationalized as institutional environment. Examples include aligning sessions with academic timetables and using group delivery for 20 to 25 students.
* Row 7. People: Operationalized as delivery agents. Examples include facilitation by trained S H plus facilitators and encouraging peer interaction to normalize stress.
* Row 8. Methods: Operationalized as mode of delivery. Examples include removing pre-recorded audio to increase engagement and reducing session duration from 90 to 60 minutes.
Field testing
Participant characteristics
The socio-demographic profile of participating medical students reflected the target population in terms of age, gender distribution, educational level, and academic background. All participants were enrolled in the first or second year of undergraduate medical training and reported no major personal or academic disruptions during the study period.
All 20 students completed the five adapted SH+ sessions and the post-intervention evaluation, enabling a complete assessment of acceptability, comprehensibility, and cultural relevance.
Participant feedback
A pragmatic framework guided content analysis was used to analyze open-ended feedback for students, facilitators and faculty. Responses were organized according to the domains relevant to adaptation, including acceptability, comprehensibility, cultural and contextual relevance and delivery format. Both constructive and critical feedback were kept to help make final refinements to the adapted SH+ materials.
Acceptability
The adapted SH+ sessions were perceived as appropriate, engaging, and relevant to students’ academic experiences. Participants particularly valued peer discussion and shared learning. One student stated,
Discussing challenges with my peers during the sessions helped me see I’m not alone, and the shared exercises made the strategies easier to practice.
Facilitators also reported increased interaction among students as sessions progressed. One facilitator noted,
At first, some students were reserved, but as the sessions progressed, they became more open and reflective, which made delivering the program much easier.
Comprehensibility
Participants reported that the adapted materials were clear and easy to understand. Students, faculty members, and facilitators agreed that the exercises and concepts were accessible. Peer group-based activities enabled students to identify unhelpful thoughts and practice adaptive coping strategies collaboratively. One of the student participants quoted that;
What I really saw were the subtle things that happened between sessions. We were reminding each other, checking in informally, saying what worked. I was impressed by the unsolicited peer momentum that really sustained the session better than anything could have done.
Facilitators observed that small-group discussions helped students internalize concepts related to stress management, emotional regulation, and value-based action.
Seeing students autonomously reinforcing each other’s psychological skill practice without any instruction to do so was genuinely encouraging.
Cultural and contextual relevance
The intervention was widely perceived as culturally appropriate and relevant to the medical education environment. Participants appreciated contextualized examples and practical exercises reflecting common stressors such as examination pressure, clinical rotations, and heavy workloads.
One of the participant students narrated that; An intervention to stress related to the actual stressors of our medical training, examinations, clinical exposure and hectic academic routine is much more likely to be accepted by us than a stress intervention that is generic.
Peer discussions were particularly valued for normalizing shared experiences of stress. Facilitators and faculty confirmed that students could relate the intervention content to their academic and clinical experiences. One of the teachers observed and reported that;
The skills in SH+ were to be simple and portable, and they transferred really well here. Students were using grounding and defusion techniques before exams, or when there was an acute stress response. Seeing skills migrating from the session room into real life was the clear indicator the program was working."
Delivery format
Most participants, including students and facilitators, appreciated the teachers as facilitator-led format as they can relate easily. However, students shared their concern about the teacher as facilitator that they should not be involved in their assessment; they collectively expressed that facilitator involvement in assessment would inhibit their willingness to engage openly in sessions.
A teacher-facilitator may understand our medical routine, relate to our stress, and guide us more effectively, but that role should remain separate from our assessment.
Same concern expressed by another participant;
If the teacher leading session and is also grading you next week, you’re not going to say what you really think, in fact no one will speak freely. That separation isn’t optional it’s necessary.
The interactive sessions promoted peer support and collaborative learning. One student commented, “Working with my peers and sharing experiences made it easier to follow the exercises, and the facilitator guided us without being too formal or intimidating.”
Facilitators reported confidence in delivering the sessions and noted that their supportive role encouraged trust and active participation.
Overall, field testing indicated that the culturally adapted SH+ intervention was acceptable, comprehensible, culturally relevant, and feasible for integration into undergraduate medical education. Students engaged actively with the sessions, understood key concepts, and applied stress-management strategies within their academic and clinical routines, while facilitators successfully delivered the program in a supportive learning environment.
As shown in Table 2, overall, participants rated the adapted SH+ program positively. Most medical students and faculty found the content very helpful and easy to understand, and facilitators reported similar perceptions. Illustrations and experiential exercises were viewed as valuable for comprehension and practical application, while self-practice activities were considered useful or extremely useful by the majority. The content was widely regarded as culturally relevant, and trained teacher facilitators without involvement in academic assessment were identified as the most appropriate delivery agents. These findings indicate that the adapted SH+ program is acceptable, comprehensible, and feasible for implementation in undergraduate medical education. However, due to the adaptation-focused design and purposive sampling, findings should be interpreted in terms of contextual transferability rather than statistical generalizability; the adapted SH+ may be transferable to similar early-year medical student groups in urban Pakistani medical colleges but needs further research to assess if it is acceptable in public-sector medical colleges, rural medical colleges, senior medical students, and other provincial/linguistic contexts.
Summary of fixed-choice feedback on adapted SH+ sessions (N = 27)
Table 2. Long description
The table consists of two columns: Domain and Summary of responses, based on a sample size of N equals 27.
* Helpfulness of S H plus content: 25 out of 27 respondents rated content as very helpful or helpful. This includes 18 out of 20 students, 4 out of 4 faculty, and 3 out of 3 facilitators.
* Comprehensibility: 25 out of 27 found content easy to understand. Peer-group discussion was a key contributor. 2 out of 20 students found it less comprehensible.
* Illustrations: 19 out of 27 reported illustrations helped, while 7 out of 27 suggested improvements. This domain had the lowest overall endorsement.
* Experiential activities and self-practice: 24 out of 27 rated activities as extremely useful or useful. Faculty and facilitators were unanimous in endorsement.
* Cultural relevance: 23 out of 27 considered content suitable for the local context. 4 out of 20 students rated this as little useful.
* Delivery format: 20 out of 27 appreciated trained teacher facilitators without pre-recorded audio. Some students expressed concerns regarding facilitators holding academic evaluation roles over participants.
Discussion
This study adapted the WHO SH+ intervention for undergraduate medical students in Pakistan. Consistent with the expectations of global mental health scholarship, the purpose was not to claim clinical effectiveness at this stage, but to describe a transparent, theory-informed process for improving local fit while preserving the intervention’s core mechanisms. The adaptation followed Bernal’s Ecological Validity Framework (Bernal et al., Reference Bernal, Jiménez-Chafey and Domenech Rodríguez2009; Bernal and Domenech Rodríguez, Reference Bernal and Domenech Rodríguez2012), which calls for systematic changes in language, concepts/metaphors, content, methods, goals, and delivery context.
A central contribution of this work is the broader interpretation of culture. Culture was not viewed solely as ethnicity, nationality or language; it was seen as the social, educational, institutional, and professional context in which distress can happen. This aligns with cultural adaptation frameworks that focus on language, as well as context, distress meaning, delivery context, what is being delivered, and fidelity to core mechanisms (Day et al., Reference Day, Laver, Jeon, Radford and Low2023; Perera et al., Reference Perera, Salamanca-Sanabria, Caballero-Bernal, Feldman, Hansen, Bird, Hansen, Dinesen, Wiedemann and Vallières2020). Psychological stress in Pakistani medical students is influenced by intense academic courses, a disturbed study–life balance, anxiety about the future, academic competition, frequent examinations, and the overall stress of medical training (Bergmann et al., Reference Bergmann, Muth and Loerbroks2019; Gondal et al., Reference Gondal, Afzal, Masood, Moeen-Ud-Din, Ahmed and Iqbal2025; Voltmer et al., Reference Voltmer, Köslich-Strumann, Voltmer and Kötter2021). Accordingly, it was not enough to simply translate; it was necessary to adapt. It needed to be connected to the lived experiences of medical training and keep its preventive, low-intensity objective.
The results indicate that the ACT concepts and principles underlying SH+ were acceptable for this group when delivered using the familiar academic and clinical contexts. Psychological flexibility, grounding, cognitive defusion, acceptance, values clarification and committed action were kept as the core elements of the intervention. These generic stress examples were, however, replaced with scenarios focused on stress associated with OSPE anxiety, ward rotations, professional identity formation, performance assessment, and examination pressure. This is in line with the evidence that culturally adapted psychological interventions are more acceptable when their examples, idioms, and practices reflect the daily lives of the target group (Chowdhary et al., Reference Chowdhary, Jotheeswaran, Nadkarni, Hollon, King, Jordans, Rahman, Verdeli, Araya and Patel2014; Hall et al., Reference Hall, Ibaraki, Huang, Marti and Stice2016).
The adapted intervention was viewed as a viable early support and stress-management program, not a treatment for a serious mental illness. This is significant in medical education, where a considerable proportion of students may suffer distress, but not in a way that necessitates specialist psychiatric treatment. Low-intensity psychological interventions can help normalize help-seeking, build coping skills and support people before symptoms become more debilitating. This is particularly pertinent in LMICs, where specialist services are limited, and gaps in treatment for common mental disorders are large (Thornicroft et al., Reference Thornicroft, Chatterji, Evans-Lacko, Gruber, Sampson, Aguilar-Gaxiola, Al-Hamzawi, Alonso, Andrade, Borges, Bruffaerts, Bunting, de Almeida, Florescu, de Girolamo, Gureje, Haro and Hinkov2017; Alonso et al., Reference Alonso, Liu, Evans-Lacko, Sadikova, Sampson, Chatterji, Abdulmalik, Aguilar-Gaxiola, Al-Hamzawi, Andrade, Bruffaerts, Cardoso, Cia, Florescu, de Girolamo, Gureje, Haro, He and de Jonge2018; World Health Organization, 2021).
The intervention may be most appropriate during the early years of medical school, when students are adjusting to new academic demands, professional expectations, and assessment systems. The literature on medical student wellbeing supports a preventive approach to supporting student wellbeing that is curriculum sensitive and reduces the need for crisis-driven intervention and includes the identification of stressors within the learning environment (Bennett-Weston et al., Reference Bennett-Weston, Keshtkar, Jones, Sanders, Lewis, Nockels, Solomon and Howick2024; Kemp et al., Reference Kemp, Hu, Bishop, Forrest, Hudson, Wilson, Teodorczuk, Rogers, Roberts and Wearn2019). Integration into orientation activities, student wellbeing programs, foundation courses, or professional development modules may allow institutions to provide support before distress becomes severe, although evidence for curriculum-embedded wellbeing interventions remains mixed and requires careful implementation and evaluation (Upsher et al., Reference Upsher, Nobili, Hughes and Byrom2022). Sessions should avoid examination periods and be scheduled so that participation does not add to students’ academic burden, as workload and assessment pressures are important contributors to student distress (Kemp et al., Reference Kemp, Hu, Bishop, Forrest, Hudson, Wilson, Teodorczuk, Rogers, Roberts and Wearn2019; Upsher et al., Reference Upsher, Nobili, Hughes and Byrom2022). The shortened 60-min session period may consequently be more viable than the original 90-min session period in the busy medical curriculum.
The most substantial delivery change was replacing the facilitator-led pre-recorded audio format with facilitator-led interactive sessions, as students experienced passive listening as less engaging and less compatible with their learning style. Therefore, the pre-recorded audio component was replaced with live facilitator delivery to improve engagement and fit with the medical education context. The facilitators were medical college teachers, who knew the students’ routine but were not directly engaged in the process of examination and assessment of the students. This was a solution that allowed feasibility to be maintained, without the need for specialist mental health staff or substantial resource requirements. It also reflects the need for effective role separation, facilitator training, and confidentiality processes to ensure the intervention is safe and consistent. This seems to be consistent with the task-sharing approach adopted in global mental health and involves structured psychological interventions delivered by trained non-specialists in resource-limited settings (Singla et al., Reference Singla, Kohrt, Murray, Anand, Chorpita and Patel2017). Facilitators could be trained counselors, student support staff, medical educators, or faculty members who do not assess the participating students in the medical college. This means that future implementation, particularly for facilitators, does not allow them to have an examination, disciplinary or supervisory role over participants. The protocol for the intervention should contain clear information regarding voluntariness, confidentiality and not being involved in assessment.
The change has implications for fidelity. The adapted format changed the mode of delivery, but not the theoretical targets of the intervention. Core SH+ processes, including grounding, unhooking from difficult thoughts, making room for difficult emotions, identifying values, and taking committed action, were retained. This distinction is important because adaptation should improve contextual fit without diluting the mechanisms through which an intervention is expected to work (Bernal and Domenech Rodríguez, Reference Bernal and Domenech Rodríguez2012; Movsisyan et al., Reference Movsisyan, Arnold, Evans, Hallingberg, Moore, O’Cathain, Pfadenhauer, Segrott and Rehfuess2019).
Explicit attention must be given to confidentiality as it is delivered in groups. Peer discussion can help to de-isolate and normalize distress by identifying common problems and issues, but it can also increase concerns around disclosure with classmates (World Health Organization, 2021; Yalom & Leszcz, Reference Yalom and Leszcz2020). Group agreements need to be set up at the beginning of the program, such as respectful listening, sharing experiences willingly, maintaining confidentiality and strict adherence to nondisclosure policy regarding personal experiences (Yalom & Leszcz, Reference Yalom and Leszcz2020). These safeguards are particularly important in collectivist and hierarchical settings, where stigma, reputation, and anticipated negative judgment may affect willingness to seek help or participate openly in psychological support (Clement et al., Reference Clement, Schauman, Graham, Maggioni, Evans-Lacko, Bezborodovs, Morgan, Rüsch, Brown and Thornicroft2015; Thornicroft et al., Reference Thornicroft, Chatterji, Evans-Lacko, Gruber, Sampson, Aguilar-Gaxiola, Al-Hamzawi, Alonso, Andrade, Borges, Bruffaerts, Bunting, de Almeida, Florescu, de Girolamo, Gureje, Haro and Hinkov2017).
One of the advantages of the model was peer interaction. Students appreciated the opportunity to identify common stressors and to practice coping mechanisms as a group. This reflects a growing body of evidence that peer support can positively influence mental health and help mitigate feelings of isolation and loneliness among young adults (Webb et al., Reference Webb, Peerbooms and Akhtar2019). In medical education, the discussion of peers is an accepted way of learning, and the adapted SH+ format was leveraged in this culture to nurture reflection, normalization, and skills practice.
The adaptation has equity and transferability implications. The study was done in the urban environment, predominantly in a private medical college. There may be variations in class size, socio-economic diversity, resources, counseling provision, availability of facilitators and language requirements in public sector colleges. Additional adjustments may be necessary prior to implementation in colleges in the public sector, in rural colleges, in other province(s) or in multilingual populations. These differences should not be seen as a hindrance to scale-up, but rather as contextual conditions that should be considered, as evidenced in mental health implementation literature from around the world that highlights contextual fit, cultural relevance, feasibility, and equity when mental health interventions are transferred across settings (Wani et al., Reference Wani, McCann, Lennon and Radu2024; Greene et al., Reference Greene, Huang, Giusto, Lovero, Stockton, Shelton, Santos, Saúte and Wainberg2021).
Safety procedures are necessary when low-intensity interventions are offered to students with psychological distress. SH+ should not replace specialist care for students with severe symptoms, suicidality, psychosis, or acute psychiatric needs. Screening, referral systems, a policy for dealing with deterioration and strong connections with counseling or psychiatric services should be incorporated into future implementation.
There is a growing body of student wellbeing literature in higher education that highlights the importance of recognizing signs of distress, making referrals, having crisis contingency plans, and making links with health or counseling services (Kemp et al., Reference Kemp, Hu, Bishop, Forrest, Hudson, Wilson, Teodorczuk, Rogers, Roberts and Wearn2019; Smith, Reference Smith2024). These are particularly important safeguards in educational contexts and for preventing the role of SH+.
Strengths and limitations
This study has several strengths. It used an established adaptation framework, engaged all relevant stakeholders and actively involved students as co-creators, not as passive recipients. The cognitive walk-through process allowed us to identify issues in terms of comprehension, flow, engagement, and feasibility prior to wider implementation. These features enhance the transparency and the usefulness of the adaptation process.
This study also has a few limitations. The sample was small and purposively selected, which is suitable for adaptation work, but does not adequately allow for generalizability of statistical types. Views presented may not reflect the views of students in other age groups, or of students in public-sector, rural, or less resourced colleges. The qualitative component was not intended to yield a comprehensive interpretive qualitative analysis, but rather to inform adaptation. Future studies should expand and include the use of a wider range of institutions, systematic coding by multiple researchers, documentation of disagreements and consensus procedures, as well as supportive and critical participant feedback.
Future research
Future studies should examine the effectiveness of the adapted SH+ intervention through larger controlled trials assessing psychological outcomes such as stress, depression, and anxiety among medical students. Longitudinal research could also evaluate whether participation in preventive interventions during medical training contributes to improved well-being, academic functioning, and reduced burnout in later stages of medical careers.
Conclusion
In conclusion, the culturally adapted SH+ intervention demonstrated high levels of acceptability, comprehensibility, and contextual relevance among undergraduate medical students in Pakistan. By integrating culturally meaningful examples, peer interaction and facilitator-guided learning, the adapted program aligns well with the educational and psychological needs of medical students. These findings suggest that culturally adapted, scalable psychological interventions may offer a promising strategy for promoting mental health and resilience within medical education in low- and middle-income settings.
Open peer review
To view the open peer review materials for this article, please visit http://doi.org/10.1017/gmh.2026.10288.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/gmh.2026.10288.
Data availability statement
The data that supports the findings of this study are available from the corresponding author, [FR], upon reasonable request.
Acknowledgments
The authors gratefully acknowledge the medical students who participated in this study, the faculty members for their continuous support during the implementation of the intervention, and the administrative and support staff whose assistance with logistics and organizational arrangements facilitated the successful conduct of this study.
Author contribution
F.R.: Conceptualization, Methodology, Cultural adaptation of the intervention, Writing – Original Draft Preparation. A.N.: Writing – Review & Editing, Critical revision of the manuscript, Intellectual input. A.M.: Supervision, Methodological guidance, technical support, Writing – Review & Editing. A.R.: Supervision, Technical oversight, Validation of the adaptation process, Writing – Review & Editing. All authors contributed to the refinement of the manuscript, reviewed the final version, and approved it for publication.
Funding statement
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
The authors declare none.
Ethics and approvals
The research was carried out in accordance with the principles of the Declaration of Helsinki and received ethical approval from the Institutional Review Board of the Health Services Academy (No. 00009 IHSA/P/D-2022). Written informed consent was obtained from all participants, and confidentiality was strictly maintained throughout the study.
Inclusivity statement
The purpose of this study was to make the adaptation process inclusive and culturally relevant. The panel of experts was multidisciplinary, and it was composed of medical educators, psychologists and trained facilitators. The field-testing phase was done with medical students in the early years. The adaptations have been developed in a manner that they are culturally relevant to the medical education setting while maintaining fidelity to the core therapeutic foundations of the Self-Help Plus intervention.
Open access
