Developing a School-based Mindfulness Intervention for Delivery in Rwanda and Ethiopia: Cultural Adaptation through Knotworking

Technical Summary: Developing a School-based Mindfulness Intervention for Rwanda and Ethiopia

Problem Statement
The paper addresses the critical gap in evidence-based mental health interventions for children and adolescents (CAs) in Sub-Saharan Africa (SSA), specifically within Rwanda and Ethiopia. Despite high rates of mental health challenges driven by conflict, poverty, and social instability, these regions suffer from a severe shortage of qualified mental health professionals, limited community awareness, and a lack of culturally appropriate, school-based interventions. While School-based Mindfulness Interventions (SBMIs) have shown promise in Global North contexts, their efficacy in Low- and Middle-Income Countries (LMICs) remains under-researched. The core challenge lies in adapting universal mindfulness curricula—often rooted in Western clinical models and resource-rich environments—to be culturally resonant, contextually feasible, and educationally meaningful within the constraints of SSA school systems, which are characterized by large class sizes, limited resources, linguistic diversity, and specific religious sensitivities.

Methodology
This study employs a qualitative research design to investigate the co-construction process of a culturally adapted SBMI. The research focuses on the development phase of an interdisciplinary project involving teacher educators, mindfulness experts, and community representatives.

• Data Collection: Semi-structured interviews were conducted with 11 participants, including teacher training college educators from Rwanda and Ethiopia, university teacher educators, community representatives, and mindfulness experts from Ireland. Interviews were conducted face-to-face or via video conference, lasting between 20 and 60 minutes.
• Data Analysis: Transcripts were analyzed using NVivo software following Clarke and Braun's (2021) updated six-phase thematic analysis approach. The analysis was inductive and data-driven, moving from familiarization and initial coding to the generation of overarching themes.
• Theoretical Framework: The development process was guided by Participatory Action Research principles and conceptualized through the lens of "knotworking" (Engestrom, 2008), describing dynamic, temporary collaborations among diverse actors to solve specific problems. The intervention design was also grounded in Crane et al.'s (2017) five essential ingredients of mindfulness-based programs.

Key Contributions
The paper contributes to the literature on global mental health and curriculum development in three primary ways:

1. Process-Oriented Insight: It moves beyond outcome evaluation to detail the complex process of co-designing a mental wellbeing intervention in low-resource settings. It highlights how curriculum development is not merely a technical transfer but a social practice involving negotiation and adaptation.
2. Conceptualization of "Knotworking": The study introduces and applies the concept of "knotworking" to describe the collaborative mechanism used to adapt the curriculum. This framework illustrates how flexible, non-hierarchical groups of stakeholders (experts, educators, community reps) dynamically assembled to address specific contextual challenges, offering a scalable model for LMIC educational systems.
3. Contextual Adaptation Strategies: It provides a concrete taxonomy of adaptations required to translate Western mindfulness practices for SSA contexts, covering linguistic translation, material substitution, religious sensitivity, and pedagogical restructuring.

Results
The thematic analysis identified five central themes characterizing the curriculum development process:

• Teacher Learning: A significant finding is that mental health promotion falls outside the traditional professional remit of teachers in Rwanda and Ethiopia. Consequently, substantial capacity building was required to shift teachers from content deliverers to facilitators of wellbeing. However, the study notes that training delivered in centralized locations sometimes failed to account for specific school-level realities like overcrowding.
• Adaptations: Extensive modifications were necessary to ensure feasibility and acceptability.
  • Temporal/Structural: Long, formal practices were replaced with short (5-minute), informal "doses" of mindfulness (e.g., "hand on the desk") that could be integrated into existing subjects without disrupting the national curriculum.
  • Material: Resources were adapted to local availability (e.g., using bananas, strawberries, and onions instead of chocolate or bulbs; using live drumming instead of recorded music).
  • Religious/Cultural: Practices were modified to respect local religious norms, such as offering the option not to close eyes during breathing exercises due to associations with prayer in the Ethiopian Orthodox Church, and avoiding candles which were perceived as Christian symbols.
• Negotiation as Knotworking: The development was driven by dynamic "knots" of stakeholders who iteratively solved problems. These groups formed and dissolved as needed to address specific issues, such as selecting culturally appropriate foods for mindful eating or navigating political sensitivities regarding color usage.
• Tensions and Trade-offs: The process involved balancing fidelity to mindfulness principles with the realities of the school environment. Tensions arose regarding the definition of "curriculum" (centralized government control vs. flexible intervention), the integration of secular practices in religious contexts, and the trade-off between comprehensive practice and the need for brevity in large classes (50+ students).
• Curriculum Integration: The resulting intervention was designed not as a standalone course but as a set of practices embedded across the school day (e.g., in PE, home economics, or language classes) to ensure sustainability and avoid the stigma of a "treatment" model.

Significance and Claims
The authors claim that the successful development of this SBMI illustrates the complexity of designing interventions that are culturally resonant and contextually feasible in low-resource settings. The paper asserts that:

• Cultural Localisation is Essential: Direct transfer of Global North programs is insufficient; meaningful adaptation of language, materials, and practices is required to maintain acceptability among teachers, students, and parents.
• Teacher Learning is Central: The success of the intervention relies heavily on sustained teacher learning and the shift in teacher identity to include mental health promotion, though this learning must be deeply embedded in authentic school environments to be effective.
• Collaborative Negotiation is Key: The "knotworking" model provides a viable mechanism for co-designing interventions in contexts with centralized curriculum governance and limited mental health infrastructure.
• Pragmatic Compromise: The resulting curriculum, characterized by short, simple, and integrated practices, represents a necessary pragmatic compromise to ensure long-term sustainability and scalability within the constraints of the Rwandan and Ethiopian educational systems.

The study concludes that while the intervention may not strictly adhere to all five original elements of mindfulness programs due to necessary adaptations, it successfully created a culturally acceptable set of practices. The authors emphasize that the findings offer new evidence on curriculum co-design for wellbeing in LMICs, highlighting that implementation success depends on responsiveness to local school realities rather than rigid adherence to external program models.