Abstract
BACKGROUND: Noncommunicable diseases (NCDs) are a growing health challenge in low- and middle-income countries (LMICs), including Pakistan. Adolescence is a critical period for shaping lifelong behaviors, yet school-based health education remains limited and inconsistently implemented. Digital health interventions offer scalable opportunities, but their feasibility, sustainability, and cultural acceptability in LMIC school settings remain underexplored. OBJECTIVE: This study examined barriers and facilitators to delivering the School eHealth Education Program Pakistan (eSHEPP) and explored stakeholder perceptions of its design, delivery, and content for adolescent NCD prevention. METHODS: An exploratory qualitative design was applied in public secondary and higher secondary schools using purposive sampling. Data were collected through four focus group discussions with students and teachers (N=36) and 11 key informant interviews with parents and administrators. Interview guides were informed by the Technology Acceptance Model and the Task-Technology Fit framework. Transcripts were thematically analyzed in NVivo v14 using a hybrid deductive-inductive approach. Credibility was supported through intercoder reliability (κ=0.71) and stakeholder validation. RESULTS: Major barriers included infrastructure gaps such as unreliable internet, electricity shortages, and lack of multimedia resources. However, students' digital familiarity and widespread mobile access were strong facilitators. Parents, teachers, and administrators endorsed eSHEPP, noting students' enthusiasm and the spillover of health knowledge to families. Stakeholders recommended a bilingual (Urdu/English), offline-accessible app with intuitive navigation, privacy safeguards, and interactive tools such as quizzes and rewards. Short Urdu videos with English subtitles, relatable scenarios, and student involvement were considered most engaging. Cultural sensitivities around mental health, gender norms, and substance use require careful framing. Sustainability was viewed as dependent on curriculum integration, teacher training, and institutional support. CONCLUSIONS: eSHEPP shows strong potential as a culturally sensitive, scalable, and pedagogically sound model for adolescent health promotion in LMIC schools. Addressing infrastructural gaps, ensuring policy integration, and promoting digital equity will be critical for long-term impact.