About FLOURISH

Young people in Eastern Europe face multiple risks to their mental health, substance use and wellbeing, for many reasons, including poverty, inequality, and other adverse experiences, now exacerbated by the ongoing conflict in Ukraine. Family plays a critical role as a potential buffer for these risks. However, research on evidence-informed approaches to supporting adolescent mental health that are affordable and scalable in LMICs is still limited.

Mental health is more than the absence of mental health problems. Early adolescence is a key period for health because it is a time of vast physical, emotional, and social changes and a distinct phase of brain development. Early adolescence is also the age when about half of mental health problems emerge. Parenting approaches that offer warmth and autonomy have been associated with healthy behaviors in children and adolescents, such as longer and higher quality sleep, healthier nutritional and dietary behaviors, and physical activity, as well as with better mental health, such as lower anxiety and depression symptoms. Parental monitoring and communication about risk behaviors, such as substance use, has been linked to lower rates of risk behaviors among adolescents.

Parenting for Lifelong Health (PLH; https://www.who.int/teams/social-determinants-of-health/parenting-for-lifelong-health) is a suite of group-based socio-behavioral interventions at the individual and family level. PLH is based on evidence regarding the components associated with positive outcomes in parenting practices, adolescent-caregiver communication, and other outcomes among families. PLH was developed with a focus on feasibility of implementation, in collaboration between researchers, the World Health Organization and UNICEF, to meet the need of child and adolescent health promotion and prevention of violence against children in LMICs. The programs are designed to be delivered by staff without specific professional background, and program manuals are freely available under Creative Commons licensing.

At FLOURISH, our aim is to optimize, and evaluate the effectiveness, cost-effectiveness, and implementation at scale of Parenting for Lifelong Health for Teens. The main project objectives are:

FLOURISH will include four interconnected phases to address the objectives of the project.

Phase 1 will focus on program adaptation to a new context, piloting of the adapted program, and exploring the selection of conditions for the factorial trial (Phase 2). We will explore the cultural changes that the program may need, while maintaining integrity to the theory of change. In adapting the intervention, we will be guided by making it as scalable as possible within the delivery systems in North Macedonia and Moldova. We will form four advisory groups: (1) advisory groups with adolescents, (2) parents, (3) implementers, (4) policy stakeholders. Each of these groups will meet for a consultation to identify program adaptations and provide feedback. Based on the consultations in each country, the program adaptations will be identified and implemented. Second, the adapted intervention will be piloted with families with young adolescents aged 10-14. The pilot study will involve pre-and post-program quantitative and qualitative data collection with adolescents, parents, and facilitators. It will (1) test the feasibility of the revised program, (2) produce updated intervention materials and theory of change, and (3) explore and prepare the elements to be tested in Phase 2.

In Phase 2, an 8-condition factorial trial will be used to select the most effective and cost-effective treatment package in the factorial experiment phase of the study. The recruitment strategy, inclusion and exclusion criteria, and measures tested in Phase 1 will be adapted based on the results related to design feasibility and measurement psychometrics, and will be used in Phase 2 and 3. The study will include a pre- and post-program measures of the primary and secondary outcomes.

Research questions for the factorial phase:

• How do participant engagement and family outcomes vary with and without an online resource component? (a chat where Helping Adolescents Thrive and other materials are shared) (on/off)
• How do participant engagement and family outcomes vary when delivering the program with the adolescent peer support/peer facilitator (on/off)?
• Does the additional of an adolescent participation booster result in higher rates of participant engagement and improvements in outcomes, compared to the conditions without a booster?

In Phase 3, a hybrid implementation effectiveness RCT will be used to test the intervention package selected in Phase 2. The pause between the intervention group delivery and the waitlist group delivery will be used to make any final iterations to the program package, if needed. The implementation and outcome measures will be consistent with Phase 1. In addition, in Phase 3 we will add a survey for caregivers on use of health and social services for themselves and their adolescents, to compare the intervention and waitlist group service use. Many programs tend to focus on one outcome – parenting programs can impact multiple outcomes and be a vector of adolescent and caregiver outcomes. FLOURISH will look at cost-effectiveness for a specific outcome, but also outline all the additional benefits.

The scaling up study will explore the dissemination of the intervention and how the intervention has been positioned with practitioners and policymakers. It is closely linked to exploring questions of policy sustainability, led by work packages 6 and 3. The scaling up study data collection methods will include:

1. Interviews with policymakers who took part in the advisory group in Phase 1, on the scalability of the final intervention package, and the impact of the project co-production and communication strategies;
2. 300 surveys with ALTERNATIVA and HYA practitioners on use and dissemination of program materials;
3. Download and engagement metrics for the project website and communication strategy.