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Prevention of child mental health problems in Southeastern Europe - Adapt, Optimize, Test, and Extend Parenting for Lifelong Health

Periodic Reporting for period 3 - RISE (Prevention of child mental health problems in Southeastern Europe - Adapt, Optimize, Test, and Extend Parenting for Lifelong Health)

Reporting period: 2021-01-01 to 2022-06-30

Phase 1: The adapted version of PLH for Young Children (2-9 years) was feasible in the Southeastern European context. This included the selected implementation characteristics which are believed to enhance parental participation and engagement: engagement boosters, text messages or individual phone consultations in between group sessions, and structured supervision. Some refining of these characteristics was necessary based on the experiences in the feasibility study helping in preparing the second phase. This phase also demonstrated the successful implementation of the PLH-YC program in the three countries. We were able to identify some relevant barriers, for example, childcare or caregivers working remotely during agricultural seasons (e.g. as mushroom pickers) while children are staying with extended family as well as implementation supports, for example the individual phone consultations after group session or the text messages.
Phase 2: Results from Phase 2 indicated that the most cost-effective version of PLH for Young Children was five sessions delivered with basic engagement boosters (e.g. providing transport and childcare to assist parents in reducing barriers for participation) and supervision on demand for program facilitators. Investment in reducing more barriers and increasing incentives did not turn out to be cost-effective in these LMICs.
Phase 3: Online delivery of the optimized intervention showed small advantageous effects in key primary outcome variables, including child mental health (oppositional defiant disorder and conduct disorder) at post-intervention that were not sustained at follow-up when compared to a group-based lecture on child development. We designed the lecture to not address the primary and secondary outcomes but still wanted it to be useful for parents which seems to have worked although some parents reported to be disappointment at not being allocated to the PLH condition.

Final conclusion:
We recommend a stepped-care approach to making parenting and child development information widely available to everyone (low-cost and helpful to many parents) while increasing intervention intensity and tailoring, such as a 5-session program, for those who report higher levels of child behavior problems and parenting challenges. Mechanisms for supporting parents with challenges over the longer term need further evaluations and low-cost solutions for sustainability – especially when using online delivery formats instead of in-person delivery.
Overview of the results and their exploitation and dissemination
Child mental health problems are a leading cause of impairment and disability everywhere in the world, but these problems are particularly challenging to address in economically restricted regions with limited human and financial resources and with limited mental health service provision. Early intervention is one of the key strategies for the effective prevention of mental health problems in children and adolescents and has the potential to reduce later mental health problems.
The aim of the RISE project was to address this urgent need for effective and affordable programs targeted at preventing child mental health problems in low-to moderate income countries. We selected three middle-income countries in Southeastern Europe as implementation sites, North Macedonia, Republic of Moldova and Romania. The RISE project was focused on families with at least one child showing elevated behavior problems (compared to other children his/her age).
We selected the Parenting for Lifelong Health (PLH) for Young Children (2-9 years) program as the prototype to adapt to the context because the program is evidence-based (found to be effective in randomized trials), is part of a suite of programs offered under the Creative Common License, freely available and easily adapted in content, structure and service delivery. It is considered a low-cost program because the original development of the program suites occurred in South Africa, a country classified as middle-income. The original program development already considered the needs of economic restrictions in service delivery, e.g. it can be delivered by para-professionals.
The project was divided into three phases: a Preparation Phase (Phase 1) in which we examined the regional / local situation of each country, sought to develop and maintain relationships with parents and professionals to jointly explore how to best implement such a program in different communities, and to find out about its acceptability and the best way to deliver it with fidelity in these contexts. In the Optimization Phase (Phase 2) we examined which implementation factors were most efficacious and cost-effective. By doing so, we created an optimized version of the program that required less human and financial resources to implement in each country. In the Evaluation Phase (Phase 3), we then tested this optimized version in a randomized controlled trial comparing it to a one-off lecture on child development (both delivered online via Zoom due to COVID-19 restrictions).
The RISE project is continuously working on developing strategies with local stakeholders to embed the optimized program into practice and policy and to sustain the intervention at scale (using the built up infrastructure).
Socio-economic impact of the project
We conducted cost analyses of the interventions to determine the economic impacts of the PLH program and the potential costs of future dissemination and scaling up. The delivery costs per group for the optimized intervention varied based on country of delivery and whether cost estimates were from a provider’s perspective or societal perspective. When considering costs balanced with what the programs each achieved, depending on from the provider’s or societal perspective and being based on the delivery costs or total costs, a one unit decrease in the aggressive behavior score (associated with program participation) was achieved for less than 100 Euro.

Project Videos:
PLH for Young Children in SE Europe (Montenegro):
PLH for Young Children in Thailand:
PLH for Young Children in Philippines:
PLH in South Africa:
Implementation team Moldova
RISE logo
RISE project team (Consortium meeting in Chisinau, Moldova)
Logo project partner ALTERNATIVA