Prevention of Addiction and Mental Ill Health in Adolescents in Georgia (PAMAd)

There is a lack of epidemiological studies on mental disorders in the general population and particularly in children and adolescents (CA) in Georgia. According to official data, 2.4% of the Georgian population is affected by mental disorders (NCDC, 2016), while international prevalence studies indicate that on average 9 -16% of the population suffer from mental disorders (Thornicroft and Tansella, 2009). Similarly, national statistics indicate that 377.5 per 100,000 population (or 11%) under 15 years suffer from mental disorders, while international evidence indicates that globally 20% of CA suffer from a disabling mental illness (Klasen & Crombag, 2012). This assumes that official statistics underreport prevalence of mental disorders among general and CA population in Georgia and especially taking into the consideration multiple risks for mental health burden to the population arising from different social and economic factors of the country: (a) since independence from the Soviet Union Georgia underwent significant demographic, economic, health and social systems transformations although every fifth Georgia is still living in relative poverty (under 60% of the median consumption) (WHO Georgia HIT, 2017); (b) during last three decades the country has experienced two main phases of conflict in the early 1990s and in 2008, resulting forced displacement of population - about 200,000 of the Georgian population remain internally displaced (IDMC, 2012) and are living in poor conditions, in poverty experiencing financial barriers to access health care and medicines; (c) the country's geopolitical uniqueness and other contextual factors have facilitated the spread of illegal drug use in Georgia. Strengthened supply control and repressive measures undertaken by the government of Georgia resulted in a shift of drug use behavior by introducing the use of new toxic preparations and subsequent harm to the physical and mental health of drug consumers (Otiashvili et al., 2016). According to the last published annual report on the drug situation in Georgia (Javakhishvili, 2016), as well as information obtained about drug use at the 2017 and 2018 youth festivals, new life-threatening cannabis-type synthetic drugs have entered the drug stage and caused drug-related deaths (Frontnews 2017; Frontnews 2018).
All of the abovementioned information indicates the necessity of targeted effective mental health interventions addressing the needs of CA in the country, although Georgia lacks such service. It should be noted that the government and policy makers in Georgia have acknowledged the problems resulting from mental health burden among CA and prepared a National Action Plan on Mental Health Reform 2015-2020, that emphasizes the needs of CA mental health (MH) interventions development in the country. However, the evidence to support the development of CAMH services in Georgia is very limited.
From spring 2019 it is planned to start implementation of MH interventions for CA and their family members with the support of the European Commission (EC) in two cities (in Tbilisi and Batumi) of Georgia.
Proposed research project aims to (a) contribute in the design stage of the EC funded initiative to refine the service to optimise a package of interventions tailored to the needs of CA with co-morbid conduct and emotional disorders and substance abuse to Prevent Addiction and Mental Ill Health among Adolescents in Georgia (PAMAd) and (b) evaluate PAMAd service (from clinical and cost-effectiveness persepctives).
This is a unique opportunity for Georgia to evaluate the donor supported activity and generate solid evidence with interventions cost estimates to inform policy decisions for further uptake of the service. The results will also be useful for other former Post-Soviet Union countries.

The study will first inform how the PAMAd service (package of interventions) is designed in collaboration with potential service beneficiaries (CA and their family members), service providers, main stakeholders and policy makers at national level and also generate evidence on effectiveness of CA targeted service (clinical effectiveness and unit costs of PAMAd service).
Proposed research project will use pre and post-test design without control groups (Shadish WR, et al.2002) with nested process evaluation. A controlled design will not be feasible because the research is being undertaken within a developing EC supported service with well-estabished plans and a strict timeline. This offers an unique opportunity for implementation research in a real-world setting that will be an integral part of the PAMAd piloting/development work. This will allow exploration of how the interventions are developed and conducted, mechanisms through which the interventions produce change, and what contextual factors may act as barriers or facilitators to PAMAd implementation.
This will be mixed methods research. Quantitative interviews with structured questionnaires will be used to determine socio-demographic status, living conditions, measure outcomes to determine effectiveness of the service and to collect cost data on service. Qualitative data (from in-depth interviews and focus group discussions) will be used to obtain depth of understanding and more comprehensively address the research questions. Data will also be collected on utilization of mental and physical health services, and social services; financial, economic and other barriers to care for common mental health and drug related problems, drug related risks awareness and risk behaviors. Qualitative data from service users and providers, different stakeholders will capture all factors important for duplication of the service in different areas and make it clear for decision makers how feasible its introduction will be.

The beneficiaries of this research will be CA with co-morbid conduct and emotional disorders and substance abuse, service providers, policy-makers and the scientific community in Georgia, the region and globally.
The aim of the proposed research is to support the design of MH service tailored to CA needs (PAMAd service) and to evaluate the effectiveness, costs and mechanisms of change of the service focused on improving the health and wellbeing of CA affected by substance use and common mental health disorders through effective service provision.
Our research will contribute to the CA MH service in two ways, (i) by supporting the design of an appropriate package of interventions, and (ii) assessing its effectiveness and costs (design and implementation) and identifying the factors that support or undermine its effectiveness, as well as documenting intended or unintended effects of the service implementation.
In addition to the PAMAd service design and evaluation of its effectiveness, the project will contribute to development of mHealth application for CA that will also be tailored to their needs and will be co-produced with service users to expand the availability and quality of mental health support in future.
The evidence produced through this research will be used by national policy-makers to reform the mental health system in a way that improves health and wellbeing of CAs through a participatory learning process. Decision makers involvement in the design and implementation stages of the service will benefit the national rollout and possible expansion of PAMAd service in future.
Moreover, findings will be beneficial for other LMICs, particularly for those with a similar socio and economic environment (most of the former Socialist countries of Eastern and Central Europe and Central Asia). Using the communication strategies outlined above, we will inform the development of MH service for CA in other contexts - highlighting positive and negative findings, as well as contextual barriers and enablers, and the wider systems effects and resource implications which are crucial to scalability and sustainability.