In recent years, increased attention has been devoted to intergenerational physical activity (PA) programs because they may have several benefits for both children and older adults . An intergenerational PA program focusing on grandchildren and grandparents in a ‘standard’ family setting that combines PA and cognitive function is innovative and may hold potential for promoting PA and improving cognitive functioning in both grandchildren and grandparents. The aim of this study is to describe the protocol of the GRANDPACT  Project, focusing on the development of an intergenerational, cognitively enriched, movement program for grandchildren and grandparents using the theoretical framework of the “Behaviour Change Wheel” in combination with a co-creation approach. Two co-creation trajectories will be organized to develop the program, followed by a pilot study to refine the program and an RCT with a pre-test (at baseline), a post-test (after 24 weeks), and a follow-up (after 36 weeks) to measure the outcomes of co-PA, cognitive functions, psychosocial well-being, and the quality of the family relationship ingrandchildren and grandparents. The outcomes will be measured using accelerometry for PA, the Cambridge Neuropsychological Test Automated Battery (CANTAB) for cognitive functions, and questionnaires for the psychological well-being and quality of the family relationship. Co-development with end-users and stakeholders during both co-creation trajectories is expected to result in an effective, attractive, and feasible program. Co-PA is expected to improve PA, cognitive functioning, psychosocial well-being, and the quality of the family relationships between grandchildren and grandparents. A physically active lifestyle is of great importance for the physical and psychological health of members of every age group. Some of the benefits of sufficient levels of PA in childhood include the prevention of obesity, better cardiorespiratory fitness, healthy motor development, and the reduction of symptoms of anxiety and depression . AccordiHowever, a lot of children and older adults do not meet these PA guidelines. No statistics are yet available on the most recent PA guidelines, but according to the guidelines from 2010, in Flanders, only 6.9% of the 6–9-year-old children, 2.6% of the 10–17-year-old children, and 12% of older adults (>75 years) met the recommended PA guidelines [Besides the physical and psychological benefits for children and older adults, PA also has a major impact on cognitive functioning . Examples of cognitive functions that improve due to sufficient PA include memory , executive functions , and attention . It is reported that children who are more physically active perform better on attention and working memory tasks . Knowing that working memory undergoes a crucial development between the ages of 6 to 11 years and ensures better academic performance, the importance of sufficient PA during childhood cannot be underestimated ,10,11,12In addition to the cognitive benefits of PA, there is evidence that PA in combination with cognitively challenging activities leads to better effects in the cognitive functioning in children and older adults. In both age groups, these positive effects are explained by structural brain changes  ,18. OldeIn addition to the physical and cognitive benefits of sufficient PA and cognitively challenging activities described in children as well as in older adults, intergenerational programs seem to have an added value to achieving these benefits in both age groups. Most existing PA interventions focus on one target group . To improve communication and social interaction between different generations, an intergenerational approach has made its appearance. The idea is that two different generations  can perform organized activities jointly so as to create a benefit for both of them ,28. Many intergenerational studies have focused on interventions with diverse program topics . There seems to be a positive impact on children in the short- and long-term, and older adults also experienced these programs as beneficial. It has been shown that the intergenerational programs lead to children’s improved perceptions of older adults, which can lead to a reduction of ageism , and that the children learned new skills from the older adults. Older adults reported more confidence, higher levels of self-esteem and social well-being, and also improvements in memory and cognition due to helping children during an academic year ,30,31,32Furthermore, there are a few intergenerational programs that focus on PA where benefits for both age groups have also been reported ,33,34,35Besides the scarcity of intergenerational PA programs in the literature, most of the existing literature is focused on children and older adults without a familial relationship . Only onIn sum, while there is evidence that PA contributes to better physical, psychological, and cognitive functioning, a very high number of children and older adults do not meet the PA guidelines of the WHO. Furthermore, the combination of PA and cognitively challenging activities leads to even better cognitive functioning, and intergenerational PA programs seem beneficial for both children and older adults. Only a few intergenerational programs that focus on PA, however, are reported in the literature, and none of these programs focus on the combination between PA and cognition. Intergenerational PA programs involving familial relationships are even scarcer. Taken together, the development, evaluation, and implementation of an intergenerational, cognitively enriched PA program for grandchildren and their grandparents who are not living together is novel and could promote PA and cognitive functioning. Additionally, such a program could improve the quality of the family relationship and well-being. This paper outlines the study protocol for the development and evaluation of an intergenerational, cognitively enriched PA program aimed at developing an attractive and feasible program for GRANDparents and GRANDchildren to improve their co-Physical Activity and Cognition using co-creaTion . To make the program more attractive and feasible, grandchildren and grandparents will be involved in the program development process to find out their needs and preferences co-creation will be used in combination with a theoretical framework, the Behaviour Change Wheel [co-creation trajectories will be followed: one that focuses on the development of a movement program for grandchildren and grandparents, and one that focuses on the cognitive enrichment of the latter movement program. Once both co-creation trajectories are finalized, a pilot study will be carried out to evaluate the feasibility and attractiveness of the intergenerational movement program in the target group . These results will be used to further refine the program. Finally, an RCT will be conducted to measure the effects of the intergenerational movement program on the outcomes of PA, cognitive functioning, psychosocial well-being, and quality of the family relationship. The RCT will consist of two intervention groups  and one control group (no intervention).An overview and timeline of the program development and evaluation is presented in ge Wheel . Two co-Development of the interventionSocial Cognitive Theory. However, this behavior change model was not originally designed to guide intervention development, and it has several shortcomings  [Most intergenerational programs described in the literature are neither evidence-based, nor grounded by a theoretical framework, and their effectiveness has often not been evaluated ,39. To divation) ,43. Behaviour Change Wheel (BCW) is a theoretical framework that covers most of the important shortcomings of other behavior change models. The BCW describes eight steps that guide the development of a health intervention, from ‘Defining the problem in behavioral terms’ (Step 1) through ‘Mode of delivery’ (Step 8). An overview of the different steps is depicted in The Steps 1–3: Researchers will complete Steps 1–3 of the BCW based on findings and evidence from the literature about PA, cognitive functioning, and psychosocial well-being in children and older adults.Step 1. Define the ProblemMany children and older adults do not meet the PA guidelines of the WHO, which has negative consequences for the health of both groups . Besides, physically inactive individuals have a higher risk of developing cognitive decline and dementia (in older adults) and impaired academic performance (in children). Furthermore, older adults who are more socially isolated  show lower levels of PA and higher amounts of sedentary time, and report more symptoms of depression ,45. PA mStep 2. Select target behaviorco-PA. Grandchildren and grandparents will participate in an intergenerational movement program OR an intergenerational movement program that is cognitively enriched to improve their overall PA by being physically active together. Cognitive functioning and psychosocial well-being are seen as consequences of the target behavior. The target behavior is Step 3. Specify target behaviorphysically active together in an intergenerational movement program OR in an intergenerational movement program that is cognitively enriched, of which all sessions will take place in Ghent. In addition, efforts will be made to boost PA ‘together’ at home  challenge game). The frequency and duration of the sessions and the activity they will do at home will depend on the input of the target group gathered during the co-creation sessions. Grandchildren and grandparents will be encouraged to be Step 4–8: Project researchers, together with participants, will complete Steps 4–8 of the BCW based on the literature about PA, cognitive functioning, and psychosocial well-being, as well as the input from the co-creation sessions.Step 4: What needs to change?Health behaviour is, in general, influenced by the combination of three broad categories of determinants: capability, opportunity, and motivation (COM-B). In the co-creation sessions, the researchers will investigate why people show or do not show a specific behavior based on these three types of determinants . The sources of behaviour will be taken into account , but other sources of behavior will also be considered , which could result in an extended version of the BCW, including new determinants. Furthermore, the threats, barriers, and difficulties to setting the PA behavior will be investigated using the Theoretical Domains Framework (TDF). These TDFs are subcategories of the three broad categories. Examples of TDFs are given in The primary outcomes will be PA and cognitive functioning in both grandchildren and grandparents; the secondary outcomes will be psychosocial well-being and the quality of the family relationship between grandchildren and grandparents. We expect to see improved levels of PA, cognitive functioning, psychosocial well-being, and quality of the family relationship in the intervention group. Cognitive functioning will improve more in grandchildren and grandparents who participate in the cognitively enriched intergenerational movement program. Step 5: Intervention functionsThe project researchers will consider the cases that emerged from Step 4 and will determine which intervention function is best suited to change the behaviour . Intervention goals will also be drafted, which will then be presented to the grandchildren and grandparents in the co-creation sessions, where they can give their input and feedback. Step 6: Policy categoriesIn this step, policy categories will be identified. The policy categories will need to support the intervention functions in Step 5. It will be of great value that the sessions will be embedded in an organization afterwards so as to ensure sustainable implementation. Some examples of organizations and policy categories are Family Sport Flanders, senior and youth sports, and municipal sports.Step 7: Behaviour change techniquesThe project researchers will aim to identify the most common behaviour change techniques (BCTs)  from the list of 93 possible BCTs  based onStep 8: Mode of deliveryAfter identifying the BCTs, it will be decided how those BCTs will be turned into practical strategies.A lot of interventions are developed using a deficit-based approach, where researchers use their knowledge to implement a general program for the participants. However, it has been shown that developing an intervention without taking the needs and requirements of the target population into account results in higher drop-out and lower participation rates for the program ,50. A deAs mentioned earlier, two co-creation trajectories will be followed. The first one will focus on the development of an intergenerational movement program ; the second one will focus on the cognitive enrichment of the intergenerational movement program . Co-creation Trajectory 1 will include a series of 5 sessions, each lasting an average of 90 min, at intervals of 2 weeks so as to provide enough time to prepare for each subsequent session. As we are working with children, the sessions must be especially creative and visual, which means time will be needed to craft  between the sessions . The firTo allow intervention replicability, the Template for Intervention Description and Replication (TIDieR) will be used to describe our intervention and to indicate the location of information  See App.Similar inclusion criteria will be applied for participation in both trajectories . Grandchildren will be 6 to 10 years old; grandparents will probably be aged between 60 and 75, but their age will depend on the age of the children. This age range for the grandchildren has been chosen because, in Flanders, the majority of children in this age category fail to reach the guidelines for PA; only 6.5% of the 6–9-year-old children have an adequate PA level . FurtherEach co-creation trajectory will include 12 grandchildren and 12 grandparents, according to Leask’s recommendations for sample sizes in co-creation activities . See Fi.Study Design and Numbers of ParticipantsConvenience sampling will be used to recruit participants for both co-creation trajectories. A first strategy will be to reach out to children via schools in the city of Ghent and to contact their grandparents (via their parents). All of the children of the first and the second grades (classes 1–4 of primary school) of 2 schools will receive an information letter about the goal of the study and some explanation about the co-creation trajectories. In the case that this results in too few respondents, additional schools will be contacted. If both children and their grandparents are interested in participating (parents must ask the grandparents), they can fill in their contact information using a paper strip attached to the information letter. Of those who respond with interest in joining, a researcher will call the parents and grandparents to ask some questions regarding the sociodemographic characteristics  and inclusion criteria  of the grandchildren and grandparents. A group of 12 grandchildren and 12 grandparents will be chosen by purposive sampling, which means that a researcher will choose the participants based on these characteristics/criteria so as to better represent the population during the co-creation trajectories. In regard to age, both younger and older grandchildren and grandparents will be chosen. In regard to gender, there will be a mix of boys and girls and grandmothers and grandfathers.Before participating in the co-creation trajectories, each participant will be asked to sign an informed consent. Grandchildren will need parental consent, as well as their own informed consent; grandparents will sign an informed consent for themselves. Grandchildren and grandparents will be asked to bring these signed forms to the first co-creation session that they attend.Co-creation Trajectory 1: Development of the Intergenerational movement program.Session 1 (grandparents): In this session, researchers and grandparents will meet each other. A short introduction about the intergenerational movement program will be given. Grandparents will be asked to write down movement activities that they would like to do (and not like to do) with their grandchildren. The barriers and motivators will be determined, which will be the implementation of Step 4 of the theoretical framework. COM-B  and the TDF  will be examined in order to obtain a better overview of their ability and potential  and the barriers and facilitators . Session 2 (grandchildren): In this session, the same structure will be used as that used in the first session with grandparents. The biggest difference between the two sessions will be that, in this session, the information will be obtained by playing games and making metaphors to motivate the children during the sessions, and a mascot—a kangaroo with a child in its pouch—will be used. A kangaroo was chosen because they are quite active animals, and it will represent the grandparent with the grandchild.After these two sessions, the intervention goals will be established/refined by the project researchers based on the barriers and motivators expressed by the grandchildren and grandparents. Furthermore, the intervention functions will be considered and selected based on Step 4 of the BCW. Both intervention goals and functions will be discussed with the grandparents; only intervention goals will be discussed with the grandchildren in the following co-creation sessions. Session 3 (grandparents): In this session, first a summary of Sessions 1 and 2 will be given. Grandparents will be able to give their input and feedback on the proposed intervention goals and intervention functions, which is Step 5 of the BCW. Second, the ideal movement session will be explored. More specifically, content and format ; frequency and duration ; intensity and environment  will be examined. Finally, we will explore which movement activities the grandchildren and grandparents can do together at home in addition to the sessions. Researchers will give some examples, and grandparents will be asked to give their opinions . In addition, grandparents will be asked how they can be motivated to participate in the sessions to keep participation rates high. Session 4 (grandchildren): In this session, the same structure will be used as in the third session with the grandparents. As in the previous session with the grandchildren, information will be obtained in a more informal way, using games, photos, and interactions with each other. Some of the elements that were explored in the session with the grandparents  will not be discussed with the grandchildren because that would be too difficult for them. After these 4 sessions, a movement session will be prepared by the project researchers and movement scientists based on the input and feedback from Sessions 1–4.Session 5 (both groups): In the last session, grandchildren and grandparents will be brought together. A movement session characteristic of the program will be presented to them. Some exercises will be tried out, and grandchildren and grandparents will be asked a few questions about attractiveness, feasibility, fun, motivation, and co-PA. At the end, they will fill in a SWOT analysis to determine the strengths, weaknesses, opportunities and threats that they associated with the exercises. Co-creation Trajectory 2: Cognitive enrichment of the intergenerational movement program. This co-creation trajectory will follow the same order and procedure as described for the first co-creation trajectory, but the information that was already obtained will be included here, and it will not be collected again. Therefore, it is expected that only three sessions will be needed in order to develop the cognitively enriched intergenerational movement program. Session 1 (grandparents): In this session, the activities that were performed and the most important findings from the previous co-creation trajectory will be explained. Furthermore, the objectives of this trajectory and the expectations will be clarified. The main goal is to find out which cognitive movement activities they found to be attractive and feasible for inclusion in this program. An introduction to PA and cognitive functioning will be given, and researchers will also provide some examples of cognitively enriched movement activities. The desired duration and challenge of the activities will be ascertained. From the literature, it is known that a combination of PA and cognitive functioning must last at least 10 minutes to observe effects, so this will be taken into account. Session 2 (grandchildren): This session will have the same content as the session with the grandparents. A big difference will be that the desired duration and challenge will not be ascertained from the children. Furthermore, everything will be explained in an understandable way for them. More examples of cognitively enriched movement activities will be provided to the children as developed by both the researchers and the grandparents (from Session 1). Session 3 (both groups): As in the previous co-creation trajectory, grandchildren and grandparents will be brought together, and the cognitively enriched movement activities for the intergenerational movement program will be tested out. Grandchildren and grandparents will be asked a few questions about attractiveness, feasibility, fun, motivation, and co-PA. At the end, they will be asked to fill in a SWOT analysis to determine the strengths, weaknesses, opportunities and threats that they associated with the exercises. After each co-creation session, participants will be asked to fill in a short questionnaire to evaluate how the session was perceived  in conversations?’). They will also be able to add suggestions for the next sessions ? What could be improved? What should be different?’). At the end of Co-creation Trajectories 1 and 2, an elaborated series of activities will be prepared by movement scientists, after which an expert meeting will be organized with experts in movement activities and cognition in children and older adults in order to obtain additional advice about the proposed activities . An observer will write down the most important findings. Evaluation of the interventionAfter the two co-creation trajectories are finalized, a pilot study will be conducted to determine whether the two different programs are attractive, feasible, and fun for grandchildren and grandparents see . The purSimilar inclusion criteria will be used to recruit participants for the pilot study as those used for the co-creation trajectories.  will take place over the course of six weeks (depending on input from the co-creation sessions) at a preferred time during the week. Group 1 will engage in the intergenerational movement program; Group 2 will engage in the cognitively enriched intergenerational movement program. The duration and content of the sessions will depend on the needs and preferences of the target group and the intervention goals that were set during the co-creation sessions . According to the recent PA guidelines of the WHO for children and older adults, researchers will integrate coordination, balance, mobility, and strength into the sessions.Process EvaluationAfter each session, a short questionnaire will be administered to probe for the thoughts and feelings of the grandchildren and grandparents regarding attractiveness and feasibility during the activities and to determine which kinds of topics or activities they prefer the most . The Physical Activity Enjoyment Scale (PACES) will be used to assess the level of enjoyment among grandparents. This short, validated questionnaire for older adults includes eight items that will assess how much fun the grandparents experienced during the (cognitively enriched) movement activities . The useEvaluating the use of outcome measures for the RCTTo objectively measure PA in the grandchildren and grandparents, the Axivity AX3 accelerometers or the ActiGraph wGT3X-BT will be used. Half of the group doing the intergenerational movement program will wear the first accelerometer; the other half will wear the second one. During the cognitively enriched sessions, half of the group will also wear the first one; the others will wear the second one. The most feasible, practical, and useable of the accelerometers will be chosen to be used as a measure in the RCT. These accelerometers will be used in combination with a seven-day diary (pre- and post-follow-up) to subjectively measure PA, and they will be worn during certain sessions. More details about the measurement instruments are described below in Outcome Measures part of To objectively measure cognitive functioning in the grandchildren and grandparents, CANTAB tests will be used. The purpose will be to assess the feasibility, usability, and practicality of the test battery. The pilot study will be used to make a final selection of which cognitive tests to include in the RCT and decide on the ideal total duration of the cognitive testing procedure  based on practicality and discriminating power. More details are described in Outcome Measures part of To measure psychosocial well-being in the grandchildren and grandparents, several questionnaires will be administered. The preferred mode of delivery (online or paper-and-pencil questionnaires), the number of questionnaires, and the total duration of completing the questionnaires will be evaluated. Potential unclarities or difficulties when completing the questionnaires will be detected in order to improve this in the actual RCT. More details are described below in Outcome Measures part of Furthermore, participants will be asked for input and feedback on the measures and measurement instruments using a short questionnaire.Depending on the findings that emerge from the co-creation sessions, a gadget or material  can be developed to optimally achieve the intervention goals. A self-administered questionnaire will assess whether these program materials are perceived as positive and supportive to achieving the intervention goals.The answers on the open-ended questions in the questionnaires will be coded using content analysis. The answers on the Likert scale questions in the questionnaires will be coded using SPSS . MultileThe RCT will be conducted subsequent to the pilot study so as to measure the effects of the two different programs on the outcomes of PA, cognitive functioning, psychosocial well-being, and quality of the family relationship in the grandchildren and grandparents and to evaluate the process of the study. The RCT will consist of two intervention groups, Arm 1: Intergenerational PA and Arm 2: Cognitively enriched intergenerational PA, and one control group. Intervention Group 1 will receive the intergenerational movement program, Intervention Group 2 will receive the cognitively enriched intergenerational movement program, and the control group will receive no intervention. The pre- (before the start of the sessions), post- (after 24 weeks) and follow-up (after 36 weeks) outcome measures of PA, cognitive functioning, psychosocial well-being, and quality of the family relationship will be compared between Group 1 and the control group, between Group 2 and the control group, and between Groups 1 and 2. An overview of the RCT is shown in n = 90 grandchildren and grandparents). Assuming an attrition rate of 20% [n = 108 grandchildren and grandparents) will be required for the 3 groups. (Each group consists of 36 participants: 18 grandchildren and 18 grandparents). See The same inclusion criteria will be used for the RCT as in the co-creation trajectories and the pilot study . Based on effect sizes of intergenerational programs of children and older adults, an effect size of 0.15 will be intended for the outcomes of PA, cognitive functioning, psychosocial well-being, and quality of the family relationship . The reqe of 20% , a totalAccording to the evaluation of the recruitment strategy of the co-creation sessions and the pilot study, the best way to recruit the target population will be chosen based on convenience sampling. The strategies and procedures for the recruitment are described above in the discussion of the recruitment for the co-creation trajectories and pilot study. The first strategy will be the recruitment of grandchildren and their grandparents via schools in (the neighborhood of) Ghent. The second strategy will be via GRAY and their partners. A combination of both strategies is also possible if needed to achieve the desired number of participants.A total of 12 (or 24) sessions (1–2 session(s) every (1 –2) week(s) per group will take place over 24 weeks at a preferred time during the week . All of this will depend on the preferences of the grandchildren and grandparents. Arm 1 and Arm 2 will receive different sessions during the same week. Arm 1 will receive only movement activities, while Arm 2 will receive cognitively enriched movement activities. The content of the sessions will have been refined during and after the pilot study to best meet the needs and preferences of the grandchildren and grandparents . After the follow-up measurements, the intervention groups will also receive a brochure detailing (cognitively enriched) movement activities that they can perform at home to achieve a long-term effect.Process evaluationSimilar to the process evaluation in the pilot study, attractiveness, feasibility, and enjoyment will be examined after each session of the finalized intergenerational movement program.Effect evaluationPA, cognitive functioning, psychosocial well-being, and quality of the family relationship will be measured in the grandchildren and grandparents to determine possible effects. A more detailed description is given in Outcome Measures Part in Outcome measuresphysical activity will be objectively measured in the grandchildren and grandparents using Axivity AX3 accelerometers or ActiGraph wGT3X-BT. These validated accelerometers in children and older adults [According to the results of the accelerometers used in the pilot study, r adults ,67,68 mur adults ,70 and or adults . The BluThe Cognitive functioning of the grandchildren and grandparents will be objectively quantified pre- , post- (after 24 weeks), and at follow-up (after 36 weeks) by means of a validated neuropsychological test battery . The CANTAB is sensitive to changes in neuropsychological performance and allows the differentiation between different cognitive functions. The standardized and automated CANTAB can be used in children from the age of 4 and has been used and recommended in research in older adults [cambridgecognition.com, accecced on 12 January 2022).r adults ,73. SevePsychosocial well-being will be measured by several questionnaires that measure well-being indicators relevant to children and older adults. For children, the 23-item PedsQL  scale will be used to obtain a reliable and valid global assessment of the children’s general quality of life and their specific emotional, social, and school functioning [ctioning . For oldctioning . Symptomctioning . Social ctioning .Quality of the family relationship will be measured in children with the Grandparent–grandchild Relationship Questionnaire using 3 sections  and Rey and Ruiz’s Socialization Styles Questionnaire, which consists of 34 items on a 4-point Likert scale, and which evaluates democratic and authoritarian socialization styles [n styles . In grann styles .Multilevel linear analysis in R will be used to estimate the between and within subject effects on PA, cognitive functioning, psychosocial well-being, and the quality of the familial relationship in grandchildren and grandparents. The mediating role of co-PA in the relationship between PA, cognitive functioning, psychosocial well-being, and the quality of the family relationship will be statistically checked in R using structural equation modelling . Open-ended questions will be conducted using content analysis in SPSS  .All data will be stored on a password-protected computer and a central hard disk of the research group. The data of the participants will be pseudonymized, and only the main researcher will have access to the key to link raw data on personal data. Data will be stored for a minimum of 5 years after the appearance of publications based on these data. After this period, the data can be destroyed.This study and its three parts  have been submitted for approval by the Committee of Medical Ethics of the Ghent University Hospital. Ethical approval has already been received so as to coincide with the beginning of the co-creation sessions (EC number: BC-11748). The RCT will be registered at ClinicalTrials.gov, which is a database of privately and publicly funded clinical studies conducted around the world. Participants in the co-creation sessions, the pilot study, and the RCT will receive an information letter and informed consent to provide them with all of the details about the study. Grandparents and parents will be asked to read and sign the informed consent; grandchildren will be asked to sign an informed assent before the start of the co-creation sessions, pilot study, and RCT. Each participant will be informed about the purpose of the study, the design, the procedure, the right to leave the study at any time, and the data confidentiality.The research intention of the program development and evaluation is a theory-based lifestyle program which aims to improve Physical Activity and Cognitive functioning in GRANDchildren and their GRANDparents using co-creaTion .For the program development, it is expected that a theoretical framework, in combination with a co-creation approach, will lead to an attractive and feasible intergenerational movement program in which grandchildren can participate together with their grandparents. The needs and requirements of end-users will be taken into account, and this will make them feel empowered. For the program’s evaluation, it is expected that the pilot study will help to refine the movement program that will be drafted after the co-creation sessions. Furthermore, the refinement of measurement instruments, recruitment strategies, ages, and group sizes will be important to optimize the program for the RCT. The RCT will be conducted to evaluate effects of the (cognitively enriched) intergenerational movement program on co-PA, cognitive functioning, psychosocial well-being, and quality of the family relationship.cognitive enrichment of co-PA . The main goal and primary outcome of the intervention is to improve co-PA in grandchildren and grandparents (based on the WHO PA guidelines), and taking feasibility into account, we aim to reach a level where grandchildren are physically active together with their grandparents 2 times per week, for a minimum of 30 min of performing MVPA. The secondary goal is to improve total PA, cognitive functioning, psychosocial well-being, and quality of the family relationship in grandchildren and their grandparents, and it is expected that co-PA (over a period of 36 weeks) will act as a mediator in this relationship. It is hypothesized that Arm 1  and Arm 2 of the RCT  will lead to a greater improvement in PA, cognitive functioning, psychosocial well-being, and quality of the family relationship than that of the control group (no intervention). Furthermore, it is expected that the cognitive enrichment of the intergenerational movement program will lead to a greater improvement in cognitive functioning in Arm 2 of the RCT.Arm 1 of the RCT will mainly focus on increasing co-PA , while Arm 2 of the RCT will mainly focus on increasing cognitive functioning in both the grandchildren and grandparents via a This paper describes the study protocol of the GRANDPACT Project. The main aim of this project is to develop an effective, attractive, and feasible (cognitively enriched) intergenerational movement program for grandchildren and their grandparents to improve their co-PA and cognitive functioning (primary outcomes), psychosocial well-being, and the quality of the family relationship between the grandchildren and their grandparents (secondary outcomes).The development of this intergenerational movement program for grandchildren and grandparents is innovative for the following four reasons. First, to our knowledge, this will be the first intervention that uses the Behaviour Change Wheel in combination with a co-creation approach to develop a cognitively enriched intergenerational movement program for grandchildren and grandparents. Previous intergenerational interventions described in literature are often not evidence-based or grounded by a theoretical framework, and if so, mostly the Social Cognitive Theory was used for the development of the PA intervention ,43. HoweA first potential strength of this study includes the experimental and longitudinal design. A second potential strength is the use of the Behaviour Change Wheel in combination with a co-creation approach in which end-users and stakeholders will collaborate in the development of the movement program. This may lead to a more effective intervention, and it will also prevent drop-out because the needs and preferences of the grandchildren and grandparents will be taken into account ,52,53,54A first potential limitation of this study includes the lack of blinding, as the researcher will be involved in the data collection and analysis. Therefore, a strict protocol has been created so as to reduce this limitation as much as possible. A second potential limitation includes the recruitment strategy. Convenience sampling will be used for the co-creation sessions, the pilot study, and the RCT. It is therefore expected that grandchildren and grandparents who are already more physically active and motivated to move will be interested participating. However, this will be taken into account during the recruitment by mentioning that the levels will be attainable for everyone and that the focus will not only be on the movement activities, but also on creating a pleasant atmosphere by making the activities fun, attractive, and feasible for the target group.Implementation of the intervention program is likely to impact its success; therefore, several strategies will be used to facilitate correct implementation of the intergenerational movement program by different organizations . First, a detailed protocol will be written to assure that the intervention will stay theory-based and to minimize attrition rates, which will both foster the success of the intervention . Second, the expert meetings with diverse stakeholders from different organizations  that will be held after the co-creation trajectories will help to gain feedback and additional advice about the feasibility of implementing the cognitively enriched movement activities for grandchildren and grandparents . This input will also be integrated into the protocol. Third, the planned pilot study will help to refine the cognitively enriched movement activities to ensure that they will be useful and correctly executed, as well as attractive and feasible for the target population. If results of the RCT show that the intervention is indeed effective at improving co-PA and cognitive functioning in the first place, and psychosocial well-being and the quality of the family relationship in the second place, a meeting with organizations who are interested in implementing this intergenerational movement program will be held to discuss the information necessary for grandparents, parents, and children, which materials are needed, which locations are preferable and feasible, which certified teachers should be recruited, etc. A very important factor is that the embedding of this project in GRAY will help to engage Flemish partners, such as Family Sports Flanders and Sports Flanders, in its execution, dissemination, and valorization.This will be the first intergenerational movement program targeting grandchildren and grandparents using the BCW in combination with a co-creation approach and using a combination of PA and cognitively enriched PA. Developing and evaluating this intergenerational, cognitively enriched movement program might be effective in improving co-PA, cognitive functioning, psychosocial well-being, and the quality of the family relationship in both grandchildren and their grandparents. If the program seems to be effective, it could be implemented in different organizations in Flanders, and it could have important implications for future research and health policies. Targeting grandchildren and their grandparents for participation in an intergenerational cognitively enriched movement program might be a novel and effective approach to improving general health in both age groups.


Enrolling young people to participate as Teach For America (TFA) teachers has a large positive effect on rates of voter turnout among those young people who participate. This effect is considerably larger than many previous efforts to increase youth voter turnout. Each year, TFA places thousands of young adults in 2-y teaching positions in disadvantaged communities around the United States. After their 2 y of service, we find that these young adults vote at a rate 5.7 to 8.6 percentage points higher than that of similar nonparticipant counterparts. Our results suggest that civilian national service programs targeted at young people show great promise in narrowing the enduring participation gap between younger and older citizens in the United States. Low rates of youth voting are a feature of contemporary democracies the world over, with the United States having some of the lowest youth turnout rates in the world. However, far too little is known about how to address the dismal rates of youth voter participation found in many advanced democracies. In this paper, we examine the causal effect of a potentially scalable solution that has attracted renewed interest today: voluntary national service programs targeted at the youth civilian population. Leveraging the large pool of young people who apply each year to participate in the Teach For America (TFA) program—a prominent voluntary national service organization in the United States that integrates college graduates into teaching roles in low-income communities for 2 y—we examine the effect of service participation on voter turnout. To do so, we match TFA administrative records to large-scale nationwide voter files and employ a fuzzy regression discontinuity design around the recommended admittance cutoff for the TFA program. We find that serving as a teacher in the Teach For America national service program has a large effect on civic participation—substantially increasing voter turnout rates among applicants admitted to the program. This effect is noticeably larger than that of previous efforts to increase youth turnout. Our results suggest that civilian national service programs targeted at young people have great promise in helping to narrow the stubborn and enduring political engagement gap between younger and older citizens. Political engagement is one of the central pillars of democracy –4. Yet, 5However, there exists far too little knowledge of what can be done—particularly at scale—to ameliorate this large, consequential, and stubborn gap in political participation. At present, we know that many campaign-based efforts to get out the vote have very modest effects –20. WhilGiven the core role that young people play in shaping the future health of civic life, young people have been the objects of many service-based efforts to inculcate the values and practices upon which democratic citizenship depends . When di22SI Appendix, section B.1). Extant sociology research finds that participation in youth service is associated with increases in 1) feelings of civic duty  undevic duty , 28; 3) vic duty –31; and vic duty .Despite these promising findings from conditional-on-observable research designs, we currently lack large-scale studies that are designed to detect the causal effects of national service programs. This raises serious inferential concerns, as previous positive associations may be driven more by the types of people who select into national service programs rather than the independent effects of national service programs. Moreover, while some evidence indicates that service learning encourages participants to better understand the challenges communities face , some scTo start to address these inferential gaps in studies of the effects of national service programs on civic engagement and political participation, we examine the causal effect of participating in TFA, a prominent national service program established in 1990 with a mission “to enlist, develop, and mobilize as many as possible of our nation’s most promising future leaders to grow and strengthen the movement for educational equity and excellence.”To evaluate the effect of this program, we utilize a large-scale, proprietary administrative dataset from TFA that contains information on all program applicants during the 2007 to 2015 period. Because nearly 80% of TFA applicants from this period are younger than 25 y old, this represents a unique opportunity to study the causal effects of a national service program on youth turnout. We match these TFA data with nationwide voter file data that contain information on all registered voters (N ≈ 200 million) in the United States. With this combined dataset, we take advantage of a natural experiment wherein we compare individuals who were marginally recommended to be accepted to participate (based on TFA’s proprietary admittance threshold) to those who were marginally recommended to be rejected from participating. This threshold allows us to employ a fuzzy regression discontinuity design, a method of causal inference developed and refined over the past 60 y that leverages continuity in potential outcomes around an arbitrary cutoff –40 and bWe find that participating in TFA has a large effect on youth political participation. Ceteris paribus, 2 y after applying for TFA (which is the duration of the TFA program), individuals who scored marginally above the admissions cutoff score and, hence, were recommended for admission into TFA, vote at a rate 5.7 to 8.6 percentage points higher than those who were marginally rejected . When we account for the fact that the admissions cutoff score has a probabilistic (rather than deterministic) relationship to likelihood of selection into the program, we estimate that participants in TFA are 30.1 to 42.3 percentage points more likely to vote than similar nonparticipants . To put these estimates into perspective, the ITT effect is 3 to 14 times larger than standard get-out-the-vote (GOTV) programs and ∼20 to 30% of the entire turnout gap between old and young voters . Regardless of the comparison point one uses, these effects are large.SI Appendix, Table S2). States are also investing in regional service programs targeting youth. For example, in January 2022, the state of California announced the creation of the #CaliforniansForAll College Corps to create debt-free college pathways for students who commit to serve their communities , and the expansion of national service is regularly discussed in Congress To estimate the effect of TFA admittance and participation on voter turnout, we linked a national voter file database from the Data Trust LLC (snapshot taken 29 September 2017) to records from TFA’s administrative data for the 2007 through 2015 admissions cycles and a 2015 to 2016 original survey of TFA applicants. TFA’s administrative data include an application quality score that strongly and discontinuously predicts admission into the program. We employ a regression discontinuity design around the TFA admittance cutoff to estimate the effect of admission to and participation in TFA on voting in subsequent national elections. . The green lines in SI Appendix, section A.4 for more details). Overall, these matching strategies lead us to a similar conclusion and illustrate the robustness of our results.SI Appendix, Fig. S6 A and B for regression discontinuity design [RDD] plots), we compare rates of voter turnout before TFA applicants were either admitted to or rejected by the program across the admissions cutoff. As can be seen, before applying to the TFA program, eventual marginal admits and marginal declines voted at rates that are statistically and substantively indistinguishable from one another. This can be seen by the insignificant and close-to-zero estimates of the CACE and ITT effect in the pretreatment period. In these pretreatment elections, the CACE ranges from –1.3 percentage points (P = 0.96) to 0.2 percentage points (P = 0.99), and the ITT effect ranges from –0.3 (P = 0.93) to –0.2 percentage points (P = 0.96). In other words, TFA participants were statistically equally as likely to participate in elections as nonparticipants when they applied to join—and before they had completed any parts of—the TFA program. This pretreatment balance lends support to the key assumption that barely admitted and barely rejected applicants would not have voted at different rates at the cutoff without the intervention of TFA.In the left pair of estimates in each panel of SI Appendix, Fig. S6 C and D for RDD plots) shows the rates of voter turnout for TFA applicants 2 or more y after their admittance into or rejection from the program . We find that TFA participation increases voter turnout in the 2012 and 2014 elections for treated respondents. The intention to treat (Bottom) estimate ranges from 5.7 (P = 0.057) to 8.6 percentage points (P < 0.001). The complier average causal effect (Top) of TFA participation ranges from 30.1 (P = 0.028) to 42.3 percentage points (P < 0.001). If we examine whether TFA participation has a positive effect on the proportion of elections in which an applicant voted, we similarly find positive effects .In contrast, the second pair of estimates in each panel of to treat , Bottom l effect , Top of These estimated effects are substantively meaningful. They are large, but not unreasonable given the nature of the program. In considering the magnitude of our effects, we pause a moment here to note the size and scope of the TFA program and TFA’s known effects on the antecedents to voting. Unlike many get-out-the-vote programs, which draw the attention of voters for a matter of minutes (at most), the TFA experience is quite an intensive treatment. TFA is not a light nudge, but is, rather, a fully immersive 2-y treatment. Those who serve as TFA teachers spend all of their working—and many of their nonworking—hours being exposed to a whole new set of experiences, networks, and cultures. In this immersive environment, TFA teachers are exposed to many students, teachers, administrators, parents, communities, and/or contexts that are outside of their normal realm of experience. Previous research on the attitudinal effects of TFA has shown that this immersive experience fundamentally shifts some of the antecedents to voting. For example, past research on TFA shows that TFA substantially increases participants’ dissatisfaction with the current political system, while simultaneously increasing their ability to see the plight of disadvantaged communities and empowering them with the optimism and efficacy needed to believe that positive reform in the policy arena is possible , 43. UnlThere are several benchmarks against which we can compare our effect sizes. None of these are perfect—each comes with its own limitations and assumptions—but using them together, we can get a sense of the magnitude of our effect. Moreover, all end up pointing in the same direction—that the effect of TFA is large and meaningful. Below, we mostly benchmark our ITT effects to the ITT effects obtained from other comparable interventions intended to increase voter turnout, to make the comparisons as equivalent as possible.Discussion.)First, we can compare the effect of TFA participation to the voter turnout gap between young and older voters. As Holbein and Hillygus  report, Second, we can compare our effects to other more immersive education-based treatments. We first compare our effects to estimates of the average effects of civics education –48. HolbFinally, we can compare our effects to other commonly used strategies to get out the vote —such as phone calls, canvassing, and mailers. Although these GOTV interventions are clearly not the same as a national-service–based TFA treatment—being significantly smaller in their treatment intensity than the TFA program—GOTV efforts are the most widely studied approach to increase voter turnout and the one approach that most frequently uses methods for causal inference . To bencIn short, all comparison points suggest that TFA’s effect on voter turnout is large and meaningful. Indeed, national service experience through TFA likely does not completely close the gap between young and older voters, but it does make a meaningful step toward doing so. In interpreting the magnitude of these effects, however, one important point about treatment scope and exposure is worth reiterating. TFA is a 2-y program, whereas many previous voting treatments are much shorter. The effects that we observe are wholly consistent with larger, more immersive programs having larger effects on voter turnout.SI Appendix, Fig. S14). Further, while we prioritize the 2012 and 2014 elections given that those elections are closest to when participants were surveyed to get reliable information on their state of residence, if we expand the analysis to include the 2008 and 2010 elections, results largely remain the same . Moreover, we note that one may be concerned that effect sizes are overestimates if nonadmits are pursuing work that may socialize individuals to participate less in politics. However, they could also be underestimates if nonparticipants systematically worked in sectors that may also encourage greater political participation. To explore this question, we examine the job sectors of nonparticipants since 2007, the first cohort year in our study. As seen in SI Appendix, Figs. S15–S17, over one-third of nonparticipants pursued work in the education sector. The next two most-represented sectors are the nonprofit and legal sectors. Nearly half of nonparticipants entered the legal, nonprofit, and education sectors, and there are no documented reasons that these three sectors would depress voter turnout. As such, it is unlikely that we overestimate the effect of TFA due to the career trajectory of nonparticipants.Our effects are robust to various alternate specifications. For example, when we use the admissions score as an instrument for TFA program completion rather than matriculation, we see that the effects are stronger . However, as with most tests of treatment effect heterogeneity, statistical power may be an issue here. Moreover, we do not see consistent evidence that the positive effects we detect are present after receiving a smaller “dose” of the program , although we interpret these results with caution given the reduced sample size .When it comes to treatment effect heterogeneity, the effect of TFA is similar for Whites and non-Whites and across several geographic areas in the United States, but effects appear to be larger among men than women and among those with higher rather than lower socioeconomic status, as measured by federal Pell Grant status . Simply put, the magnitude of effects may differ by the type of service one is charged to provide.Our work uses a natural experiment unique in its scale and size to study the causal effect of national service participation on youth voter turnout; however, it should not be the last to examine this important topic. Future research is needed to explore questions of external validity. While we established that the effects of TFA participation are positive across many subsets of the population of applicants, we cannot estimate how effects would differ in other populations. This may be especially important, as individuals who apply to national service programs may differ from the general population in important ways. Future work should also explore whether effects like those we document here generalize to other subsets of compliers, like to noncollege graduates and to older citizens (to name a few). That said, scholars doing such work in the future would do well to note that, to a certain extent, all individual voluntary youth service programs—given their voluntary nature—likely experience selection effects into application. Conversely, while mandatory national service programs may cover a broader subset of participants—being mandatory, after all—they may struggle to produce all-else-equal counterfactual comparisons. Moreover, mandatory national service programs may have different effects on participation given differences in the potential attitudinal effects of compelling service. Future research would also do well to see whether we observe similar causal effects of other voluntary service programs beyond TFA, like the Peace Corps. Doing so would allow us to answer questions like whether the effects we document are larger for national service programs that involve teaching, as there is suggestive evidence that under certain conditions, being a teacher increases voter turnout  —as a necessary response to bolster COVID-19 recovery. The intention of these efforts is to create more opportunities for young people to help the nation combat, and recover from, the devastation of the COVID-19 pandemic . Crucially, there was no difference in response rates of admits and nonadmits close to the admissions cutoff .Our analysis leverages administrative data from TFA, a nationwide voter file, and a survey of TFA applicants. The Committee for Protection of Human Subjects (CPHS) at University of California, Berkeley provided institutional review board approval to conduct this research (2020-02-13026). TFA maintains detailed selection data  at the time a given applicant applied to the program, and we use this information for all applicants who were competitive to join the program. We focus on the set of applicants who made it to the final round of interviews for the 2007 to 2015 application cycles and, hence, received a selection score. This amounts to 120,329 applicants. All of these applicants were also targeted by Mo and Conn  between In the United States, voting is public record and, as such, individual states make the list of registered voters in their state available to researchers. The voter file data that we use have been collected and collated by the data and analytics firm Data Trust. We use their snapshot of the nationwide voter file from 29 September 2017. Much like other large-scale voter-file vendors—like Catalist, L2, and Aristotle—Data Trust appends voting information from all 50 US states along with the District of Columbia into a single file. This appended dataset contains voting and registration histories of all registered voters in the United States—with ∼200 million voters contained therein. Whereas other firms share 1% samples of their voter files with researchers, we have the entire Data Trust file for all 200 million individuals, thus making it possible to match individuals who applied to participate in TFA. There is evidence that the Data Trust file is high quality; indeed, extant research –67 notesSI Appendix, section A.5 for more details). We focus on the two most recent general elections to minimize the time elapsed between the elections in our voter file data and information on individuals’ current state of residence from the 2015 to 2016 survey. For all survey respondents, we searched for voting records in the current states of residence reported in the survey . Following previous practice, if no voting record is found, we assume that person did not vote; this allows us to avoid issues with posttreatment bias . As long as the (often modest) assumption that the potential outcomes of the control and treatment groups are continuous around the cutoff is met, RDDs will provide causal estimates that benchmark remarkably well with randomized control trial estimates . RDDs are a natural experimental technique that have grown in popularity in recent years, especially in contexts where formal randomization is not/cannot be conducted. The design leverages scenarios where there is an arbitrary value of some variable—a cutoff—that sorts individuals into treatment and control groups; individuals on one side of the cutoff are in the treatment group, while individuals on the other are in the control group. As has been well established, regression discontinuity designs exploit continuity in potential outcomes around an arbitrary cutoff . Importantly, this cutoff and the weight given to the constituent parts that go into determining one’s score are not public knowledge to the interviewees and the interviewers. This provides us with a strong precondition for estimating the causal effect of TFA using an RDD: It is unlikely that individuals will be able to precisely sort around the admittance cutoff  and the density of the running variable  are balanced at the cutoff. This approach allows us to overcome issues of selection bias, endogeneity, and/or simultaneous/reverse causation and estimate the causal effect of being chosen to participate in TFA (the ITT effect) and actually participating in TFA (the CACE). As is standard practice, the CACE is estimated via a fuzzy regression discontinuity design that instruments program participation with program selection (The discontinuity that we leverage in this paper is found in the selection scores given to all of the young people who apply to participate in TFA. As background, in 2007 TFA instituted a selection process that assigns a continuous score to all applicants. This score represents TFA’s holistic assessment of how effective the applicant will be in the classroom based on the applicant’s application materials. This is based on applicants’ educational history, extracurricular activities, transcripts, personal statements, and interviews. Individuals who score above a certain preset score are recommended to be admitted to the TFA program, whereas those who score below the cutoff are not recommended to be admitted, although the score is not the only factor that determines whether an applicant will be admitted to the program (see e cutoff . As we welection .Supplementary File


AGEM= 12.89, SD = 0.45) from three schools in France participated in this study. The participants attended one of two programs (Unplugged/IPSELF). The effectiveness of the IPSELF add-on session was measured with the Self-Concept Clarity Scale, and the differences between the two programs was measured with the prototype willingness model. Adolescents in IPSELF rated the typical nonsmoker and cannabis nonsmoker more favorably, and the typical drinker less favorably. They felt more different from the typical smoker and drinker after participation in IPSELF. More alcohol experimenters were observed in Unplugged. The knowledge gained in IPSELF appeared to help adolescents more than that gained in Unplugged to change their smoking behavior. Furthermore, IPSELF had a more beneficial effect for girls, who felt that they had gained more control over their alcohol and cannabis use than boys, whereas Unplugged had a more positive effect on boys, who gained better control over their consumption. Moreover, the girls felt that they had gained more knowledge about the substances discussed in IPSELF than in Unplugged. We therefore recommend the use of IPSELF especially with female audiences.The “Intervention Program based on Self” (IPSELF) project was created to address the gap between the acquisition of life skills during prevention programs and their application with a session for developing one’s self-concept included in the European program “Unplugged”. The present study evaluated its effectiveness. A total of 157 middle school students (94 girls, 63 boys,  In France, addictive behaviors are a major public health problem. French adolescents are the most frequent users of cannabis in Europe, and the second most frequent users of other illicit substances . The useFor a long time, primary prevention programs focused on imparting knowledge about illicit substances, but these have had no significant effect . Today, Despite the effectiveness of these modern prevention programs, some studies have highlighted a gap between the acquisition of life skills and their application in context by the adolescents . The acqThe objective of this study was to implement and evaluate the effectiveness of the “Intervention Program based on Self” program, consisting of the Unplugged program sessions and a complementary session on self-concept development, by comparing it to the reference program Unplugged.In order to examine the impact of self-concept on the effectiveness of the Unplugged program, the present study relies on the prototype willingness model. The prototype willingness model focuses on reactive decision making and deliberative decision making in order to predict behaviors ,27. It pThis is why, in the test of the “Intervention Program based on Self”, we hypothesize a greater clarity of self-concept and greater gains in knowledge about themselves, with greater change in self-perception, for adolescents in the IPSELF program compared to those in the Unplugged program after participation. We believe that this development of self-concept will allow adolescents to feel less similar to prototype substance users and more similar to non-users, which should decrease their willingness to consume harmful substances, and thus reduce their consumption of them. We also believe that the knowledge gained about harmful substances in IPSELF will be more helpful in changing use behavior in adolescents than that gained in Unplugged. However, we expect no impact of self-concept on attitude, norm or control towards substance use, and thus no impact on the intention to use. We will consider the effect of gender in order to observe the effectiveness of each program for girls and boys, due to the differences in consumption and prevention sensitivity identified in the literature.M = 12.89, SD = 0.45) from three middle schools in the Auvergne Rhône Alpes region of France took part in this study. The classes in each middle school were randomly assigned (by lottery) to the two programs (Unplugged (n = 83 (52.87%) and IPSELF (n = 74 (47.13%)), ensuring that each school had the same number of classes for each program. Thus, the Unplugged and IPSELF programs were delivered at each middle school to an equivalent number of students to avoid possible differences between the middle schools (see One hundred and fifty-seven middle school students (94 (59.87%) girls and 63 (40.13%) boys) in grade 8 .The middle schools were recruited on a voluntary basis. Students could only participate with parental consent. This study was conducted in accordance with ethical standards and received approval from local ethics committees . The current study is available in the OSF repository at: The participants attended one of two prevention programs (Unplugged or IPSELF) at their middle school during the 2020–2021 school year. The distribution was conducted by lottery. Unplugged consists of 12 sessions and IPSELF of 13 . The sessions took place for one hour every two weeks in a half-group format. Because the IPSELF program had an additional session, we added a control session for the groups in the Unplugged condition (a game presented as a session working on communication) to avoid a bias related to the number of sessions. Session 10 of the program (“Drugs: Getting Informed”) had to be conducted virtually (via the Zoom software) during the lockdown period due to the COVID-19 pandemic. This change in format was common to both groups and the content was the same (acquiring knowledge about drugs). We know that the most important element in effective prevention is the acquisition not so much of knowledge as of life skills . Thus, wA questionnaire was completed by the participants at the beginning (T1) (between 7 and 9 October 2020) and end (T2) of the program (between 16 June and 1 July 2021), in a digital format at their middle school, on a tablet via the Qualtrics online questionnaire creation software.The measures in this study were based on the self-concept and the Prototype Willingness Model . The difSelf-concept clarity (SCC) was measured by averaging a 12-item scale , p < 0.05) and alcohol  experimenters was found between T1 and T2. A main effect of the program (p < 0.01) highlighted greater alcohol experimentation among participants in the Unplugged condition . Nevertheless, no interaction between time and program was observed. No gender effect, either in terms of main effect or interaction with time, was found.A significant increase in the number of tobacco  and alcohol  users between T1 and T2 was observed. No main effect of program or gender, or interaction with time, was found.An increase in the number of annual tobacco  and alcohol  users increased between T1 and T2. No difference in the effect of the program or gender, either in terms of main effect or interaction with time, was observed.The number of recent tobacco . No main effect of program or gender, or their interaction with time, was found.The number of participants who reported being drunk at least once increased between T1 and T2  felt they had gained more knowledge  = 5.640, p < 0.05, 2pη= 0.036) than boys . The interaction between program and gender  = 7.325, p < 0.01, 2pη= 0.046) highlighted that the girls in the IPSELF condition  estimated gaining more knowledge than the girls in the Unplugged condition , while for boys, those in the Unplugged condition  felt that they gained more knowledge than those in the IPSELF condition   see .M = 4.47, ET = 2.25) had a stronger sense that acquiring this knowledge would help them change their smoking behavior  = 3.900, p = 0.05, 2pη= 0.025) than those in the Unplugged condition . No main effect of gender or interaction between gender and the program was found.In addition, the participants in the IPSELF condition  felt that they had gained more knowledge about alcohol  = 4.687, p < 0.05, 2pη= 0.030) than boys . The interaction between program and gender  = 5.784, p < 0.05, 2pη= 0.036) showed that the girls in the IPSELF condition  felt that they had gained more knowledge than those in the Unplugged condition , while the boys in the IPSELF program  felt that they had gained less knowledge than those in the Unplugged condition   see .Nevertheless, neither the program, the gender, nor their interaction influenced a change in behavior related to acquiring this knowledge.F = 7.134, p < 0.01, 2pη= 0.045) highlighted that the girls in the IPSELF condition  felt that they had gained more knowledge about cannabis than those in the Unplugged condition , whereas the boys in the IPSELF condition  felt that they had gained less knowledge than those in the Unplugged condition   see .No main effect of program, gender or their interaction was observed on a change in cannabis behavior related to the acquisition of this new knowledge. = 4.461, p < 0.05, 2pη= 0.028), as for other substances, indicated that the girls in the IPSELF condition  felt that they had gained more knowledge about other drugs than the girls in the Unplugged condition , whereas the boys in the IPSELF condition  felt that they had gained less knowledge than those in the Unplugged condition  (see No main effect of program or gender was found on knowledge acquisition about other drugs. The interaction between program and gender .59) see .No main effect of program or gender, or their interaction, showed differences in the extent to which the new knowledge would help change behavior toward other drugs.This study sought to improve addiction prevention among adolescents through the development of self-concept. This is why we implemented and evaluated the effectiveness of the “Intervention Program based on Self” program by comparing it to the Unplugged reference program. On the one hand, adolescents in the IPSELF program adopted a more favorable image of the typical nonsmoker and cannabis nonsmoker, and a less favorable image of the typical drinker than those in Unplugged. The development of self-concept provided by IPSELF allowed adolescents to feel more different from the typical smoker and drinker over time. More alcohol experimenters were observed among the adolescents in Unplugged. The knowledge gained in IPSELF may also help adolescents more than that gained in Unplugged to change their smoking behavior. On the other hand, IPSELF had a more beneficial effect for girls, who gained more control over their alcohol and cannabis use than boys.In addition, the girls in the IPSELF program felt that they had gained more knowledge about the substances discussed than those in the Unplugged program.First, the complementary work on self-concept proposed in IPSELF highlighted differences between it and Unplugged. Adolescents in the IPSELF program rated the typical nonsmoker and cannabis nonsmoker more favorably and the typical drinker less favorably than those in Unplugged. They also came to feel less favorably toward the typical smoker, while those who participated in Unplugged felt more favorably. The literature shows that the more favorable adolescents’ image of the smoker or drinker, the more likely they are to smoke or drink ,38,39,40Regardless of the differences between the programs, and consistent with the literature on the prototype willingness model in adolescents, we observed on the one hand an increase in favorability toward the typical drinker and a decrease for all typical non-users. In addition, we noted an increase in the feeling of similarity to all typical users and a decrease for the typical nondrinker and cannabis nonsmoker. These elements explain the increase in the willingness to use tobacco and alcohol ,44. On tWe found the gender differences classically observed in the literature with, first, a clearer self-concept for boys than girls . After pWe identified several limitations to our study. The first is the lack of a difference in the evolution of the clarity of one’s self-concept and the feeling of having acquired knowledge about oneself between Unplugged and IPSELF, whereas IPSELF aimed to develop this knowledge. A measure of self-concept positivity might be more appropriate than a measure of self-concept clarity. In addition, work on the self could be incorporated into each session to reinforce its development. Secondly, the low Cronbach’s alpha observed for some two-item scales such as the tobacco and cannabis perceived norm, and tobacco, alcohol and cannabis perceived control, should be noted. The choice of other scales may be considered in the event of a new evaluation of the project.In conclusion, in addition to the positive effects of Unplugged already highlighted in the literature, the original project “Intervention Program based on Self”, with its development of self-concept, had a more beneficial effect on user and non-user prototypes perception and on changes in smoking behavior. Moreover, it had a more favorable effect on girls’ perceived control over their use of drugs, whereas Unplugged had a more favorable effect on boys. We therefore recommend the use of IPSELF especially with female audiences.


Maternal mental health concerns and parenting stress in the first few years following childbirth are common and pose significant risks to maternal and child well-being. The COVID-19 pandemic has led to increases in maternal depression and anxiety and has presented unique parenting stressors. Although early intervention is crucial, there are significant barriers to accessing care.To inform a larger randomized controlled trial, the current open-pilot trial investigated initial evidence for the feasibility, acceptability, and efficacy of a newly developed online group therapy and app-based mental health and parenting program (BEAM) for mothers of infants. Forty-six mothers 18 years or older with clinically elevated depression scores, with an infant aged 6–17 months old, and who lived in Manitoba or Alberta were enrolled in the 10-week program (starting in July 2021) and completed self-report surveys.t-tests indicated significant pre- to post-intervention change in maternal depression, anxiety, and parenting stress, and in child internalizing, but not externalizing symptoms. Effect sizes were in the medium to high range, with the largest effect size observed for depressive symptoms (Cohen’s d = .93).The majority of participants engaged in each of the program components at least once and participants indicated relatively high levels of app satisfaction, ease of use, and usefulness. However, there was a high level of attrition (46%). Paired-sample This study shows moderate levels of feasibility and strong preliminary efficacy of the BEAM program. Limitations to program design and delivery are being addressed for testing in adequately powered follow-up trials of the BEAM program for mothers of infants.NCT04772677. Registered on February 26 2021. This is the first study to determine the feasibility and acceptability of a multimodal digital intervention tailored to the needs of parents of infants with elevated depression symptoms.Participants favourably rated the program App interface, as well as their satisfaction and perceived usefulness of the program. Although participant recruitment was successful and engagement was promising, attendance rates in group telehealth sessions were low and attrition rates were high. Findings suggested the need for program and trial design updates to promote more seamless app registration and use, participation in the forum, attendance at telehealth groups, and completion of follow-up questionnaires.Future trials will implement strategies to improve participant retention including program orientation meetings, streamlining the participant enrollment process, and curating a more flexible telehealth schedule that better suits family needs.Postpartum mental health concerns are common –5 and poDuring the COVID-19 pandemic, the prevalence of depression symptoms in pregnancy and the postpartum increased around the world –29, whicEarly intervention is crucial to prevent long-term adverse consequences of mental health symptoms for mothers and their children. Without treatment, maternal depressive symptoms tend to persist throughout the preschool years  and the E-health interventions offer a promising avenue to address the barriers to traditional healthcare services. It is estimated that in 2018, 91.3% of Canadians 15 years and older use the Internet and 88.1% have a smartphone at home. These estimates increase to 98.2% of Canadians who use and have access to Internet and 97.1% who have a smartphone when examining individuals between the ages of 24 and 44 , 40. TheHowever, although digital interventions can increase flexibility and convenience for health care delivery, issues of inequality can emerge due to concerns with the distribution of digital technologies with some already disadvantaged groups reporting more barriers to accessing eHealth . These bFurthermore, there are significant issues when using app-based interventions related to engagement and retention of participants. Downloading an intervention app has been found to be a significant challenge for individuals experiencing depression, specifically. In one clinical trial for adults with mild to moderate depression, less than half of the participants who were instructed to download an intervention App did so . In an aThere is evidence to suggest that the inclusion of a peer support component in app designs can increase participants’ app engagement  and inclIn addition to the limitations of previous digital interventions targeting mental health, there has been little evidence for the efficacy of existing digital interventions targeting parenting practices on parent and child outcomes. A meta-analysis suggests small-moderate effect sizes of digital parenting interventions, with larger effects observed when programs include interactive platforms with a therapist instead of being completely self-led . OverallIn response to these limitations of previous digital programs, our group has developed the Building Emotional Awareness and Mental Health (BEAM) program, a 10-week app-based intervention that provides mothers with mental health and parenting psychoeducation, a peer support forum, and weekly e-health group therapy sessions. This open-pilot trial investigated initial evidence for the feasibility, acceptability, and efficacy of the BEAM program when delivered to mothers of infants aged 6–17 months to help inform a larger randomized controlled trial. It was hypothesized that participation in the BEAM program would be associated with decreased maternal depression and parenting stress (primary outcomes), as well as reduced maternal anxiety and child internalizing and externalizing symptoms (secondary outcomes) from pre- to post-intervention.Eligible individuals were people who identified as mothers or as a female primary caregiver and who were 18 years or older with a 6–17-month-old child. Participants had to live in Manitoba or Alberta, Canada, and report a clinically elevated score of depression  . EligiblAll eligible mothers completed a survey between 4 and 8 weeks prior to the program start date (which will be referred to as “pre” hereafter) and a survey 3–6 weeks after the end of the program (which will be referred to as “post” hereafter). Data collection was conducted online using self-report surveys collected using Research Electronic Data Capture (REDCap). Socio-demographic characteristics of the sample are presented in Table The content from the BEAM program was delivered via mobile application and was supported by weekly group zoom sessions led by psychologists and clinical psychology trainees . The BEAM app is a 10-week program that includes weekly 15–30-min video sessions on mental health and parenting as well as closed community forums that participants use to connect and communicate with each other and with parent and support coaches (described below).The BEAM program includes a psychoeducation component which is comprised of video modules about mental health and parenting. Most weeks consisted of two videos  that were each approximately 10 min in length (ranging from 6 to 14 min). Mental health videos provided information and tools following the principles of the Unified Protocol, a best-practice program based on cognitive-behavioural principles, to address dysregulated emotions across mood and anxiety disorders , 54. SupWeekly zoom telehealth groups provided an opportunity for clinical coaches  to review weekly content and facilitate conversations among participants. Participants had the opportunity to discuss material with their clinical coach and other mothers in the BEAM program, ask questions, and gain a better sense of community. Including facilitator contact to promote human support has been found to help enhance the effectiveness of and adherence to e-health interventions –57. ContThe program included online community forums which were designed to encourage mothers to continue to build social connections with other mothers in the program outside of the weekly telehealth groups. The forums were moderated by clinical and parent coaches (described below). There were intervention forums which included semi-structured discussion topics related to the weekly video content. For example, mothers discussed how the weeks went and their experience implementing the weekly topics into their daily lives. There was also a support forum that consisted of open-ended discussions and provided a space for mothers to post questions to their peers and coach and share anecdotes and/or photos of their wellness journey. Participants were also invited to ask mental health and parenting questions on an “Ask the Expert” forum, which was monitored and responded to by clinical coaches.Parent coaches were mothers who had recently completed another research lab-implemented group-based intervention for their own mental health needs (at the University of Manitoba) and who were interested in being a part of the BEAM community to promote the mental wellness of mothers. The parent coach provided support for the mothers in the program and participated in the community to promote discussion and monitor the content posted on the forum. Clinical coaches were MA, PhD, or student clinicians who were responsible for responding to questions about group content and responding to clinically sensitive content on the forum. Clinical coaches conducted risk assessments in a one-to-one email or phone check-in when participants expressed significant distress on the forum, in group, or in weekly survey responses.Demographic information was collected via a self-report questionnaire administered as part of the baseline questionnaire. Demographic variables collected included maternal age, ethnicity, education level, employment status, community type, marital status, medication and service use in the past month, parity, age and sex of child, and household income.) to 7 (agree), with higher scores indicating better usability of the app. The MAUQ has been found to have excellent internal reliability (α = 0.914) [The mHealth App Usability Questionnaire (MAUQ)  was used= 0.914) . QuestioSymptoms of depression were assessed at the participant eligibility screener and at the post-questionnaire using the Patient Health Questionnaire (PHQ-9) . The PHQThe Parenting Stress Index—Short Form (PSI/SF) was administered to participants at pre- and post-intervention. The PSI is a self-administered 36-item scale that measures parent-reported stress and interactional style along 3 domains: how parents feel in their role, how satisfied they are in the relationship with the child, and how difficult they perceive their child to be . ParentsSymptoms of general anxiety were assessed at pre- and post-intervention using the Generalized Anxiety Disorder 7-Item Scale (GAD-7) . The GAD1/2 –5 was used, which is commonly used for children ages 18 months and older [Child mental health and behaviour were assessed at pre- and post-intervention using the Child Behaviour Checklist (CBCL) . The CBCnd older , 72.t-tests were conducted to analyse whether participants experienced changes in their mental health and parenting stress as well as their children’s internalizing and externalizing challenges [d statistic was used to measure effect sizes, with 0.20, 0.50, and 0.80 representing small, medium, and large effect sizes, respectively [All analyses were conducted using IBM SPSS Statistics 28.0. A series of paired-sample allenges . Cohen’sectively . Clinican = 25  were eligible, consented to participation, and were enrolled in the BEAM program. After enrollment, mothers were required to provide a preferred login and password to our project coordinator and register with their phone number and address on our clinical electronic record-keeping system. Five participants did not provide this information and therefore were not registered for the app and never accessed the intervention. Forty-one mothers were successfully registered on the app. Due to several technological delays in the app launch, the actual program’s start date was mid-July 2021. Sixteen participants did not complete the T2 post-questionnaires and were excluded from the analysis. Twenty-three mothers completed all post-program measures and two had partial completion of the post-questionnaire, leaving a complete sample of t-tests and chi-square tests were conducted to determine whether there were any significant differences in baseline characteristics or sociodemographic variables between participants based on completion status. No significant group differences emerged (p = .068–.943).The enrollment process was limited by a potentially complex number of steps (e.g. requesting that participants emailed the research team following an eligibility screener to confirm interest) and failing to ensure that participants were interested in downloading the App and attending telehealth groups. Independent sample In terms of program engagementIn terms of social support, 60.9% of respondents rated ≥ 4 on a 6-point scale  on an item that asked whether participants agreed with the following statement: “The BEAM program was a good source of social support for me.” Results from the MAUQ questionnaire indicated relatively high levels of ease of use, app satisfaction, and usefulness. Most participants rated ≥ 5 on the following items: “The app was very easy to use” (76.1%), “It was easy for me to learn to use the app” (85.8%), “Overall, I am satisfied with this app” (71.4%), and “The app would be useful for my health and well-being” 63.6%). See Table .6%. See t-tests  and moderate support for clinically significant reductions in maternal mental health concerns.d = .93), parenting stress (d = .63), anxiety (d = .58), and infant internalizing problems (d = .51). Compared to recent meta-analyses of studies testing interventions  for maternal mental health in the postpartum period, our study found similar or slightly greater effect sizes in terms of reductions in depression and anxiety symptoms, infant internalizing problems, and parenting stress [As hypothesized, participants reported reductions in depression symptoms . Furthermore, telehealth group attendance was lower than expected, which may have been impacted by difficulties related to determining a suitable time for telehealth sessions across multiple provinces (e.g. dinner and bedtime interferences). For instance, some participants shared conflicts with needing to care for and put children to bed during this time. In addition, due to delays with app development, the program ran over the summer months, a time when many families were away on vacation and were not able to attend groups. To help reconcile low attendance rates, a 4-week break was introduced halfway through the program (between weeks 5 and 6). During this break, there were “expert talks” on topics of interest (e.g. self-compassion and sleep). However, it is possible that this break impacted treatment outcomes, attrition, and/or satisfaction with the intervention. For future trials, groups will occur at various times throughout the day and participants will be provided with the choice that is most suitable. Furthermore, trials will not occur in the summer months.Participants who completed post-intervention questionnaires favourably rated app interface and satisfaction as well as usefulness. Although this is consistent with previous work showing high user satisfaction in mental health app-based interventions, review findings have shown that many previous evaluations of mobile mental health apps have used non-standardized measures of usability and satisfaction, potentially inflating these reported ratings . A strenStrengths of the BEAM program include the combination of both parenting and mental health content, which can lead to greater treatment effects compared to those that target either one or the other, as supported by our medium-to-large effect sizes. Targeting parental mental health, and equipping parents with evidence-based parenting strategies can improve health outcomes for both parents and their young children , 36. TheIt is possible that challenges regarding program design and program delivery and the resulting trial design limitations contributed to the high attrition rate and ratings of app usability and acceptability. During the app development process, there were challenges in communication with the digital design company (see ). ChalleFurthermore, there was no control group in this open-pilot trial. Thus, it is possible that extraneous factors contributed to the observed reductions in mental health and parenting stress. For instance, COVID-19 lockdown protocols and restrictions were eased in mid-summer in Alberta and Manitoba, Canada, which may have impacted levels of mental health concerns and parenting stress. Furthermore, the time of year may have played a role as mental health has been found to improve during summer, compared to winter months . Future The use of the CBCL to test child outcomes may have been a limitation due to the age of our sample at the date of recruitment (6–17 months). Although the CBCL has not specifically been validated for ages 6–17 months, there are limited scales of child outcomes that have been validated for this age group. Due to the longitudinal design of the current study where we were collecting data as children grew older, the CBCL was used as an exploratory measure of child outcomes. However, future efficacy trials will ensure the use of measures that are more appropriate for the sample age range.Furthermore, although those who did not complete the post-intervention surveys did not statistically significantly differ from the completer sample in terms of baseline characteristics, it is possible that those who did not complete post-survey questionnaires did not experience the same benefits or perceive the same degree of usability or feasibility of the BEAM program. Future randomized controlled trials will use missing data handling strategies in the data analysis stage to help control for this possibility. Moreover, although this feasibility study did not correct for multiple comparisons due to the small sample size, future trials will implement a more robust statistical analysis plan that includes corrections for multiple comparisons .Lastly, it is important to address issues of generalizability. This sample was largely European Canadian and of high socio-economic status. Parents with greater socio-economic stressors are at higher risk of parenting stress and depression , 92 and A pilot randomized controlled trial has also been conducted in an older child age range . This piThis study found moderate levels of feasibility as well as strong preliminary efficacy of the BEAM program. Limitations to program design and delivery are being addressed for testing in adequately powered follow-up trials of the BEAM program for mothers of infants.