Barriers and facilitators to the implementation of a community-based mental health and wellbeing service for black, Asian and minoritized young people: a qualitative study

Barriers and facilitators to the implementation of a community-based mental health and wellbeing service for black, Asian and minoritized young people: a qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Barriers and facilitators to the implementation of a community-based mental health and wellbeing service for black, Asian and minoritized young people: a qualitative study Sharea Ijaz, Shumona Sharmin Salam, Jo Williams, Geraldine Smyth, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5289830/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Young people from minoritized ethnic backgrounds often encounter challenges in accessing mental health support. We evaluated implementation of a pilot mental health and wellbeing service in a community youth centre for young people from minoritised ethnic backgrounds. Methods We evaluated the service during its first 12 months of implementation. We held twelve service provider interviews and six paired interviews with young people. Fieldnotes were taken and used to contextualise data. Service providers recorded young people’s attendance and wellbeing data. Interview data were analysed thematically to identify barriers and facilitators to successful service implementation. The quantitative attendance and wellbeing data were analysed descriptively using Excel. Results The service was developed iteratively at the youth centre over several months. Once established the service included a weekly two-hour session with mental health practitioners involving opportunistic wellbeing conversations and activities, an offer of one-to-one and group drop-in and mentoring sessions, and an identification and referral pathway to secondary community services. Attendance of young people was inconsistent, and only a few young people provided wellbeing data. Both providers’ and young people’s accounts indicated that implementation was supported by the positive influence of the setting, lived experience of the service providers, iterative development of the service, and trust building. Barriers included inconsistent attendance of young people, the informal and unstructured nature of activities delivered, slow pace of service delivery, and the young people’s reluctance to engage in wellbeing services and evaluation. Conclusion Successful implementation of wellbeing services in community settings for minoritized young people requires investing in relationship building between providers and recipients, and flexibility in how the intervention is delivered and at what pace. Development and evaluation of similar services in future should account for these requirements. Adolescent Mental Health Ethnicity Community setting Qualitative Research Complex health interventions Background Mental health conditions are increasingly common among children and young people (CYP) in the UK, with nearly 1 in 5 young people under 25 likely to have a mental health disorder ( 1 ). Evidence indicates disparities in diagnosis and management of mental health problems for CYP from black, Asian, or minoritized ethnic (BAME) backgrounds, and these CYP are underrepresented in NHS services compared to other populations, despite rates of mental health conditions being greater among this group ( 2 – 5 ). CYP from minoritised ethnic backgrounds often encounter greater challenges in accessing sources of mental health support ( 6 ). Research suggests that barriers to access may include young people’s lack of awareness of services and service locations, differences between CYP and health professionals' language and culture, and higher social stigma or embarrassment around mental health in minoritized communities ( 2 , 6 – 9 ). Ethnic minority CYP are more likely to be referred to Child and Adolescent Mental Health Services (CAMHS) through education, social services, or judicial pathways rather than via the usual primary care route ( 10 , 11 ). They also are more likely to seek support from informal services, community organisations, or family and friends ( 2 , 10 – 13 ). Developing and delivering culturally appropriate mental health services has been identified as one way to reduce barriers to service access for minoritised CYP ( 14 – 17 ). The UK mental health framework encourages the use of local community assets, such as youth groups or sports facilities, as settings to support and promote CYP’s wellbeing ( 18 ). Community-led, grass root organisations can be useful for provision of context-specific preventive mental health services within a community, but evidence indicates gaps in evaluative research of these services ( 19 – 21 ). A new community-based mental health and wellbeing service was commissioned by a local authority in Southwest England, in consultation with 12 local, minority led, voluntary and community organisations. The aim of this service was to improve wellbeing support and access to mental health services for CYP from BAME communities, via the provision of a culturally sensitive referral pathway and tailored mental health support, such as group or one-to-one mentoring. The service was jointly developed and delivered by a community-based youth activities provider, and an established third-sector provider of youth wellbeing and mental health support service. It was underpinned by a trauma-informed perspective( 22 ). We undertook a mixed method process study to evaluate implementation of this new wellbeing service in its first year of operation. We sought to identify barriers and facilitators to implementation, in order to consider how the service could be further developed and to identify what commissioners and researchers should consider when designing, delivering or evaluating community-based complex health interventions. This paper presents findings from this study and our reflections for future service development and implementation. Methods Service setting and study design The service was collaboratively developed and delivered by two community organisations. One was a community mental health provider and the other a community centre for youth activities where the service was set. The setting is an established community centre located in an urbanised, ‘inner-city’, area of high deprivation (UK Index of Multiple Deprivation Decile = 2). The centre serves an ethnically and culturally diverse population, with ward-level 2021 census data indicating between 30 and 35% of the local population being from an ethnic minority background (23). The service was delivered by two trained mental health practitioners from the mental health organisation and two youth practitioners from the community centre. To assess the reach and potential impact of the new service, the plan was for service providers to gather quantitative data on young people’s attendance at the centre, wellbeing, and the number of referrals service providers made to specialist mental health support services. We worked with the service providers and an independent young people’s research advisory group (YPAG) to identify an acceptable wellbeing measure, in advance of service implementation. Members of the YPAG were all from minoritized ethnic backgrounds. Both groups identified the Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS) (24) as being suitable and this measure was used for assessing wellbeing in the study. We planned interviews with the service providers at three time points (start, mid and end of the 12-month evaluation) to explore their experiences of implementing and embedding the service within existing centre activities. We planned to hold up to eight focus groups with CYP attending the centre at the same time points. We also planned to hold semi-structured interviews with CYP who received referrals or one-to-one mentoring services, to explore their experiences of the service. Participants and recruitment process Eligible study participants were CYP aged 11-17 years from a minoritized ethnic background attending the centre, and the four service providers directly involved in developing and implementing the service. All four service providers were approached for interview at the start middle and end of the study, in line with the time frame of the study. For the recruitment of young people, study promotional materials (study flyers and adverts to generate interest) were co-developed with the YPAG and service providers. These were distributed to young people at the youth centre and given to parents/ carers during scheduled research ‘drop-in’ sessions at the centre and online via Zoom(25), where the research team were available to answer any questions. The intention was to purposefully sample young people of varying age and gender for the focus groups. Individuals sampled to take part in a focus group were approached in person by one author (SS) or centre staff and invited when it was time to conduct a focus group. We aimed to interview any CYP referred for further support. These CYP were to be approach for interview, by a service provider, within a month of them being referred. Data Collection One author (SS) visited the centre once a week throughout the implementation period. She attended the sessions where all providers (two centre staff and two mental health practitioners) were present and when the centre was open to CYP aged 11 to 17. During these visits, SS took fieldnotes based on what she observed such as physical description of the community centre, and the activities carried out. These notes provided contextual data for the providers and young people’s accounts. Young people’s attendance at the centre’s weekly activity sessions was recorded by centre staff. Information regarding referrals and the implementation of the quarterly SWEMWBS was managed by the staff implementing the service and shared with the researchers on a quarterly basis. As an incentive, a £5 Amazon shopping voucher was provided to CYPs who completed the SWEMWBS. All interviews and focus groups were conducted by SS, who is a trained social science researcher experienced in qualitative research. Interviews and focus groups were held at a private location in the centre or via phone, at a time convenient to the participant. Written informed consent was secured in advance and the interviews were audio-recorded and fully transcribed. For interviews with service providers, a topic guide was used to ensure consistency across the interviews and the same guide was used at each of the three time points. It was based on the purpose of the interviews and informed by relevant literature, knowledge of the planned intervention and discussions within the research team. It included open-ended questions to elicit details and description from the participants about the service, its implementation, and the barriers and facilitators to service delivery. The interviews were held at a private location in the centre or via phone, at a time convenient to the participant. For the focus groups with young people, a flexible and open-ended topic guide was designed to explore their awareness and experiences with the service. This guide was also refined in conjunction with our YPAG. It included open questions about their perception of mental health and of the new service. A guide was also developed for the interviews with young people who were referred for mentoring or additional mental health support. It included questions about young person’s perceptions of the additional support and referral components, and processes and how it could be improved in future. Young people were offered a £10 Amazon shopping voucher as an incentive for their participation in either a focus group or interview. Data analysis In terms of analysing the quantitative data, descriptive analysis was done in Excel and summary data were tabulated. The interviews were transcribed verbatim by professional transcribers. Fieldnotes relating to a specific interview were typed up. Data collection and analysis were conducted simultaneously, so that findings from earlier interviews informed the focus of later data collection. The interview data and fieldnotes were analysed using an inductive thematic approach. A subsample of all transcripts was independently read and manually coded by SS and KT, who then met to discuss their coding and interpretation of the data. Following this discussion, and drawing on the coding of both researchers, a coding frame was developed. Transcripts were uploaded into NVivo v14 (26) and electronically coded using this coding frame. As data collection progressed, new codes were added and transcripts that had previously been coded were re-coded where necessary. Finally, codes were grouped together to develop categories and collated into potential themes and sub-categories in NVIVO. Ethics Ethical approval for the study (application ID 13984) was obtained from Faculty of Health Sciences Research Ethics Committee (FREC), University of Bristol. Results Quantitative findings The specialist mental health practitioners were present at 50 activity sessions between November 2022 and December 2024. 94 CYP who were registered at the community centre attended at least one of these 50 sessions. Irregular attendance was common and total attendance highly variable across the CYP. The proportion of sessions attended by a young person ranged from 2% to 58%. Only 19 CYP attended >=20% of the offered activity sessions. Only 10% of attenders completed a SWEMWBS questionnaire at 2 or more of the four planned timepoints. Consequently, we do not report wellbeing data in this paper. In the study sample (n=94), 5 young people were offered off-site 1:1 additional therapeutic support by the specialist mental health practitioners but had not taken up the offer at the time of writing. Qualitative findings The findings below start by detailing the characteristics of study participants and the centre, before moving on to detail the content and implementation of the service. Quotes have been used to illustrate points made. They have been tagged to indicate whether the interviewee being quoted was a provider or CYP, and with the participants unique study identification number. The participants Four service providers and six young people were interviewed during the course of the study. Service providers were two youth centre staff from the community centre (a youth worker and a manager) and two mental health practitioners who visited the centre every week to deliver the mental health service. Because of the very small number of providers, their characteristics are not being listed to avoid identification. All four providers were involved in implementing the service. All four were interviewed on three different occasions; once at the start of implementing the service, and then again 7 and 13 months later. These interviews were conducted between December 2022 and March 2024. The two mental health practitioners from youth wellbeing and mental health organisation had more than three years’ experience in delivering one-to-one youth mentoring or group interventions among different minoritised communities and schools. The other two providers were a centre manager, who also oversaw the management of mental health services, and a youth mental health practitioner from the centre. This youth mental health practitioner initially worked as a youth worker but later transitioned to the role of a mental health practitioner with some training on the subject. In this paper, all four have been referred to as providers as their accounts were similar, although instances where they need to be distinguished, we have indicated the individual(s) concerned. These interviews lasted, on average, one hour. Five interviews were conducted face-to-face, either at the centre or at the mental health organisation’s office, while the remaining seven interviews were conducted over the phone. Young people were reluctant to take part in a focus group and in the end, only three paired interviews with six young people were conducted. The six young people interviewed were aged between 11 and 15 years old. Because of small sample we are not listing their characteristics. The paired interviews were held in a private room at the centre between May and November 2023. These interviews lasted, on average, 30 minutes. As the young people were reluctant to talk, they did not elicit rich information. Thus, most of the findings below are based on the providers’ accounts. The Centre Centre staff explained the centre had been offering community-based services for over four decades, serving multiple generations of families in the local community over the years. They mentioned the centre offered three weekly activity sessions for young people of various ages, with one dedicated two-hour session designed specifically for CYP aged 11-17 years old. This was the session that intervention was set in, and that specialist mental health practitioners and researcher (SS) attended. This session featured a range of engaging activities aimed at combining enjoyment with skill enhancement including sports, music production, games, movies, cooking, drawing, arts, and crafts. The activities were overseen by youth workers employed by the centre, and it was apparent that majority of youth workers were from minority ethnic backgrounds. A music studio, supported by another youth support organisation, was available to centre attendees at no cost. Furthermore, during the latter part of the year, the centre started offering hot meals to attending CYP. The centre staff explained that CYP attending the centre resided in the local vicinity and were primarily from minoritised ethnic backgrounds. The CYP interviewed recounted engaging in various activities, including playing games, drawing, crafting, cooking, and participating in sports. They said these activities were soothing and contributed to the development of their skills and confidence. It was evident that participation in any activity was not mandatory, and CYP could move freely within the space, using it predominantly to socialise with their peers and friends. CYP described how this meant the centre provided them with a space where they could relax and feel safe: “Maybe like how to cook for yourself and how to speak to people and just talk to people, anyone, and that it would be safe …safe space ...” (CYP02, paired interview) “… it doesn't feel like at school when it's like you don't really have a choice. I'm more relaxed here… the staff just let you know every time and then you can just choose what you want to do…” (CYP01, paired interview ) Service content The providers said the goal of the pilot wellbeing service was to ensure a clear pathway for young people to access mental health services, and to normalise mental health and wellbeing conversations among young people. Providers explained that the service was being developed iteratively, on-site, over several months, and that it comprised of four components: Consistent (weekly) presence of mental health practitioners in the space. Identifying CYP in need of further support and directing or referring them to appropriate services. Opportunistically embedding discussions and activities about mental health and wellbeing into daily conversations and activities Offering drop-in sessions for one-to-one or group mentoring. Service Implementation Implementation of the service was slow. Providers explained that this was because they had limited experience of implementing such interventions, and becausetime was needed to build mutual understanding and trust between themselves, and between them and the CYP. In addition, they felt the service needed to be developed through trial and error so that it worked within the constraints of the setting and was tailored to the needs to the CYP. Facilitators to implementation Fostering trust and building relationships with young people Providers stated that fostering trust and building relationships were crucial aspects of implementing the service and the first step in delivering it. They mentioned their expertise and lived experience helped them recognise the apprehension and stigma surrounding mental health in minoritised communities, enabling them to be responsive to the needs of these communities: “We’re known as being a project that not only provides a service, but connects with young people that we work with on a deeper level than most practitioners can because we understand the lived experience because we all are practitioners from the lived experience...but we’re also reflective of a lot of the young people in that space, and their lived experiences and what they’ve gone through and how they’ve experienced it.” (SP3 Interview) Providers further explained that their approach transcended the traditional therapist-client dynamic, aiming to cultivate informal, youth-friendly relationships akin to those of youth workers, in order to mitigate power imbalances and cultivate meaningful connections with the young people: “They know that they’re mental health practitioners, but the relationship isn’t one ‘of oh, that’s a mental health therapist’ and ‘I’m a young person in need of help’. The relationship building has made it more of a sort of youth worker type of friendship relationship.” (SP2 Interview) “…I’m very much conversing and engaging with them in vernacular with a presentation that very much matches them. With the core principles of building slow trust…it’s not going in and rushing an engagement or rushing an interaction or connection.” (SP3 Interview) During their initial interviews, the service providers also highlighted the importance of establishing trust with the young people without immediately identifying themselves as "mental health practitioners”. They believed that labelling themselves as such from the outset might discourage communication. Observation as well as interviews with service providers showed that the promotion of the service or service provider’s presence in the centre was subtly executed: “… I didn’t advertise that fact (that they were a mental health practitioner) because I don’t think, when you’re developing relationships, you want to be watched…going forward…I’d probably want to use language that would be more understood with children, to explain to them better because some don’t even know what mental health is, or have heard of it as a buzzword on TikTok. So, at the moment, I just like to be the friendly face that they can come to…” (SP1 Interview) Subsequent interviews with the providers highlighted that the process of establishing relationships and building trust was gradual and ongoing. It deepened over time with the consistent presence and growing familiarity of the practitioners in the space. “ Over the past seven months it’s just been about consistently having familiar faces making the mental health practitioners become familiar faces - in the sessions. ” (SP2 Interview) Additionally, the mental health practitioners from the mental health organisation acknowledged that their positive relationship with centre staff facilitated the process of them being accepted by the CYP. “I would even say that I’ve seen how my relationship with one person has developed has directly affected at least two young people – seeing me and speaking to me and how we engage. ” (SP4 Interview) Trust building between the organisations Ongoing engagement, knowledge-sharing and training initiatives (by the practitioners of mental health organisation to the staff at the centre) facilitated the development of a collaborative relationship between the two organisations providing the service. This fostered mutual understanding and built trust, enabling staff at the centre to seek guidance in addressing specific challenges related to safeguarding, engaging disengaged young people, and responding to young people’s mental health needs: “…the youth centre is familiar… but they’re not necessarily maybe fully clued up on what it is that we offer ... So, the way in which we’ve developed that relationship further through offering training for staff members… …we’ve developed that relationship with staff where staff are asking us questions in relation to safeguarding concerns, mental health questions around how to work with certain young people presenting as disengaged…We’ve opened up that dialogue and as a consequence built a relationship that’s more sort of collaborative but also in some instances almost consultative…” (SP3 Interview) Developed through trial and error Service providers, especially from the centre, mentioned that without previous experience of implementing a mental health and wellbeing service in a youth space or having knowledge of established models, the process of implementing the service was one characterised by trial and error, involving experimentation, adaptation, and refinement of the service delivery approaches over time: “There’s lots of things to just consider so we are providing a more robust service but ‘cause it’s the first time we are trying this the challenge is okay, what’s working, what’s not working, how can we go forward in a better way so it’s more streamlined, smoother, necessarily trying to learn as we’re delivering.” (SP2 Interview) Tailoring activities to the context Providers explained that they provided activities following children’s interests, and children could choose to take part or not. This meant that while the providers wanted to implement structured educational activities, and actively identify young people needing additional support for their mental health, uptake depended on the CYP’s willingness to engage. ” I think the approach here is slightly different where it’s a bit more run by the children and things are quite relaxed and unstructured, which is its complete beauty, but does have difficulties when trying to implement a more structured…” (SP1 Interview) “ some young people may not want one-to-one support because it may make them feel like if there’s something wrong with them but in a group there’s been lots open discussions and free-flowing let’s say engagement where they’re not forced to engage with our practitioners…they more see them as someone who’s in the sessions to assist them …so they are more engaging with them in their own space at their own pace and in their own time.” ( SP2 Interview) For this reason, providers also incorporated more opportunistic approaches to integrate mental health conversations and activities into their usual interactions with the CYP. Examples included regularly checking in with CYP attending the centre about how they were feeling, encouraging individuals to reflect on their experiences and emotions through “Rose and Thorn” conversations (conversations where the CYP were invited to discuss something positive (rose) or challenging (thorn) that happened during their day) or discussing how acts of kindness can be an uplifting experience. This was also reflected in the interviews with CYP, and while CYP could not mention any specific mental health activities, they mentioned about staff checking-in on them, having conversations about their emotions, participating in activities such as “Rose and Thorn”. It was also evident that they felt the providers genuinely cared. “…they genuinely want to know how I feel, not just for the sake of asking.” (CYP 03 paired interview) Barriers to implementation: Despite the services having a positive impact, the providers also talked about implementation barriers. These related to inconsistent attendance of young people, the informal or unstructured nature of activities delivered in the centre, slow pace of service delivery, and the young people’s reluctance to engage in wellbeing services or conversations. There were also challenges in collecting data using the SWEMWBS scale. Inconsistent attendance of young people Although young people valued the centre, their attendance was inconsistent, which not only hindered or delayed the development of trust and rapport between the providers and young people, but also affected the continuity of service delivery. “…Young people’s attendance is quite inconsistent. So will show up for a week, two weeks. We’ll build a bond. They’ll disappear for a week. So, consistency is also a barrier that we’re facing, which is a fundamental pillar to our work as practitioners.” (SP3 interview) “I didn’t really consider the transitory nature of this space – when people aren’t there, when people are there. Young people moving out of the space – I’ve just never been accustomed to that in the work that I do.” (SP4 interview) Informal and relaxed structure Service providers repeatedly highlighted a ‘tension’ between the formality of the service and the informality of the community setting. To engage with young people, the service providers had to navigate their activities around the habitual actions of the young people: “… it’s an established space already. This is a new project, a new face in the service, but the young people…have particular expectations of the space…So people are acting habitually in the space. They will go to the studio. They will hang out, stay on their phones, chat with each other, and disengage from people and professionals in the space because that’s their space and that’s their time. Working alongside established habitual actions within the space, and what young people themselves expect from that space…that’s also been a bit of a barrier for us in terms of being able to work our angle in the space.” (SP3 Interview) Slow pace of service delivery All the service providers acknowledged that the process of implementing the service progressed more slowly than anticipated or desired. It was evident from the interviews that several factors listed above had contributed to this along with the time needed to develop the necessary formal procedures for safely implementing a mental health service in a youth setting. The impact of this slow pace was that wellbeing sessions were far fewer in the first 3 months of implementation and, while their frequency increased in 2023, the service only began to be fully implemented (all four service components running regularly) when the study ended, i.e. it took nearly a year to establish. It also meant that providers were unsure of their roles during this time. Slow implementation also meant the service was not clearly visible to the young people. There was no clear mark or timepoint from which it was being implemented and described to them. This was evident when talking to the CYP, as they all said they were not aware of a new service. Hesitancy in engaging with service and providers Service providers described in several of their interviews that young people did not want to converse about mental health issues or access further support for their mental health when it was offered. They suggested that in the early phases of the service, this might have been because they were not familiar with the mental health service providers, although they knew the centre staff. They also commented that it could be due to the young people’s perception that participating could signal that they had problems, underscoring the need for practitioners to approach them with care and sensitivity. “… you know young people don’t wanna feel like there’s something wrong with them. …You’ve got to be more therapeutic with your approach or more mindful with your approach because we don’t want them to feel like oh, there’s something wrong with me why this mental health person keeps trying to talk to me…” (SP2 Interview) Based on the CYPs' accounts, their unwillingness or reluctance to engage could also be because they were unsure what was being offered, as they explained they were unsure was meant by 'mental wellbeing' or 'emotions', and what the activities were being offered. They also mentioned that they did not see the service as relevant to them. This was because they thought their mental health was fine. At the same time, they could see how individuals who may be upset or in a stressful situation could benefit from additional support. CYP were also unsure how to discuss their mental health and explain how they were feeling. “ I think it [activity with SP03] helped us understand our emotions a bit more because sometimes you just don't understand what you're feeling and like you just… Well, you can't understand it. …. Yeah. I think it helped me understand emotions because when you describe them [pause] like it helps you understand them because like people just say emotions, but they don't really understand what that actually means.” (CYP02, paired interview) Challenges in collecting monitoring data on well-being and attendance Staff at the centre identified obstacles when implementing the SWEMWBS scale to collect data on well-being. They mentioned initially feeling uncomfortable using it, as mental health and wellbeing had not been a focus of the centre, and therefore they needed to explain to the CYP why they were being asked to complete it. Additionally, managing attendance data initially proved challenging due to the lack of a systematic register, prompting the creation of a new register to improve data recording. “… we didn’t have a register that was properly monitoring attendance, so we had to create a new register which I created to then get the new details of every young person to ensure that I had the right information to input the data…” (SP1 Interview). Impact of implementation During follow-up interviews, service providers emphasised that despite the service's gradual implementation, they had established relationships with young people and between organizations, and extended the service to other young people in the community. They had also started offering mentoring sessions and developed a clear referral pathway to support and refer CYPs needing specialist mental health support. Although the process of trust building was slow, it had led to CYP opening up to the providers and confiding in them: "One of the young girls became particularly close with our community mental health practitioner, and she’s been able to confide in things that have been upsetting her." (SP2 Interview) “…I would say it’s going well and now that we do have a framework of how it could be delivered…Well the framework would be the (referral) pathway. It would be the whole process…what it looks like to identify young people, what we do as part of our process once we’ve identified that young person...” (SP2 Interview)” During follow-up interviews providers emphasised how effective communication, and understanding and clarification of their respective roles and responsibilities, had led to a more equitable partnership between the youth centre practitioners and the two specialist mental health providers. Providers also mentioned that having the service in place, and having established a collaboration between both organisations and their practitioners, meant they could quickly respond to challenges as they occurred. This was demonstrated by the providers organising additional drop-in sessions and support for the friendship group of a young community member (also an attendee of the centre since childhood) who was tragically murdered during the time of the study. “…so a good thing is that ‘cause we do have this service in place …able to layer on another support for…his immediate friendship group, to access because we have this programme in place already. That was a very big benefit and we’ve had three sessions so far and… young people turned up and they just off-loaded and poured and poured and poured… I’m just saying to me the fact that we have got this sort of collaboration…it’s allowed us to be more readily responsive…” (SP2 Interview). Discussion We identified facilitators and barriers to successful implementation of a community-based wellbeing service for minoritized young people. Key facilitators included the positive influence of the setting, lived experience of service providers, iterative and tailored development of the service, and trust building between all those involved. Barriers included inconsistent attendance of young people, the informal or unstructured nature of activities delivered in the centre, slow pace of service delivery, the young people’s reluctance to engage in wellbeing services or the evaluation. When comparing our findings with recent similar research, it is evident that building trust and relationships, following young people’s preferences and interests, and collaborative development, have been identified by others as facilitators to implementation of interventions focused on young people’s mental health ( 27 ). However, we found having to work to young people’s preferences, can also mean they may choose to not engage with a service. Recent evidence from UK shows interventions in community centres positively impact young people’s mental health and general wellbeing, particularly for those from marginalized backgrounds ( 28 ). The profile of young people attending these community settings has shifted markedly since the 1980s, when it was mostly boys from marginalized backgrounds, to mostly children from well-off families in safe neighbourhoods in recent years ( 28 ). This may be due to long-standing public-sector funding limitations and the current cost of living crisis. Recognising these trends, this intervention, made possible through local funding and community organisations, aimed to support and embed local provision for minoritised young people. A strength of our study was that all the providers took part, and data were collected at 3 time points from them, allowing their views and experiences of the service to be explored as it was implemented. This was particularly important because implementation was slow and went through the phases of building trust, intervention development, to finally establishing activities and a pathway. Another strength is the method of data collection used (in-depth interviews) which meant the providers could describe their views and experiences in detail, raise issues that were important to them (e.g., trust building) and explain the rationale behind how the service was being implemented (e.g., the need for activities to be child-led). A key limitation of the study is that only six CYP were interviewed, and that these interviews were held at the end of the study, so we have limited insight into their views and experiences. We also have limited wellbeing data, so can only reflect on the potential impact of the study from a qualitative perspective. That said, we have identified some important facilitators and barriers to implementation of a wellbeing services in a community setting for minoritized young people. Future researchers developing and evaluating such interventions, and practitioners working with young people, might want to consider these to ensure these interventions can be implemented in practice and have positive impact on CYP's wellbeing. Conclusion It is feasible to provide wellbeing services in community settings for minoritized young people. The successful implementation of such services in community settings requires commitment to relationship building between providers and with recipients, and flexibility in how the intervention is delivered and at what pace. Wellbeing services should provide CYP with the tools to talk about mental health and wellbeing and trusting relationships are required for this. Abbreviations Black, Asian, and minoritized ethnic (BAME) Children and young people (CYP) Child and Adolescent Mental Health Services (CAMHS) Faculty of Health Sciences Research Ethics Committee (FREC) Service Provider (SP) Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS) Young People's Advisory Group (YPAG) Declarations Ethics approval and consent to participate: Ethical approval for the study (application ID 13984) was obtained from Faculty of Health Sciences Research Ethics Committee (FREC), University of Bristol and NHS Bristol, North Somerset and South Gloucestershire ICB (reference 2022-089). Written informed consent was obtained from all service providers participating in the study. For children and young people under 16 years of age participating in focus groups an assent from them and informed consent from their legal guardian was planned to be obtained. However, to improve participation in focus groups (paired interviews), the process was amended and only written informed consent was obtained from all CYP. All methods were performed in accordance with the relevant guidelines and regulations. Consent for publication: Not applicable. Availability of data and materials: Due to the small sample size, we are not making the provider or young people’s transcripts available with the manuscript. Competing interests : SS, DC & KT declare no competing interests. SI is embedded part time in the Bristol City Council’s (BCC) Public Health team with a remit to increase their research activity and this project was developed in that role. JW is Consultant in Public Health (Healthy Children and Families), and the departmental academic lead. GS is the commissioner for this evaluated service, and the providers reported quarterly on the service to her. Funding: This research was funded as part of the Three NIHR Research Schools Mental Health Programme Practitioner Evaluation Scheme (MH022). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Sharea Ijaz ’s time is supported by the National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West), NIHR Clinical Research Network West of England (PHLARP funding), and NIHR Research Support Service Specialist Centre for Public Health (LARP funding) Authors' contributions: JW, GS, KT, DC and SI developed the protocol. SS carried out recruitment and data collection. SS, KT and DC analysed the data. SS and SI drafted the manuscript. All authors contributed to revisions, and read and approved the final manuscript. Acknowledgements: We are grateful to the providers for their contribution to data collection, setting up and recruitment, to the YPAG members for their advice, and to the young people who participated in the evaluation. References Newlove-Delgado T, Marcheselli F, Williams T, Mandalia D, Davis J, McManus S, et al. Mental Health of Children and Young People in England, 2022-wave 3 follow up to the 2017 survey. 2022. Meechan H, John M, Hanna P. Understandings of mental health and support for Black male adolescents living in the UK. Children and Youth Services Review. 2021;129:106192. https://www.sciencedirect.com/science/article/pii/S0190740921002681. Dogra N, Singh SP, Svirydzenka N, Vostanis P. Mental health problems in children and young people from minority ethnic groups: The need for targeted research. British Journal of Psychiatry. 2012;200(4):265-7. https://www.cambridge.org/core/product/785424B16C5779F76915CB980F3F48B3. Ruphrect-Smith H, Davies S, Jacob J, Edbrooke-Childs J. Ethnic differences in treatment outcome for children and young people accessing mental health support. European Child & Adolescent Psychiatry. 2023. https://doi.org/10.1007/s00787-023-02233-5. Zilanawala A, Sacker A, Nazroo J, Kelly Y. Ethnic differences in children's socioemotional difficulties: Findings from the Millennium Cohort Study. Soc Sci Med. 2015;134:95-106. Memon A, Taylor K, Mohebati LM, Sundin J, Cooper M, Scanlon T, et al. Perceived barriers to accessing mental health services among black and minority ethnic (BME) communities: a qualitative study in Southeast England. BMJ Open. 2016;6(11):e012337. Prajapati R, Liebling H. Accessing Mental Health Services: a Systematic Review and Meta-ethnography of the Experiences of South Asian Service Users in the UK. J Racial Ethn Health Disparities. 2022;9(2):598-619. Linney C, Ye S, Redwood S, Mohamed A, Farah A, Biddle L, et al. “Crazy person is crazy person. It doesn’t differentiate”: an exploration into Somali views of mental health and access to healthcare in an established UK Somali community. International Journal for Equity in Health. 2020;19(1):190. https://doi.org/10.1186/s12939-020-01295-0. Coelho H, Price A, Kiff F, Trigg L, Robinson S, Thompson Coon J, et al. Experiences of children and young people from ethnic minorities in accessing mental health care and support: rapid scoping review Health and Social Care Delivery Research. 2022. Edbrooke-Childs J, Newman R, Fleming I, Deighton J, Wolpert M. The association between ethnicity and care pathway for children with emotional problems in routinely collected child and adolescent mental health services data. European Child & Adolescent Psychiatry. 2016;25(5):539-46. https://doi.org/10.1007/s00787-015-0767-4. Edbrooke-Childs J, Patalay P. Ethnic differences in referral routes to youth mental health services. Journal of the American Academy of Child & Adolescent Psychiatry. 2019;58(3):368-75. e1. https://doi.org/10.1016/j.jaac.2018.07.906. Lavis P. The importance of promoting mental health in children and young people from black and minority ethnic communities (Better Health Briefing 33). Race Equality Foundation; 2014. Chui Z, Gazard B, MacCrimmon S, Harwood H, Downs J, Bakolis I, et al. Inequalities in referral pathways for young people accessing secondary mental health services in south east London. European Child & Adolescent Psychiatry. 2021;30(7):1113-28. https://doi.org/10.1007/s00787-020-01603-7. Forman-Hoffman VL, Middleton JC, McKeeman JL, Stambaugh LF, Christian RB, Gaynes BN, et al. Quality improvement, implementation, and dissemination strategies to improve mental health care for children and adolescents: a systematic review. Implement Sci. 2017;12(1):93. https://implementationscience.biomedcentral.com/articles/10.1186/s13012-017-0626-4. Kurtz Z, Street C. Mental health services for young people from black and minority ethnic backgrounds: the current challenge. Journal of Children's Services. 2006;1(3):40-9. https://doi.org/10.1108/17466660200600022. Street C, Stapelkamp C, Taylor E, Malek M, Kurtz Z. Minority voices: Research into the access and acceptability of services for the mental health of young people from black and minority ethnic groups. London: Young Minds; 2005. Report No.: ISBN: 0-9545123-7-5. Troy D, Anderson J, Jessiman PE, Albers PN, Williams JG, Sheard S, et al. What is the impact of structural and cultural factors and interventions within educational settings on promoting positive mental health and preventing poor mental health: a systematic review. BMC Public Health. 2022;22(1):524. Department of Health & Social Care. Improving the mental health of babies, children and young people: a framework of modifiable factors. 2024(19/02/2024). https://www.gov.uk/government/publications/improving-the-mental-health-of-babies-children-and-young-people/improving-the-mental-health-of-babies-children-and-young-people-a-framework-of-modifiable-factors#examples-of-approaches-that-can-positively-influence-the-mental-health-of-babies-children-and-young-people. Creswell C, Harris E, Koppel K, Peters-Corbett A, Thomson A. Barriers and facilitators of community-based implementation of evidence-based interventions in the UK, for children and young people's mental health promotion, prevention and treatment: rapid scoping review. BJPsych Open. 2023;9(4):e132. https://www.cambridge.org/core/product/1FF3DF6E9EDEC667B9960A41A8DA6BDB. Baskin C, Zijlstra G, McGrath M, Lee C, Duncan FH, Oliver EJ, et al. Community-centred interventions for improving public mental health among adults from ethnic minority populations in the UK: a scoping review. BMJ Open. 2021;11(4):e041102. https://bmjopen.bmj.com/content/bmjopen/11/4/e041102.full.pdf. Duncan F, Baskin C, McGrath M, Coker JF, Lee C, Dykxhoorn J, et al. Community interventions for improving adult mental health: mapping local policy and practice in England. BMC Public Health. 2021;21(1):1691. https://doi.org/10.1186/s12889-021-11741-5. Alessi EJ, Kahn S. Toward a trauma-informed qualitative research approach: Guidelines for ensuring the safety and promoting the resilience of research participants. Qualitative Research in Psychology. 2023;20(1):121-54. https://doi.org/10.1080/14780887.2022.2107967. Office for National Statistics (ONS). Ward-level population estimates In: ONS, editor. Population Estimates. https://www.ons.gov.uk/2021. https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/datasets/wardlevelmidyearpopulationestimatesexperimental. Stewart-Brown S, Tennant A, Tennant R, Platt S, Parkinson J, Weich S. Internal construct validity of the Warwick-Edinburgh Mental Well-being Scale (WEMWBS): a Rasch analysis using data from the Scottish Health Education Population Survey. Health and Quality of Life Outcomes. 2009;7(1):15. https://doi.org/10.1186/1477-7525-7-15. Zoom Video Communications Inc. Security guide. Zoom Video Communications Inc. ; 2016. https://d24cgw3uvb9a9h.cloudfront.net/static/81625/doc/Zoom-Security-White-Paper.pdf. Lumivero. NVivo (version 14). Lumivero; 2023. www.lumivero.com. Reed J, Hunn L, Smith T, Bosworth R, Gee B, Berry C, et al. Barriers and facilitators in the implementation of youth and young adult models of mental health care. Early Intervention in Psychiatry. 2024;n/a(n/a). https://doi.org/10.1111/eip.13555. SQW & University of Warwick. Youth provision and life outcomes: Systematic literature review. London: Department for Culture, Media and Sport.; 2024. Additional Declarations Competing interest reported. SS, DC & KT declare no competing interests. SI is embedded part time in the Bristol City Council’s (BCC) Public Health team with a remit to increase their research activity and this project was developed in that role. JW is Consultant in Public Health (Healthy Children and Families), and the departmental academic lead. GS is the commissioner for this evaluated service, and the providers reported quarterly on the service to her. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5289830","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":369127541,"identity":"171b3e5e-e825-4c6d-b2b1-dc1aa0afa74a","order_by":0,"name":"Sharea Ijaz","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIie3RMQrCMBSA4VcCdXnQNUOhV0jo4FL1KhXBUYQujhGHLIJrvIXgBQId3PQALnXRxaGjQweTTk4xo2D+LSVf+kIAQqGfLBIMoCiB2MWy/0R8yNySSADzIn112WMvkgkilq/ushjKwaNpGWSJwJy5CNOR4Fu8VmmNfK0YcKUxL53E3gXpdaoIRhs0ywNgrt2Dmb907GzI4GbJ5CsBM1iOpTYEuCVTS9yD1YakelZRgnyvGJ2pOq6c18+kvPNnN17Q5NS07aoY7eTmSJ2DEYg/z6ReD0ma73tCoVDor3sDY+Y/fa/TU7kAAAAASUVORK5CYII=","orcid":"","institution":"University of Bristol","correspondingAuthor":true,"prefix":"","firstName":"Sharea","middleName":"","lastName":"Ijaz","suffix":""},{"id":369127542,"identity":"21c1f93b-20fd-4366-8330-9414866024a9","order_by":1,"name":"Shumona Sharmin Salam","email":"","orcid":"","institution":"University of Bristol","correspondingAuthor":false,"prefix":"","firstName":"Shumona","middleName":"Sharmin","lastName":"Salam","suffix":""},{"id":369127543,"identity":"580e55cb-34d1-4b06-9a4d-08916637bbcf","order_by":2,"name":"Jo Williams","email":"","orcid":"","institution":"University of Bristol","correspondingAuthor":false,"prefix":"","firstName":"Jo","middleName":"","lastName":"Williams","suffix":""},{"id":369127546,"identity":"be2ba3cd-e63d-401e-8394-da4a38a03965","order_by":3,"name":"Geraldine Smyth","email":"","orcid":"","institution":"Bristol City Council","correspondingAuthor":false,"prefix":"","firstName":"Geraldine","middleName":"","lastName":"Smyth","suffix":""},{"id":369127554,"identity":"56523bae-2f04-4e8b-a8ca-c5ec29be1914","order_by":4,"name":"Deborah Caldwell","email":"","orcid":"","institution":"University of Bristol","correspondingAuthor":false,"prefix":"","firstName":"Deborah","middleName":"","lastName":"Caldwell","suffix":""},{"id":369127559,"identity":"20a46a8b-5d0e-486d-87d7-e8fe9f59ae71","order_by":5,"name":"Katrina Turner","email":"","orcid":"","institution":"University of Bristol","correspondingAuthor":false,"prefix":"","firstName":"Katrina","middleName":"","lastName":"Turner","suffix":""}],"badges":[],"createdAt":"2024-10-18 13:38:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5289830/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5289830/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":67834798,"identity":"a05943ef-8d91-42f9-9dce-b982fc1e0f4a","added_by":"auto","created_at":"2024-10-30 08:02:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":537838,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5289830/v1/a0251cee-f180-47b8-a9b8-3ae1ad2af691.pdf"}],"financialInterests":"Competing interest reported. SS, DC \u0026 KT declare no competing interests. SI is embedded part time in the Bristol City Council’s (BCC) Public Health team with a remit to increase their research activity and this project was developed in that role. JW is Consultant in Public Health (Healthy Children and Families), and the departmental academic lead. GS is the commissioner for this evaluated service, and the providers reported quarterly on the service to her.","formattedTitle":"Barriers and facilitators to the implementation of a community-based mental health and wellbeing service for black, Asian and minoritized young people: a qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003eMental health conditions are increasingly common among children and young people (CYP) in the UK, with nearly 1 in 5 young people under 25 likely to have a mental health disorder (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Evidence indicates disparities in diagnosis and management of mental health problems for CYP from black, Asian, or minoritized ethnic (BAME) backgrounds, and these CYP are underrepresented in NHS services compared to other populations, despite rates of mental health conditions being greater among this group (\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCYP from minoritised ethnic backgrounds often encounter greater challenges in accessing sources of mental health support (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Research suggests that barriers to access may include young people\u0026rsquo;s lack of awareness of services and service locations, differences between CYP and health professionals' language and culture, and higher social stigma or embarrassment around mental health in minoritized communities (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Ethnic minority CYP are more likely to be referred to Child and Adolescent Mental Health Services (CAMHS) through education, social services, or judicial pathways rather than via the usual primary care route (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). They also are more likely to seek support from informal services, community organisations, or family and friends (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11 CR12\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDeveloping and delivering culturally appropriate mental health services has been identified as one way to reduce barriers to service access for minoritised CYP (\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The UK mental health framework encourages the use of local community assets, such as youth groups or sports facilities, as settings to support and promote CYP\u0026rsquo;s wellbeing (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Community-led, grass root organisations can be useful for provision of context-specific preventive mental health services within a community, but evidence indicates gaps in evaluative research of these services (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA new community-based mental health and wellbeing service was commissioned by a local authority in Southwest England, in consultation with 12 local, minority led, voluntary and community organisations. The aim of this service was to improve wellbeing support and access to mental health services for CYP from BAME communities, via the provision of a culturally sensitive referral pathway and tailored mental health support, such as group or one-to-one mentoring. The service was jointly developed and delivered by a community-based youth activities provider, and an established third-sector provider of youth wellbeing and mental health support service. It was underpinned by a trauma-informed perspective(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe undertook a mixed method process study to evaluate implementation of this new wellbeing service in its first year of operation. We sought to identify barriers and facilitators to implementation, in order to consider how the service could be further developed and to identify what commissioners and researchers should consider when designing, delivering or evaluating community-based complex health interventions. This paper presents findings from this study and our reflections for future service development and implementation.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eService setting and study design\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe service was collaboratively developed and delivered by two community organisations. One was a community mental health provider and the other a community centre for youth activities where the service was set. The setting is an established community centre located in an urbanised, ‘inner-city’, area of high deprivation\u0026nbsp;(UK\u0026nbsp;Index of Multiple Deprivation Decile = 2). The centre serves an ethnically and culturally diverse population, with\u0026nbsp;ward-level 2021 census data indicating between 30 and 35% of the local population being from an ethnic minority background\u0026nbsp;(23). The service was delivered by two trained mental health practitioners from the mental health organisation and two youth practitioners from the community centre.\u003c/p\u003e\n\u003cp\u003eTo assess the reach and potential impact of the new service, the plan was for service providers to gather quantitative data on young people’s attendance at the centre, wellbeing, and the number of referrals service providers made to specialist mental health support services. We worked with the service providers and\u0026nbsp;an\u0026nbsp;independent young people’s research advisory group (YPAG) to identify an acceptable wellbeing measure, in advance of service implementation. Members of the YPAG were\u0026nbsp;all from minoritized ethnic backgrounds.\u0026nbsp;Both groups identified the Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS)\u0026nbsp;(24)\u0026nbsp;as being suitable and this measure was used for assessing wellbeing in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe planned interviews with the service providers at three time points (start, mid and end of the 12-month evaluation) to explore their experiences of implementing and embedding the service within existing centre activities. We planned to hold up to eight focus groups with CYP attending the centre at the same time points. We also planned\u0026nbsp;to hold semi-structured interviews with CYP who received referrals or one-to-one mentoring services,\u0026nbsp;to explore their experiences of the service.\u003c/p\u003e\n\u003ch2\u003eParticipants and recruitment process \u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eEligible study participants were CYP aged 11-17 years from a minoritized ethnic background attending the centre, and the four service providers directly involved in developing and implementing the service.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll four service providers were approached for interview at the start middle and end of the study, in line with the time frame of the study.\u003c/p\u003e\n\u003cp\u003eFor the recruitment of young people, study promotional materials (study flyers and adverts to generate interest) were co-developed with the YPAG and service providers. These were distributed to young people at the youth centre and given to parents/ carers during scheduled research ‘drop-in’ sessions at the centre and online via Zoom(25), where the research team were available to answer any questions. The intention was to purposefully sample young people of varying age and gender for the focus groups. Individuals sampled to take part in a focus group were approached in person by one author (SS) or centre staff and invited when it was time to conduct a focus group. We aimed to interview any CYP referred for further support. These CYP were to be approach for interview, by a service provider, within a month of them being referred.\u003c/p\u003e\n\u003ch2\u003eData Collection\u003c/h2\u003e\n\u003cp\u003eOne author (SS) visited the centre once a week throughout the implementation period. She attended the sessions where all providers (two centre staff and two mental health practitioners) were present and when the centre was open to CYP aged 11 to 17. During these visits, SS took fieldnotes based on what she observed such as physical description of the community centre, and the activities carried out. These notes provided contextual data for the providers and young people’s accounts.\u003c/p\u003e\n\u003cp\u003eYoung people’s attendance at the centre’s weekly activity sessions was recorded by centre staff. Information regarding referrals and the implementation of the quarterly SWEMWBS was managed by the staff implementing the service and shared with the researchers on a quarterly basis. \u0026nbsp;As an incentive, a £5 Amazon shopping voucher was provided to CYPs who completed the SWEMWBS.\u003c/p\u003e\n\u003cp\u003eAll interviews and focus groups were conducted by SS, who is a trained social science researcher experienced in qualitative research. Interviews and focus groups were held at a private location in the centre or via phone, at a time convenient to the participant. Written informed consent was secured in advance and the interviews were audio-recorded and fully transcribed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor interviews with service providers, a topic guide was used to ensure consistency across the interviews and the same guide was used at each of the three time points. It was based on the purpose of the interviews and informed by relevant literature, knowledge of the planned intervention and discussions within the research team. It included open-ended questions to elicit details and description from the participants about the service, its implementation, and the barriers and facilitators to service delivery. The interviews were held at a private location in the centre or via phone, at a time convenient to the participant.\u003c/p\u003e\n\u003cp\u003eFor the focus groups with young people, a flexible and open-ended topic guide was designed to explore their awareness and experiences with the service. This guide was also refined in conjunction with our YPAG. It included open questions about their perception of mental health and of the new service. A guide was also developed for the interviews with young people who were referred for mentoring or additional mental health support. It included questions about young person’s perceptions of the additional support and referral components, and processes and how it could be improved in future. Young people were offered a £10 Amazon shopping voucher as an incentive for their participation in either a focus group or interview.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData analysis\u003c/h2\u003e\n\u003cp\u003eIn terms of analysing the quantitative data, descriptive analysis was done in Excel and summary data were tabulated. The interviews were transcribed verbatim by professional transcribers. Fieldnotes relating to a specific interview were typed up. Data collection and analysis were conducted simultaneously, so that findings from earlier interviews informed the focus of later data collection.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe interview data and fieldnotes were analysed using an inductive thematic approach. A subsample of all transcripts was independently read and manually coded by SS and KT, who then met to discuss their coding and interpretation of the data. Following this discussion, and drawing on the coding of both researchers, a coding frame was developed. Transcripts were uploaded into NVivo v14\u0026nbsp;(26)\u0026nbsp;and electronically coded using this coding frame. As data collection progressed, new codes were added and transcripts that had previously been coded were re-coded where necessary. Finally, codes were grouped together to develop categories and collated into potential themes and sub-categories in NVIVO.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eEthics\u003c/h2\u003e\n\u003cp\u003eEthical approval for the study (application ID 13984) was obtained from Faculty of Health Sciences Research Ethics Committee (FREC), University of Bristol.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eQuantitative findings\u003c/h2\u003e\n\u003cp\u003eThe specialist mental health practitioners were present at 50 activity sessions between November 2022 and December 2024. 94 CYP who were registered at the community centre attended at least one of these 50 sessions. Irregular attendance was common and total attendance highly variable across the CYP. The proportion of sessions attended by a young person ranged from 2% to 58%. Only 19 CYP attended \u0026gt;=20% of the offered activity sessions. Only 10% of attenders completed a SWEMWBS questionnaire at 2 or more of the four planned timepoints. Consequently, we do not report wellbeing data in this paper.\u003c/p\u003e\n\u003cp\u003eIn the study sample (n=94), 5 young people were offered off-site 1:1 additional therapeutic support by the specialist mental health practitioners but had not taken up the offer at the time of writing.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eQualitative findings\u003c/h2\u003e\n\u003cp\u003eThe findings below start by detailing the characteristics of study participants and the centre, before moving on to detail the content and implementation of the service. Quotes have been used to illustrate points made. They have been tagged to indicate whether the interviewee being quoted was a provider or CYP, and with the participants unique study identification number.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eThe participants\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eFour service providers and six young people were interviewed during the course of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eService providers\u0026nbsp;were\u0026nbsp;two youth centre staff from the community centre (a youth worker and a manager) and two mental health practitioners who visited the centre every week to deliver the mental health service. Because of the very small number of providers, their characteristics are not being listed\u0026nbsp;to avoid identification.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll four providers were\u0026nbsp;involved in implementing the service. All four were interviewed on three different occasions; once at the start of implementing the service, and then again 7 and 13 months later. These interviews\u0026nbsp;were conducted\u0026nbsp;between December 2022 and March 2024.\u0026nbsp;The two mental health practitioners from\u0026nbsp;youth wellbeing and mental health organisation had more than three years\u0026rsquo; experience in delivering one-to-one youth mentoring or group interventions among different minoritised communities and schools. The other two providers were a centre manager, who also oversaw the management of mental health services, and a youth mental health practitioner from the centre. This youth mental health practitioner initially worked as a youth worker but later transitioned to the role of a mental health practitioner with some training on the subject. In this paper, all four have been referred to as providers as their accounts were similar, although\u0026nbsp;instances where they need to be distinguished, we have indicated the individual(s) concerned.\u0026nbsp;These interviews\u0026nbsp;lasted, on average, one hour. Five interviews were conducted face-to-face, either at the centre or at the mental health organisation\u0026rsquo;s office, while the remaining seven interviews were conducted over the phone.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eYoung people were reluctant to take part in a focus group and in the end, only three paired interviews with six young people were conducted. The six young people interviewed were aged between 11 and 15 years old. Because of small sample we are not listing their characteristics. The paired interviews were held in a private room at the centre between May and November 2023. These interviews lasted, on average, 30 minutes. As the young people were reluctant to talk, they did not elicit rich information. Thus, most of the findings below are based on the providers\u0026rsquo; accounts.\u003c/p\u003e\n\u003ch3\u003eThe Centre\u003c/h3\u003e\n\u003cp\u003eCentre staff explained the centre had been offering community-based services for over four decades, serving multiple generations of families in the local community over the years. They mentioned the centre offered three weekly activity sessions for young people of various ages, with one dedicated two-hour session designed specifically for CYP aged 11-17 years old. This was the session that intervention was set in, and that specialist mental health practitioners and researcher (SS) attended. This session featured a range of engaging activities aimed at combining enjoyment with skill enhancement including sports, music production, games, movies, cooking, drawing, arts, and crafts. The activities were overseen by youth workers employed by the centre, and it was apparent that majority of youth workers were from minority ethnic backgrounds. A music studio, supported by another youth support organisation, was available to centre attendees at no cost. Furthermore, during the latter part of the year, the centre started offering hot meals to attending CYP.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe centre staff explained that CYP attending the centre resided in the local vicinity and were primarily from minoritised ethnic backgrounds. The CYP interviewed recounted engaging in various activities, including playing games, drawing, crafting, cooking, and participating in sports. They said these activities were soothing and contributed to the development of their skills and confidence. It was evident that participation in any activity was not mandatory, and CYP could move freely within the space, using it predominantly to socialise with their peers and friends. CYP described how this meant the centre provided them with a space where they could relax and feel safe:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Maybe like how to cook for yourself and how to speak to people and just talk to people, anyone, and that it would be safe \u0026hellip;safe space ...\u0026rdquo; (CYP02, paired interview)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; it doesn\u0026apos;t feel like at school when it\u0026apos;s like you don\u0026apos;t really have a choice. I\u0026apos;m more relaxed here\u0026hellip;\u003c/em\u003e \u003cem\u003ethe staff just let you know every time and then you can just choose what you want to do\u0026hellip;\u0026rdquo; (CYP01, paired interview\u003c/em\u003e)\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eService content\u003c/h3\u003e\n\u003cp\u003eThe providers said the goal of the pilot wellbeing service was to ensure a clear pathway for young people to access mental health services, and to normalise mental health and wellbeing conversations among young people.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProviders explained that the service was being developed iteratively, on-site, over several months, and that it comprised of four components:\u003c/p\u003e\n\u003col style=\"list-style-type: lower-roman;\"\u003e\n \u003cli\u003eConsistent (weekly) presence of mental health practitioners in the space.\u003c/li\u003e\n \u003cli\u003eIdentifying CYP in need of further support and directing or referring them to appropriate services.\u003c/li\u003e\n \u003cli\u003eOpportunistically embedding discussions and activities about mental health and wellbeing into daily conversations and activities\u003c/li\u003e\n \u003cli\u003eOffering drop-in sessions for one-to-one or group mentoring.\u003c/li\u003e\n\u003c/ol\u003e\n\u003ch3\u003eService Implementation\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eImplementation of the service was slow. Providers explained that this was because they had limited experience of implementing such interventions, and becausetime was needed to build mutual understanding and trust between themselves, and between them and the CYP. In addition, they felt the service needed to be developed through trial and error so that it worked within the constraints of the setting and was tailored to the needs to the CYP. \u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eFacilitators to implementation\u003c/h3\u003e\n\u003ch4\u003eFostering trust and building relationships with young people\u003c/h4\u003e\n\u003cp\u003eProviders stated that fostering trust and building relationships were crucial aspects of implementing the service and the first step in delivering it. They mentioned their expertise and lived experience helped them recognise the apprehension and stigma surrounding mental health in minoritised communities, enabling them to be responsive to the needs of these communities:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We\u0026rsquo;re known as being a project that not only provides a service, but connects with young people that we work with on a deeper level than most practitioners can because we understand the lived experience because we all are practitioners from the lived experience...but we\u0026rsquo;re also reflective of a lot of the young people in that space, and their lived experiences and what they\u0026rsquo;ve gone through and how they\u0026rsquo;ve experienced it.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(SP3 Interview)\u003c/p\u003e\n\u003cp\u003eProviders further explained that their approach transcended the traditional therapist-client dynamic, aiming to cultivate informal, youth-friendly relationships akin to those of youth workers, in order to mitigate power imbalances and cultivate meaningful connections with the young people:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They know that they\u0026rsquo;re mental health practitioners, but the relationship isn\u0026rsquo;t one \u0026lsquo;of oh, that\u0026rsquo;s a mental health therapist\u0026rsquo; and \u0026lsquo;I\u0026rsquo;m a young person in need of help\u0026rsquo;. The relationship building has made it more of a sort of youth worker type of friendship relationship.\u0026rdquo;\u003c/em\u003e (SP2 Interview)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;I\u0026rsquo;m very much conversing and engaging with them in vernacular with a presentation that very much matches them. With the core principles of building slow trust\u0026hellip;it\u0026rsquo;s not going in and rushing an engagement or rushing an interaction or connection.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(SP3 Interview)\u003c/p\u003e\n\u003cp\u003eDuring their initial interviews, the service providers also highlighted the importance of establishing trust with the young people without immediately identifying themselves as \u0026quot;mental health practitioners\u0026rdquo;. They believed that labelling themselves as such from the outset might discourage communication. Observation as well as interviews with service providers showed that the promotion of the service or service provider\u0026rsquo;s presence in the centre was subtly executed:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; I didn\u0026rsquo;t advertise that fact (that they were a mental health practitioner) because I don\u0026rsquo;t think, when you\u0026rsquo;re developing relationships, you want to be watched\u0026hellip;going forward\u0026hellip;I\u0026rsquo;d probably want to use language that would be more understood with children, to explain to them better because some don\u0026rsquo;t even know what mental health is, or have heard of it as a buzzword on TikTok. So, at the moment, I just like to be the friendly face that they can come to\u0026hellip;\u0026rdquo;\u0026nbsp;\u003c/em\u003e(SP1 Interview)\u003c/p\u003e\n\u003cp\u003eSubsequent interviews with the providers highlighted that the process of establishing relationships and building trust was gradual and ongoing. It deepened over time with the consistent presence and growing familiarity of the practitioners in the space.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eOver the past seven months it\u0026rsquo;s just been about consistently having familiar faces making the mental health practitioners become familiar faces - in the sessions.\u003c/em\u003e\u003cem\u003e\u0026rdquo;\u0026nbsp;\u003c/em\u003e(SP2 Interview)\u003c/p\u003e\n\u003cp\u003eAdditionally, the mental health practitioners from the mental health organisation acknowledged that their positive relationship with centre staff facilitated the process of them being accepted by the CYP.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003e\u0026ldquo;I would even say that I\u0026rsquo;ve seen how my relationship with one person has developed has directly affected at least two young people \u0026ndash; seeing me and speaking to me and how we engage.\u003c/em\u003e\u0026rdquo; (SP4 Interview)\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eTrust building between the organisations\u003c/h4\u003e\n\u003cp\u003eOngoing engagement, knowledge-sharing and training initiatives (by the practitioners of mental health organisation to the staff at the centre) facilitated the development of a collaborative relationship between the two organisations providing the service. This fostered mutual understanding and built trust, enabling staff at the centre to seek guidance in addressing specific challenges related to safeguarding, engaging disengaged young people, and responding to young people\u0026rsquo;s mental health needs:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;the youth centre is familiar\u0026hellip; but they\u0026rsquo;re not necessarily maybe fully clued up on what it is that we offer ... So, the way in which we\u0026rsquo;ve developed that relationship further through offering training for staff members\u0026hellip; \u0026hellip;we\u0026rsquo;ve developed that relationship with staff where staff are asking us questions in relation to safeguarding concerns, mental health questions around how to work with certain young people presenting as disengaged\u0026hellip;We\u0026rsquo;ve opened up that dialogue and as a consequence built a relationship that\u0026rsquo;s more sort of collaborative but also in some instances almost consultative\u0026hellip;\u0026rdquo;\u0026nbsp;\u003c/em\u003e(SP3 Interview)\u003c/p\u003e\n\u003ch4\u003eDeveloped through trial and error\u003c/h4\u003e\n\u003cp\u003eService providers, especially from the centre, mentioned that without previous experience of implementing a mental health and wellbeing service in a youth space or having knowledge of established models, the process of implementing the service was one characterised by trial and error, involving experimentation, adaptation, and refinement of the service delivery approaches over time: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There\u0026rsquo;s lots of things to just consider so we are providing a more robust service but \u0026lsquo;cause it\u0026rsquo;s the first time we are trying this the challenge is okay, what\u0026rsquo;s working, what\u0026rsquo;s not working, how can we go forward in a better way so it\u0026rsquo;s more streamlined, smoother, necessarily trying to learn as we\u0026rsquo;re delivering.\u0026rdquo;\u003c/em\u003e (SP2 Interview)\u003c/p\u003e\n\u003ch4\u003eTailoring activities to the context\u003c/h4\u003e\n\u003cp\u003eProviders explained that they provided activities following children\u0026rsquo;s interests, and children could choose to take part or not. This meant that while the providers wanted to implement structured educational activities, and actively identify young people needing additional support for their mental health, uptake depended on the CYP\u0026rsquo;s\u0026nbsp;willingness to engage.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026rdquo; I think the approach here is slightly different where it\u0026rsquo;s a bit more run by the children and things are quite relaxed and unstructured, which is its complete beauty, but does have difficulties when trying to implement a more structured\u0026hellip;\u0026rdquo;\u0026nbsp;\u003c/em\u003e(SP1 Interview)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003esome young people may not want one-to-one support because it may make them feel like if there\u0026rsquo;s something wrong with them but in a group there\u0026rsquo;s been lots open discussions and free-flowing let\u0026rsquo;s say engagement where they\u0026rsquo;re not forced to engage with our practitioners\u0026hellip;they more see them as someone who\u0026rsquo;s in the sessions to assist them \u0026hellip;so they are more engaging with them in their own space at their own pace and in their own time.\u0026rdquo; (\u003c/em\u003eSP2 Interview)\u003c/p\u003e\n\u003cp\u003eFor this reason,\u0026nbsp;providers also incorporated more opportunistic approaches to integrate\u0026nbsp;mental health conversations and activities into their usual interactions with the CYP. Examples included regularly checking in with CYP attending the centre about how they were feeling, encouraging individuals to reflect on their experiences and emotions through \u0026ldquo;Rose and Thorn\u0026rdquo; conversations (conversations where the CYP were invited to discuss something positive (rose) or challenging (thorn) that happened during their day) or discussing how acts of kindness can be an uplifting experience. This was also reflected in the interviews with CYP, and\u0026nbsp;while CYP could not mention any specific mental health activities, they mentioned about staff checking-in on them, having conversations about their emotions, participating in activities such as \u0026ldquo;Rose and Thorn\u0026rdquo;. It was also evident that they felt the providers genuinely cared.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;they genuinely want to know how I feel, not just for the sake of asking.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(CYP 03 paired interview)\u003c/p\u003e\n\u003ch3\u003eBarriers to implementation:\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eDespite the services having a positive impact, the providers also talked about implementation barriers. These related to inconsistent attendance of young people, the informal or unstructured nature of activities delivered in the centre, slow pace of service delivery, and the young people\u0026rsquo;s reluctance to engage in wellbeing services or conversations. There were also challenges in collecting data using the\u0026nbsp;SWEMWBS\u0026nbsp;scale.\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eInconsistent attendance of young people\u003c/h4\u003e\n\u003cp\u003eAlthough young people valued the centre, their attendance was inconsistent, which not only hindered or delayed the development of trust and rapport between the providers and young people, but also affected the continuity of service delivery.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;Young people\u0026rsquo;s attendance is quite inconsistent. So will show up for a week, two weeks. We\u0026rsquo;ll build a bond. They\u0026rsquo;ll disappear for a week. So, consistency is also a barrier that we\u0026rsquo;re facing, which is a fundamental pillar to our work as practitioners.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(SP3 interview)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I didn\u0026rsquo;t really consider the transitory nature of this space \u0026ndash; when people aren\u0026rsquo;t there, when people are there. Young people moving out of the space \u0026ndash; I\u0026rsquo;ve just never been accustomed to that in the work that I do.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(SP4 interview)\u003c/p\u003e\n\u003ch4\u003eInformal and relaxed structure\u003c/h4\u003e\n\u003cp\u003eService providers repeatedly highlighted a \u0026lsquo;tension\u0026rsquo; between the formality of the service and the informality of the community setting. To engage with young people, the service providers had to navigate their activities around the habitual actions of the young people:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; it\u0026rsquo;s an established space already. This is a new project, a new face in the service, but the young people\u0026hellip;have particular expectations of the space\u0026hellip;So people are acting habitually in the space. They will go to the studio. They will hang out, stay on their phones, chat with each other, and disengage from people and professionals in the space because that\u0026rsquo;s their space and that\u0026rsquo;s their time. Working alongside established habitual actions within the space, and what young people themselves expect from that space\u0026hellip;that\u0026rsquo;s also been a bit of a barrier for us in terms of being able to work our angle in the space.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(SP3 Interview)\u003c/p\u003e\n\u003ch4\u003eSlow pace of service delivery\u003c/h4\u003e\n\u003cp\u003eAll the service providers acknowledged that the process of implementing the service progressed more slowly than anticipated or desired. It was evident from the interviews that several factors listed above had contributed to this along with the time needed to develop the necessary formal procedures for safely implementing a mental health service in a youth setting.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe impact of this slow pace was that wellbeing sessions were far fewer in the first 3 months of implementation and, while their frequency increased in 2023, the service only began to be fully implemented (all four service components running regularly) when the study ended, i.e. it took nearly a year to establish. It also meant that providers were unsure of their roles during this time. Slow implementation also meant the service was not clearly visible to the young people. There was no clear mark or timepoint from which it was being implemented and described to them. This was evident when talking to the CYP, as they all said they were not aware of a new service.\u003c/p\u003e\n\u003ch4\u003eHesitancy in engaging with service and providers\u003c/h4\u003e\n\u003cp\u003eService providers described in several of their interviews that young people did not want to converse about mental health issues or access further support for their mental health when it was offered. They suggested that in the early phases of the service, this might have been because they were not familiar with the mental health service providers, although they knew the centre staff. They also commented that it could be due to the young people\u0026rsquo;s perception that participating could signal that they had problems, underscoring the need for practitioners to approach them with care and sensitivity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; you know young people don\u0026rsquo;t wanna feel like there\u0026rsquo;s something wrong with them. \u0026hellip;You\u0026rsquo;ve got to be more therapeutic with your approach or more mindful with your approach because we don\u0026rsquo;t want them to feel like oh, there\u0026rsquo;s something wrong with me why this mental health person keeps trying to talk to me\u0026hellip;\u0026rdquo;\u003c/em\u003e (SP2 Interview)\u003c/p\u003e\n\u003cp\u003eBased on the CYPs\u0026apos; accounts, their unwillingness or reluctance to engage could also be because they were unsure what was being offered, as they explained they were unsure was meant by \u0026apos;mental wellbeing\u0026apos; or \u0026apos;emotions\u0026apos;, and what the activities were being offered. They also mentioned that they did not see the service as relevant to them. This was because they thought their mental health was fine. At the same time, they could see how individuals who may be upset or in a stressful situation could benefit from additional support. CYP were also unsure how to discuss their mental health and explain how they were feeling.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI think it [activity with SP03] helped us understand our emotions a bit more because sometimes you just don\u0026apos;t understand what you\u0026apos;re feeling and like you just\u0026hellip; Well, you can\u0026apos;t understand it. \u0026hellip;. Yeah. I think it helped me understand emotions because when you describe them [pause] like it helps you understand them because like people just say emotions, but they don\u0026apos;t really understand what that actually means.\u0026rdquo; \u0026nbsp; (CYP02, paired interview)\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003eChallenges in collecting monitoring data on well-being and attendance\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eStaff at the centre identified obstacles when implementing the SWEMWBS scale to collect data on well-being. They mentioned initially feeling uncomfortable using it, as mental health and wellbeing had not been a focus of the centre, and therefore they needed to explain to the CYP why they were being asked to complete it. Additionally, managing attendance data initially proved challenging due to the lack of a systematic register, prompting the creation of a new register to improve data recording.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; we didn\u0026rsquo;t have a register that was properly monitoring attendance, so we had to create a new register which I created to then get the new details of every young person to ensure that I had the right information to input the data\u0026hellip;\u0026rdquo; (SP1 Interview).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003eImpact of implementation\u003c/h2\u003e\n\u003cp\u003eDuring follow-up interviews, service providers emphasised that despite the service\u0026apos;s gradual implementation, they had established relationships with young people and between organizations, and extended the service to other young people in the community. They had also started offering mentoring sessions and developed a clear referral pathway to support and refer CYPs needing specialist mental health support. Although the process of trust building was slow, it had led to CYP opening up to the providers and confiding in them:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003e\u0026quot;One of the young girls became particularly close with our community mental health practitioner, and she\u0026rsquo;s been able to confide in things that have been upsetting her.\u0026quot;\u003c/em\u003e (SP2 Interview)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;I would say it\u0026rsquo;s going well and now that we do have a framework of how it could be delivered\u0026hellip;Well the framework would be the (referral) pathway. It would be the whole process\u0026hellip;what it looks like to identify young people, what we do as part of our process once we\u0026rsquo;ve identified that young person...\u0026rdquo;\u003c/em\u003e (SP2 Interview)\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eDuring follow-up interviews providers emphasised how effective communication, and understanding and clarification of their respective roles and responsibilities, had led to a more equitable partnership between the youth centre practitioners and the two specialist mental health providers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProviders also mentioned that having the service in place, and having established a collaboration between both organisations and their practitioners, meant they could quickly respond to challenges as they occurred. This was demonstrated by the providers organising additional drop-in sessions and support for the friendship group of a young community member (also an attendee of the centre since childhood) who was tragically murdered during the time of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;so a good thing is that \u0026lsquo;cause we do have this service in place \u0026hellip;able to layer on another support for\u0026hellip;his immediate friendship group, to access because we have this programme in place already. That was a very big benefit and we\u0026rsquo;ve had three sessions so far and\u0026hellip; young people turned up and they just off-loaded and poured and poured and poured\u0026hellip; I\u0026rsquo;m just saying to me the fact that we have got this sort of collaboration\u0026hellip;it\u0026rsquo;s allowed us to be more readily responsive\u0026hellip;\u0026rdquo;\u0026nbsp;\u003c/em\u003e(SP2 Interview).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eWe identified facilitators and barriers to successful implementation of a community-based wellbeing service for minoritized young people. Key facilitators included the positive influence of the setting, lived experience of service providers, iterative and tailored development of the service, and trust building between all those involved. Barriers included inconsistent attendance of young people, the informal or unstructured nature of activities delivered in the centre, slow pace of service delivery, the young people\u0026rsquo;s reluctance to engage in wellbeing services or the evaluation.\u003c/p\u003e \u003cp\u003eWhen comparing our findings with recent similar research, it is evident that building trust and relationships, following young people\u0026rsquo;s preferences and interests, and collaborative development, have been identified by others as facilitators to implementation of interventions focused on young people\u0026rsquo;s mental health (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). However, we found having to work to young people\u0026rsquo;s preferences, can also mean they may choose to not engage with a service.\u003c/p\u003e \u003cp\u003eRecent evidence from UK shows interventions in community centres positively impact young people\u0026rsquo;s mental health and general wellbeing, particularly for those from marginalized backgrounds (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The profile of young people attending these community settings has shifted markedly since the 1980s, when it was mostly boys from marginalized backgrounds, to mostly children from well-off families in safe neighbourhoods in recent years (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). This may be due to long-standing public-sector funding limitations and the current cost of living crisis. Recognising these trends, this intervention, made possible through local funding and community organisations, aimed to support and embed local provision for minoritised young people.\u003c/p\u003e \u003cp\u003eA strength of our study was that all the providers took part, and data were collected at 3 time points from them, allowing their views and experiences of the service to be explored as it was implemented. This was particularly important because implementation was slow and went through the phases of building trust, intervention development, to finally establishing activities and a pathway.\u003c/p\u003e \u003cp\u003eAnother strength is the method of data collection used (in-depth interviews) which meant the providers could describe their views and experiences in detail, raise issues that were important to them (e.g., trust building) and explain the rationale behind how the service was being implemented (e.g., the need for activities to be child-led).\u003c/p\u003e \u003cp\u003eA key limitation of the study is that only six CYP were interviewed, and that these interviews were held at the end of the study, so we have limited insight into their views and experiences. We also have limited wellbeing data, so can only reflect on the potential impact of the study from a qualitative perspective. That said, we have identified some important facilitators and barriers to implementation of a wellbeing services in a community setting for minoritized young people. Future researchers developing and evaluating such interventions, and practitioners working with young people, might want to consider these to ensure these interventions can be implemented in practice and have positive impact on CYP's wellbeing.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIt is feasible to provide wellbeing services in community settings for minoritized young people. The successful implementation of such services in community settings requires commitment to relationship building between providers and with recipients, and flexibility in how the intervention is delivered and at what pace. Wellbeing services should provide CYP with the tools to talk about mental health and wellbeing and trusting relationships are required for this.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBlack, Asian, and minoritized ethnic (BAME)\u003c/p\u003e\n\u003cp\u003eChildren and young people (CYP)\u003c/p\u003e\n\u003cp\u003eChild and Adolescent Mental Health Services (CAMHS)\u003c/p\u003e\n\u003cp\u003eFaculty of Health Sciences Research Ethics Committee (FREC)\u003c/p\u003e\n\u003cp\u003eService Provider (SP)\u003c/p\u003e\n\u003cp\u003eShort Warwick-Edinburgh Mental Well-being Scale (SWEMWBS)\u003c/p\u003e\n\u003cp\u003eYoung People\u0026apos;s Advisory Group (YPAG)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate: \u003c/strong\u003eEthical approval for the study (application ID 13984) was obtained from Faculty of Health Sciences Research Ethics Committee (FREC), University of Bristol and NHS Bristol, North Somerset and South Gloucestershire ICB (reference 2022-089).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from all service providers participating in the study. For children and young people under 16 years of age participating in focus groups an assent from them and informed consent from their legal guardian was planned to be obtained. However, to improve participation in focus groups (paired interviews), the process was amended and only written informed consent was obtained from all CYP. All methods were performed in accordance with the relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials: \u003c/strong\u003eDue to the small sample size, we are not making the provider or young people\u0026rsquo;s transcripts available with the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e SS, DC \u0026amp; KT declare no competing interests. SI is embedded part time in the Bristol City Council\u0026rsquo;s (BCC) Public Health team with a remit to increase their research activity and this project was developed in that role. JW is Consultant in Public Health (Healthy Children and Families), and the departmental academic lead. GS is the commissioner for this evaluated service, and the providers reported quarterly on the service to her.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding: \u003c/strong\u003eThis research was funded as part of the Three NIHR Research Schools Mental Health Programme Practitioner Evaluation Scheme (MH022). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSharea Ijaz \u0026rsquo;s time is supported by the National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West), NIHR Clinical Research Network West of England (PHLARP funding), and NIHR Research Support Service Specialist Centre for Public Health (LARP funding)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions: \u003c/strong\u003eJW, GS, KT, DC and SI developed the protocol. SS carried out recruitment and data collection. SS, KT and DC analysed the data. SS and SI drafted the manuscript. All authors contributed to revisions, and read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to the providers for their contribution to data collection, setting up and recruitment, to the YPAG members for their advice, and to the young people who participated in the evaluation. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNewlove-Delgado T, Marcheselli F, Williams T, Mandalia D, Davis J, McManus S, et al. Mental Health of Children and Young People in England, 2022-wave 3 follow up to the 2017 survey. 2022.\u003c/li\u003e\n\u003cli\u003eMeechan H, John M, Hanna P. Understandings of mental health and support for Black male adolescents living in the UK. 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Implement Sci. 2017;12(1):93. https://implementationscience.biomedcentral.com/articles/10.1186/s13012-017-0626-4.\u003c/li\u003e\n\u003cli\u003eKurtz Z, Street C. Mental health services for young people from black and minority ethnic backgrounds: the current challenge. Journal of Children\u0026apos;s Services. 2006;1(3):40-9. https://doi.org/10.1108/17466660200600022.\u003c/li\u003e\n\u003cli\u003eStreet C, Stapelkamp C, Taylor E, Malek M, Kurtz Z. Minority voices: Research into the access and acceptability of services for the mental health of young people from black and minority ethnic groups. London: Young Minds; 2005. Report No.: ISBN: 0-9545123-7-5.\u003c/li\u003e\n\u003cli\u003eTroy D, Anderson J, Jessiman PE, Albers PN, Williams JG, Sheard S, et al. What is the impact of structural and cultural factors and interventions within educational settings on promoting positive mental health and preventing poor mental health: a systematic review. BMC Public Health. 2022;22(1):524.\u003c/li\u003e\n\u003cli\u003eDepartment of Health \u0026amp; Social Care. Improving the mental health of babies, children and young people: a framework of modifiable factors. 2024(19/02/2024). https://www.gov.uk/government/publications/improving-the-mental-health-of-babies-children-and-young-people/improving-the-mental-health-of-babies-children-and-young-people-a-framework-of-modifiable-factors#examples-of-approaches-that-can-positively-influence-the-mental-health-of-babies-children-and-young-people.\u003c/li\u003e\n\u003cli\u003eCreswell C, Harris E, Koppel K, Peters-Corbett A, Thomson A. Barriers and facilitators of community-based implementation of evidence-based interventions in the UK, for children and young people\u0026apos;s mental health promotion, prevention and treatment: rapid scoping review. 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Zoom Video Communications Inc. ; 2016. https://d24cgw3uvb9a9h.cloudfront.net/static/81625/doc/Zoom-Security-White-Paper.pdf.\u003c/li\u003e\n\u003cli\u003eLumivero. NVivo (version 14). Lumivero; 2023. www.lumivero.com.\u003c/li\u003e\n\u003cli\u003eReed J, Hunn L, Smith T, Bosworth R, Gee B, Berry C, et al. Barriers and facilitators in the implementation of youth and young adult models of mental health care. Early Intervention in Psychiatry. 2024;n/a(n/a). https://doi.org/10.1111/eip.13555.\u003c/li\u003e\n\u003cli\u003eSQW \u0026amp; University of Warwick. Youth provision and life outcomes: Systematic literature review. London: Department for Culture, Media and Sport.; 2024.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adolescent, Mental Health, Ethnicity, Community setting, Qualitative Research, Complex health interventions","lastPublishedDoi":"10.21203/rs.3.rs-5289830/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5289830/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eYoung people from minoritized ethnic backgrounds often encounter challenges in accessing mental health support. We evaluated implementation of a pilot mental health and wellbeing service in a community youth centre for young people from minoritised ethnic backgrounds.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe evaluated the service during its first 12 months of implementation. We held twelve service provider interviews and six paired interviews with young people. Fieldnotes were taken and used to contextualise data. Service providers recorded young people\u0026rsquo;s attendance and wellbeing data. Interview data were analysed thematically to identify barriers and facilitators to successful service implementation. The quantitative attendance and wellbeing data were analysed descriptively using Excel.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe service was developed iteratively at the youth centre over several months. Once established the service included a weekly two-hour session with mental health practitioners involving opportunistic wellbeing conversations and activities, an offer of one-to-one and group drop-in and mentoring sessions, and an identification and referral pathway to secondary community services. Attendance of young people was inconsistent, and only a few young people provided wellbeing data. Both providers\u0026rsquo; and young people\u0026rsquo;s accounts indicated that implementation was supported by the positive influence of the setting, lived experience of the service providers, iterative development of the service, and trust building. Barriers included inconsistent attendance of young people, the informal and unstructured nature of activities delivered, slow pace of service delivery, and the young people\u0026rsquo;s reluctance to engage in wellbeing services and evaluation.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eSuccessful implementation of wellbeing services in community settings for minoritized young people requires investing in relationship building between providers and recipients, and flexibility in how the intervention is delivered and at what pace. Development and evaluation of similar services in future should account for these requirements.\u003c/p\u003e","manuscriptTitle":"Barriers and facilitators to the implementation of a community-based mental health and wellbeing service for black, Asian and minoritized young people: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-24 05:56:23","doi":"10.21203/rs.3.rs-5289830/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a4b73992-a702-4fdb-a857-d92ca7bd0766","owner":[],"postedDate":"October 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-30T07:54:10+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-24 05:56:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5289830","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5289830","identity":"rs-5289830","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}