Co-designing strategies to support children and young people’s mental health in Newham and Northern Devon

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The argument for greater investments in prevention is well-established, with growing calls to address the social determinants of CYP’s mental health. However, there is a gap between this rhetoric and the knowledge required to design and implement such approaches locally. Methods : This paper outlines the methods and approaches used in two distinct local communities where CYP, community partners, and system leaders collaborate to co-design contextually relevant and prevention-focused solutions to improve CYP’s mental health and wellbeing. Results and Conclusions : This paper examines the benefits, inherent tensions, and limitations of this approach. Youth-centred co-design approaches have value and potential, but to address the social determinants of mental health, it is crucial to maintain this focus and ensure that those with the power to effect structural and systemic change are integral members of co-design teams. Adolescent Mental Health Co-Design Community-Based Participatory Research Group Model Building Systems Thinking Social Determinants and Participatory Design. Figures Figure 1 Figure 2 Figure 3 Introduction Background Despite increasing efforts to provide mental health and wellbeing support for CYP, reported rates of poor wellbeing and probable mental disorders have risen [1, 2]. Demand for specialist services has also increased over the past decade [3]. Mental health specialists offer various explanations for this trend, including changes in diagnostic criteria for mental disorders ('diagnostic inflation') [4]; an increase in experienced symptoms of poor mental health [2]; heightened awareness, recognition, and potential over-interpretation [1]; and the increased complexity of CYP’s lives, including new challenges associated with social media [5]. A crucial aspect to consider is the role of prevention in these discussions, aiming to address not only the manifestations of need and the outcomes of these challenges [6] but also the underlying systemic and structural drivers that perpetuate these issues [7]. Marmot et al [8, 9, 10] have also underscored the need for a focus on structural and contextual factors that influence health inequalities, and impact on population mental health. The social determinants literature provides a useful framework to explore how social, environmental, and behavioural risk factors [11, 12] and the conditions and contexts in which people are born and live influence their mental health and wellbeing outcomes [13]. To comprehensively support CYP, it is necessary to not only offer targeted and specialised services for those with diagnosed mental disorders but also to invest in prevention measures addressing these underlying social determinants, and provide early intervention to prevent needs from escalating [6, 14]. Furthermore, the design and implementation of prevention and early intervention efforts must consider how these social determinants are experienced in varying local contexts and the implications for developing contextually relevant strategies to support CYP’s wellbeing and mental health needs, which may differ from national policy and strategies [15, 16]. For example, CYP in urban and rural areas may encounter similar social determinants such as poverty, racism, or limited employment opportunities, but the manifestations can vary significantly. While job insecurity and underemployment, both social determinants of health [11, 13], might affect both rural and urban areas, rural areas may suffer from a lack of local industries and transportation [17, 18], which might not be the primary issue in urban contexts. Overlooking contextual factors, such as demographics, leadership, history of the local area and socioeconomic conditions can lead to an underdeveloped understanding of needs and local influences [16], thereby undermining the design and implementation of suitably contextualised and nuanced strategies [19]. Such strategies often focus only on the surface-level manifestations of needs and individual understanding of mental health rather than addressing the underlying root drivers and wider system influence [16, 20]. The meaningful participation of local CYP and other community members in the exploration, co-design, and implementation of strategies aimed at improving mental health and wellbeing, enhances the likelihood of these strategies reflecting local views and needs [21]. It also elucidates the complex and nuanced ways in which the social determinants of mental health are experienced by CYP in different contexts, thereby informing effective interventions [22]. Additionally, co-design and other participatory design methods can provide individual benefits to CYP involved in these activities, supporting their own wellbeing [23], and benefiting wider groups of CYP through the application of their lived experiences to strategy development [24]. However, recent literature indicates a gap in the evidence supporting the effectiveness of co-design methodologies in significantly improving CYP's mental health, calling for further research to enhance the evidence base [25, 26]. This paper will: (1) describe the methods used to support the co-design of contextually relevant and prevention-oriented strategies for CYP mental health and wellbeing in two distinct areas; and (2) report the learning and recommendations derived from this youth-centred co-design approach to addressing the social determinants of mental health at the local level. About Kailo Co-design took place in two intentionally distinct communities in the UK as part of Kailo, a place-based research and design initiative aimed at addressing the social determinants of CYP's mental health in local contexts. The meaningful engagement of CYP and other community members in addressing inequalities and the social determinants of CYP’s mental health, are key features of Kailo's co-design process. The Kailo team was guided by the Kailo Pillars (Figure 1) and the Lundy model of child participation [27], focusing on four key areas: space, voice, audience, and influence. The Kailo framework is currently being tested and delivered in two initial sites: Northern Devon (a rural/coastal region in the South-West of England) and the London Borough of Newham (a densely populated and diverse inner-city area). As illustrated in Figure 2, Kailo has three phases [7]: Early Discovery : This phase focuses on building trusted relationships with local partners, understanding what matters to local community members, and forming communities around shared priorities. Deeper Discovery and Co-Design : This phase is centred on co-designing strategies and interventions to address prioritised issues. Implementation : This phase focuses on embedding and sustaining the strategies developed in the co-design phase. The framework is currently being further developed and refined to embed and scale the approach in local areas. Early Discovery Phase The Early Discovery phase of Kailo in the initial two sites was conducted between May 2022 and May 2023. This phase involved qualitative engagements with over 500 individuals, including CYP and community professionals, across Northern Devon and Newham. The focus was on understanding what mattered to these groups in improving CYP’s mental health through a social determinants lens. Researchers and local partners collaborated with CYP and community professionals to narrow down and prioritise a set of contextually relevant areas of focus for the Deeper Discovery and Co-design phase of the program. These areas of focus, referred to as ‘Opportunity Areas’ (OA), were used to form committed local partnerships for engaging in co-design activities in the Deeper Discovery and Co-Design phase [17]. In Northern Devon, the prioritised OAs identified were: (i) building stronger informal community support networks to promote mental health awareness and literacy ( OA1 ); (ii) creating and enhancing access to more diverse opportunities for studies, employment, and recreation ( OA2 ); and (iii) fostering a sense of identity and belonging ( OA3 ) as a cross-cutting theme. In Newham, the prioritised OAs were: (i) reducing the impact of violence and crime and enhancing safety ( OA4 ); and (ii) strengthening the role of local community infrastructure and activities for wellbeing ( OA5 ). The primary aim of this paper is to describe and reflect on the methods used in the subsequent Deeper Discovery and Co-Design phase of Kailo. This provides context for a concurrent developmental and complex systems change evaluation [32]. The discussion in this paper reflects the experiences and learning of the design and implementation teams, informed in part by emerging insights from these accompanying evaluation activities. The third and final phase of Kailo, Implementation, will be discussed in future outputs. Methods This section describes the Deeper Discovery and Co-Design phase of Kailo and its associated methods and implementation in the two pilot sites: Northern Devon and Newham. Deeper Discovery and Co-Design phase overview Using co-design and group model-building approaches, the Deeper Discovery and Co-Design phase of Kailo aims to: Build on Early Discovery work and undertake deeper research around OAs identified and prioritised in the Early Discovery phase to identify root causes and systemic drivers of CYP’s mental health and wellbeing in the local context. Develop a more nuanced understanding of the prioritised OAs as defined and experienced by CYP and the broader local communities. Gain a comprehensive understanding of the systemic behaviours driving the identified OAs and pinpoint leverage or intervention points for impactful change. Generate ideas and co-design responses around these OAs to support CYP’s mental health and wellbeing within the Kailo pilot sites. Engage and collaborate with key stakeholders and actors related to the identified OAs, including CYP, youth and community organisations, local commissioners, and other critical actors. Foster local partnerships' capacity to engage in the Deeper Discovery and Co-Design phase by gradually transitioning ownership from the Kailo team to these partnerships, ensuring the process is community-led and owned. Address gaps in engagement and knowledge identified during the Early Discovery phase. This is achieved by forming and bringing together Kailo Site Teams (KST), Kailo Community Partners (KCP), Kailo Community Researchers and Designers (KCRD), Wider Kailo Consortium (WKC) and other community members to develop local strategies and interventions (See Additional File 1). These groups played crucial roles in the effective implementation and sustainability of the co-design efforts, ensuring that the process remained community-led and focused on the specific needs and contexts of the participating areas. These efforts contribute to addressing locally relevant social determinants of CYP’s mental health and wellbeing as part of a wider, portfolio-based approach [28]. Core elements of Deeper Discovery and Co-Design phase The Deeper Discovery and Co-Design process is grounded in the use and integration of two broad methodologies: co-design and group model building, supported by considerations of the extant literature and evidence integration. Co-design: Co-design, as defined by Blomkamp [29], signifies the active involvement of a diverse range of participants in exploring, developing, and testing responses to shared challenges. This approach enables strategy and intervention design efforts to centre the voices of CYP in shaping and defining supports, interventions, and strategies that are specific and appropriate to their mental health needs [21, 30]. The intent is to produce strategies that are more likely to address pertinent and relevant needs while enhancing engagement and traction with the intended audiences, which is a critical prerequisite for impact. Additionally, participating in co-design can offer wellbeing benefits for CYP, including feelings of pride, achievement, and enjoyment, as well as the opportunity to learn and use skills such as teamwork and collaborative working [24]. Group model building: Group model building is a participatory approach developed within the field of system dynamics to facilitate group decision-making and problem structuring [31]. It allows for the consideration and better understanding of complex problems through mapping and modelling process that capture underrepresented perspectives and emphasise consensus building, which is critical for sustainable community-led change [33]. Group model building was integrated into the co-design process. Further details and protocols for this element of the Kailo design process are described by Keenan et al [34]. Evidence integration: Incorporating and using knowledge from the extant research literature around areas of focus was interspersed throughout the Deeper Discovery and Co-Design process. This pragmatic, rapid, and non-systematic approach aimed to: (a) offer insight into the current state of academic evidence [35] around the topics explored in the Deeper Discovery Circles; (b) surface insights not otherwise considered; and (c) provide a generalised consideration of what prior research indicates is impactful, ineffective, or harmful, which may be considered in relation to the local context, knowledge, and lived experience of co-design teams [35]. As discussed later, integrating such forms of knowledge into a rapid, adaptive, and emergent design process presented challenges. Two Small Circles benefited from an Evidence Brief, conducted by one of the Kailo Consortiums partner universities. Co-Design team formation and wider supporters As illustrated in Figure 3, the Deeper Discovery and Co-Design phase comprises three main groups: The ‘Small Circle’: This group leads the co-design work, with varying levels of participation and commitment to accommodate their preferences, specific needs, and availability [30]. The ‘Circle of Research’: This group undertakes supplementary community research as required by the Small Circle. The ‘Big Circle’: This group comprises local policy, commissioning, and practice leaders and professionals who provide regular review, input, connection to related work, and championing efforts. All Deeper Discovery and Co-Design Circles’ members have a role - directly or indirectly - in supporting CYP’s mental health and wellbeing within local community areas. The formation and activities of these circles were supported and facilitated by Kailo Site Teams (KSTs) and Kailo Community Partners (KCPs), who also enabled accompanying community research. Participants in the Deeper Discovery and Co-Design phase Sampling and recruitment Small Circle of co-design Kailo places a particular focus on engaging CYP who are most impacted and often less heard regarding the OAs identified in each site. The KST recruitment strategy and sampling was informed by insights around engagement gaps from the Early Discovery phase and the experiences of KCP. Although KST members were committed to engaging a diverse range of CYP, certain groups were not sufficiently engaged during the Early Discovery phase [17]. These groups varied across the sites and included neurodivergent CYP, those identifying as LGBTQIA+, and those living in rurally isolated areas in Northern Devon, and CYP from racially and ethnically minoritised groups in Newham. In response to these gaps, the recruitment criteria during the codesign phase focused on individuals belonging to these underrepresented groups and others with relevant lived experiences of the OAs prioritised in the Early Discovery phase. To aid this recruitment, the KST created a guide based on insights from the Early Discovery phase and KCP’s experiences, which included questions and prompts to support conversations with CYP. This was used to assess their comfort in the co-design sessions and identify any reasonable adaptations needed to improve session accessibility (See Additional File 2, 3, 4). To access a broader network of diverse groups , CYP were recruited through KCP, who approached individuals they had had existing relationships with and/or those they felt would be able to engage in the project in a group setting. Adults participating in the Small Circles were recruited by KCP and KST, all subject to safeguarding checks and protocols. Both CYP and adults regularly involved in the Small Circles were compensated for their participation in line with the National Living Wage rate [36]. These groups of CYP and community members were supported and facilitated by the KST. In Northern Devon, this included one Site Lead (Designer), one Researcher, two Community Researchers, and three to five individuals from KCP organisations in each circle. In Newham, this included one Site Lead (Public Health Specialist), two Researchers, and one to two individuals from KCP organisations. These trusted local community members played roles in supporting CYP’s mental health and wellbeing (either directly or indirectly), in each site. Some community members and professionals also played safeguarding roles and provided additional support for particular CYP attending the sessions. Circle of Research In addition to the core ‘Small’ and ‘Big’ circle members, at specific points in the co-design process, the Small Circle, KST, and KCPs consulted wider members of the local community. This included CYP, community members, or other local organisations or partnerships to undertake ad-hoc outreach, engagements, or community research to inform aspects of co-design. Methods such as rapid literature searches, surveys of CYP and other community members, and focus groups were employed to inform prioritisation or design decisions in the Small Circle co-design sessions. The intention was that these efforts by the Circle of Research ensured that the co-design process was informed by a broader spectrum of community input, enhancing the relevance and impact of the design decisions made by the Small Circle. Big Circle Big Circle recruitment aimed to represent local systems leadership [37], and "local people who represent and speak for their community" [38], which included local community leaders, youth and community organisational representatives, public systems leaders, funders and commissioners, education providers, and academics. Members of the Big Circle were identified and engaged through the Early Discovery phase [17], via snowballing recommendations from existing Big Circle members and KCPs, or through invitations to specific Kailo forums or via presentations or inputs to pre-existing public sector forums, such as local authority or health system boards. Participants were typically individuals or representatives from organisations with power, specialism, or influence regarding the specific OA themes or broader CYP mental health. Co-Design Process and Analysis Settings and delivery Overall, 34 Small Circle co-design workshop sessions were held between July 2023 and June 2024 across the two Kailo pilot sites; Northern Devon held 17 sessions for both their small circles, and 1 joint session where the two circles came together, and Newham held 15 and 17 sessions across its two small circles. In Northern Devon, sessions were facilitated in person at a local charity building that offers therapeutic support for CYP and their families, as well as at a local youth centre. In Newham, sessions were facilitated across two youth centres and a community centre. Sessions occurred weekly or fortnightly, depending on participant availability. These activities were facilitated by KST members and Community Researchers, with support from KCPs. Big Circle group sessions were conducted online, supplemented by additional one-on-one conversations with Big Circle and members who were either unable to attend sessions or wished to support or engage further. These activities were facilitated by KST members, supported by KCRs. Lastly, the Circle of Research engagements were facilitated online through surveys or in-person through focus groups when appropriate across the sites. Co-design delivery and analysis Additional File 5 illustrates the various Small Circle co-design sessions facilitated by the KST. Although there was some variation in the sessions, most included the elements described below. These sessions were designed to build on one another rather than being standalone events, whilst also ensuring flexibility to the needs of each group. The KST led engagements such as Kailo Deeper Discovery Circles sessions, one-on-ones with specific community organisations, and surveys, involving data collection and analysis across the circles. Simple and interactive tools such as posters, cards, voice notes/recordings, LEGO ©, arts, crafts, and sticky notes were used to facilitate discussions and collect information within Small Circle sessions, encouraging CYP and community members to be reflective and creative. The information collected during these sessions was transferred into a digital whiteboard by the KST, acting as a collaborative workspace for data collection, remote collaboration, and communication. After each co-design session, various methods were used to analyse and summarise outputs, supporting Small Circle members in building on their discussions and learning. These approaches included clustering and thematic analysis [39]. Additionally, in many sessions, subsequent refinement was carried out by the KST as the sessions focused on producing specific outputs such as systems maps, personas, and empathy or journey maps. Throughout the process, findings were presented back to the Big Circle, either through regularly scheduled online sessions or via ad-hoc sessions as required. This enabled sense-checking, feedback, and review. Big Circle members had the opportunity to contribute their reflections via virtual whiteboards and/or discussions, which were incorporated into the Small Circle insights and outputs. These insights and outputs were then presented back to the Small Circle members in subsequent sessions, allowing for multiple cycles of sensemaking and feedback. Prioritisation exercises were also facilitated within the Small Circle sessions (either during the sessions or following the thematic analysis) to identify areas of focus at different stages of the process. These activities were informed by wider community research, rapid engagements with research literature, surveys, and focus groups, allowing for external input and diverse knowledge and expertise to be incorporated into the prioritisation exercises. Furthermore, throughout the Deeper Discovery and Co-Design phase, the delivery and support teams engaged in regular cycles of review and reflection to analyse outputs and discuss adaptations to the approaches based on CYP’s views and the observations of the delivery and support teams. KCPs were involved in co-facilitating Small Circle sessions with KSTs, as well as reviewing insights and findings from Small and Big Circle sessions. Ethics Ethical approval for the study and associated co-design activities was obtained from the University College London (UCL) Research Ethics Committee (REC). Project ID/Title 18773/002. Results Participants Small Circle The recruitment process resulted in the involvement of 44 CYP aged 12-25 living in the Kailo pilot site communities, with an average of 22 CYP being recruited in each site. These CYP came from diverse groups including those from low-income households (Northern Devon and Newham), those from white and mixed backgrounds (Northern Devon and Newham), and those from Muslim and Christian faiths (Newham). On average, three community members attended each Small Circle across the pilot sites, including local youth workers, parents, counsellors, and practitioners. Additionally, in Northern Devon, eight practitioners joined later stages of one of the Small Circles to contribute to further refinement of the co-design process. In Northern Devon and Newham an average of eight CYP were regularly engaged in each Small Circle co-design session. In other words, an average of 32 young participated in all Small Circle sessions across both pilot sites. However, in Newham attendance fluctuated and new members had to be recruited at various stages of the process. Key barriers to initial and regular participation in sessions identified by the KST and KCP (parentheses include the strategies used by the KST team to mitigate or address these challenges): Access to reliable and affordable transport (CYP had access to taxis and full contribution towards transport) Evening sessions in communities where violence and crime and personal safety was a concern (Session times were changed to fit CYP’s needs and safeguarding, taxis were also offered to enable CYP to safely access session’s location) Other commitments (e.g., school, college and work) Perceptions of the place where the sessions were happening (Sessions were held in youth and community centres i.e., places that CYP knew and felt comfortable in). Key barriers to participation within sessions identified by the KST and KCP: Meeting the needs of neurodiverse groups of CYP (Session plans were adapted to neurodiverse and neurotypical needs) Current experience of mental health symptoms (CYP were supported through KCP, and other local professionals) Underlying motivations (e.g., engaging to spend time with their friends, engaging because they needed the money offered for participation) (CYP were invited to reassess their motivation to participate and develop group agreements and aims within sessions. Reflection spaces were also facilitated with the purpose of regularly reviewing these) Competing individual priorities and needs between different groups of CYP in the sessions (e.g., neurodiverse and neurotypical in Northern Devon, white and ethnic diverse groups in Newham) Lack of experience or knowledge of how the systems supporting/hinder CYP’s mental health. However, CYP were expected to only have a minimum understanding of this, as other community members with more relevant knowledge and experience were involved in contributing to insights (using youth friendly language to explain complex terms, concepts and systems. Simultaneously, ensuring Big Circle inputs were shared within sessions with Small Circles). Big Circle Overall, over 57 people participated in the Big Circles workshops across the pilot sites (47 participated in Northern Devon, and 10 in Newham (percentage breakdown of organisation type in Table 3). Additionally, some Big Circle members were engaged in other types of engagements including 1:1 conversations with Kailo partners, invitation and participation at Kailo-hosted online and in-person events and workshops, or by inviting Kailo partners to present at pre-existing forum, such as local authority, health boards, or associated governance structures. These participants included local or regional commissioners and policymakers, elected members, public or mental health specialists, practitioners, academics and others. Table 3: Organisations involved in the Kailo Big Circles Type of organisation % Across the two sites Health (includes primary care, mental health, specialist services, both charities and NHS services) 12 Delivery organisations working directly with CYP and families (including youth work organisations, family support charities, organisations supporting SEN and neurodiverse CYP, and organisations supporting CYP's mental health needs) 30 Community organisations (includes organisations working within sectors such as local heritage, environment, and community networks) 7 Funders and commissioners (including clinical commissioning groups of local health services) 2 Voluntary services (organisations supporting and providing advice to charities to represent, support and champion community action within their local area) 7 Local businesses (including cafes, activity centres, music and theatre companies) 3 Research organisations (universities, independent research organisations) 3 Education (primary, secondary, further and higher education providers) 16 Local government and council members (public health, community engagement, economic development) 16 Statutory services 3 Big Circle community members were involved in three online workshops in Northern Devon and one in-person event in Northern Devon, and one online workshop in Newham (Example workshop plan shown in Additional File 6). Key barriers to participation within sessions identified by the KST and KCP: Time and capacity to engage in a meaningful way (Community members were given opportunities to join the Big Circles session or have 1:1s conversations) Perceived lack of alignment with their current priorities (Part of KST work around managing relationships involved regular engagements to better understand wider community members current priorities) Initial lack of clarity around how their role would contribute to the Small Circle outputs and Implementation (Focused 1:1s with community members who could play a specific role in the development and implementation of Small Circles co-designs). Key enablers identified by the KST and KCP: Alignment with their current priorities Commitment to youth voice and participation Commitment to systems change Opportunities to engage in different ways (e.g., group conversation, 1:1s etc) Feeling heard and listened to Willingness and availability to adapt approaches and sessions Connected and joined ways of working. Circle of Research In Northern Devon, a survey was used to support prioritisation of design opportunities between Small Circle sessions 7-8. The Survey was shared on social media, in schools, and at local events, and responses were taken back into the Small Circles; 68 community members responded to the survey pertaining to the Northern Devon OA1 and 75 to the OA2. In Newham, a survey was conducted between sessions 7-8 (for both OA’s) to assess areas of impact and potential change related to the themes of co-design explored in Small Circle sessions. The Survey was also shared on social media and schools; 44 community members responded to the survey. There was great variation in attendance of the Big Circle and engagement in survey across the pilot two sites. It is possible that this variation was a result of how crowded (with other initiatives, research projects, interventions, etc) each context was before Kailo was adopted or variations in the approaches utilised by researchers and designers across the two sites, which led to variable engagement. A developmental evaluation has been conducted which will explore this further. Resulting maps from deeper research group model building Systems Maps were developed in the Group Model Building Small Circles sessions across the two pilot sites (and reviewed in the Big Circles). These maps translated CYP’s lived experience and view of the systems around them. All the maps were centred on the OAs the Small Circles were exploring and the social determinants related to them such as unemployment, violence and crime and community/neighbourhood supports. Simultaneously, the maps showed how the issues explored in the OAs were not isolated but related to other social determinants, as they had the same mediating factors or led to each other. For instance, some CYP were able to see the relationship between their experiences of poverty, unemployment and exclusion. In the maps, poverty was interrelated with and amplified by limited opportunities for employment, inequalities in educational opportunities and school exclusion, and family pressures, all of which are social determinants of mental wellbeing for CYP. See Additional File 7 (Newham) and Additional File 8 (Northern Devon) for maps and their accompanying narratives. Resulting Co-Design Strategies The ideas, interventions, and strategies explored and designed by Small Circles in the Deeper Discovery and Co-Design phase were diverse. This paper does not aim to describe these in detail, as they are expected to be iterated upon while host/delivery partners are identified and they are piloted/implemented. Nonetheless, brief overviews are provided in Additional File 9. Some Small Circle teams created well-developed strategies, including detailed blueprints, stakeholder involvement details, and associated implementation plans. Others developed early-stage ideas and user maps, but not fully formed strategies. These initial concepts are not yet sufficiently developed for the implementation stage of Kailo but may be further refined in the future. In both sites, the design orientation focused on several key similarities: Reducing unemployment by upskilling CYP through life skills, formal and alternative education, and learning, providing them with the knowledge and skills to pursue diverse career goals Emphasising the importance of signposting and increasing awareness of existing local community resources for CYP Addressing experiences of discrimination and their impacts on CYP's mental health and wellbeing, with a particular emphasis on promoting inclusion, encouraging participation, and extending reach Collaborating with professionals and service providers within the local areas to deliver services and supports that meet the needs and wants of local CYP, such as youth clubs, youth workers, and existing services Utilising peer support and its benefits for CYP's mental health and wellbeing. Differences between the sites were also evident in the design process. In the urban site (Newham), there was a specific emphasis on the impacts of violence or trauma within the local community, as well as CYP's experiences of discrimination due to their race and ethnicity. This differed from the rural Northern Devon context, where, although the impacts of discrimination were still considered important, there was a greater focus on the experiences of neurodiverse CYP and those from LGBTQIA+ groups. Additionally, while both sites acknowledged the importance of promoting and developing mental health literacy within the local community, the emphasis on where this fitted within the co-designs differed. In the rural site, mental health literacy was seen as a specific issue needing focus and was thus framed as an OA, leading to the development of co-designs around this. In contrast, in the urban site, mental health literacy promotion and development were not a specific focus or OA but were instead incorporated into co-designs developed to tackle other challenges and issues. The KST is currently working with co-design teams and KCPs to refine these co-designs, as well as engaging in conversations with community members and system leaders to discuss and assess the next steps and local piloting and implementation plans. Evidence integration Evidence briefs were produced for one of the Small Circles in each site (OA2 in Northern Devon, and OA5 in Newham). These briefs were used differently by each site, depending on the ongoing process in the Small Circles at the time of their completion (See Table 2 Small Circles Timeline). Additionally, Evidence Reviews were planned for the other two Small Circles in each site. However, due to difficulties in aligning research and co-design timelines and priorities, these plans were abandoned. Discussion This paper aims to describe and discuss the methods employed in Kailo’s Deeper Discovery phase, and learning in relation to the extent to which the process supported Kailo’s overarching aims and ambitions of designing local responses that address the social determinants of CYP’s mental health and wellbeing in each area. It is not the intention or focus of this paper to consider the efficacy or effectiveness of the resulting co-designs. The following discussion represents reflections and learning from the KST, some of which have been informed by iterative insight generation from an accompanying developmental evaluation [32]. This evaluation will report further on learning about the wider Kailo framework design and delivery. What worked well? Community Partner involvement throughout Involving community organisations, community researchers, and CYP in the recruitment, refinement, and delivery of the Kailo Deeper Discovery Circles was crucial in ensuring that diverse perspectives and needs were heard and addressed throughout the co-design process and within the co-designs developed [40]. The trust and relationships that CYP had with KCPs enabled them to openly discuss, question, and explore the Kailo activities, the parameters of their participation, the types of support required to make meaningful contributions (e.g., adult support within sessions, taxis, breaks from sessions), and to engage in decision-making within the sessions. Local organisations are experts in the local context and provide the knowledge of where and how to engage CYP who may otherwise have experienced inequalities in inclusion [41]. This contributed to adaptations which were tailored to meet the individual needs of those participating, so they were able to engage in a way that best suited them. Thus, involving local organisations in the recruitment and induction process for the CYP enabled the process to be conducted in less extractive ways, providing CYP with autonomy within the research process [42]. Furthermore, despite limitations, the engagement with the Big Circle ensured there was an audience to listen to the Small Circle members' views and a commitment to work towards ensuring they are acted upon during the implementation phase of Kailo [27]. Focusing on what matters The process and outputs of the Deeper Discovery phase suggest that the CYP participating in the Small Circles of co-design in Newham and Northern Devon had the necessary tools, support, skills, and lived experience to identify key factors, barriers, enablers, desirable outcomes, and impacts related to the OAs prioritised in the Early Discovery phase. The strong emphasis on CYP’s knowledge, experience, and understanding of the issues affecting their own lives, mental health, and wellbeing, as well as those of others in their local context, was critically important for informing the subsequent design of responses that are meaningful and contextually relevant [29]. Centring Youth and Community Voice through a Flexible and Adaptive Approach Central to the co-design process was creating conditions for centring youth voices by providing diverse groups of CYP and other community members with various ways to be meaningfully involved in exploring ideas and strategies to support CYP’s mental health and wellbeing in their communities [43]. This was achieved by adapting the co-design approach (pace, tools, and facilitation style) based on the types of potential co-designs identified, group dynamics (influenced by size and composition), and CYP's needs [44, 45]. For example, accommodating the needs of neurodiverse and neurotypical group members, or pausing circle sessions for CYP in Newham during Ramadan. The literature highlights the importance of flexibility when utilising co-design principles and approaches with CYP [46]. Methods need to be adapted to the unique skills and experiences of the group [44], enabling individuals to develop the confidence to share their experiences [47] and encouraging engagement in reflective practice [48]. Through this flexible approach and by addressing power imbalances between different groups of CYP and adults within the sessions, Small Circle members were able to have nuanced conversations and collaboratively develop various potential solutions to support diverse groups of CYP and their mental health. Inherent tensions Flexibility vs pace There can be inherent tensions between building and maintaining pace and momentum and ensuring flexibility and adaptation in a codesign process [49]. Pace and momentum were achieved by scheduling approximately 16 co-design sessions in advance, along with relevant planning and content adaptation. However, to accommodate the varying and emerging needs of CYP, as well as new lines of inquiry in the co-design process, the focus or delivery of planned sessions often needed to change. This resulted in a trade-off with momentum and pace. This underscores the importance of building in sufficient time, flexibility, and resources so the process can reach its potential without being unduly rushed or pressured by fixed timelines [24]. However, this emergent approach does not always align with the timescales or expectations of research projects, funders and wider community members [50]. Youth-led vs Youth-centred A key challenge KSTs had to manage across all co-design circles was the tension between being youth-centred, where CYP work collaboratively with researchers as equals [53], and being explicitly youth-led, where CYP instigate potential solutions to a problem, often one they have identified or defined themselves, and take responsibility for developing and implementing a solution [51]. However, in the context of designing responses to address the social determinants of mental health and discussing sensitive topics, this created challenges in maintaining sufficient focus on the social determinants of mental health, respecting CYP’s boundaries, and managing who was in the room. The co-design experience highlighted that being overly youth-led risks inappropriately or disproportionately burdening some CYP and excluding others who did not feel equipped to develop particular types of solutions or were managing complex challenges in their personal lives. This underscores the importance of planning for and providing appropriate support and training for CYP and co-design participants [24], as well as preparation time and support to build the knowledge and skills required to develop and implement particular types of solutions [52]. In some cases, the KST and CYP recognised that the responsibility and capabilities required to further develop and lead the implementation of particular co-designs needed to be with other individuals, organisations, and communities (particularly those involving the roles and responsibilities of adult users), thus preventing the overburdening of CYP [54, 55]. Across different Small Circle teams, these roles were variably held by KST, KCPs, or wider individuals, organisations, and communities around CYP, with clarity on role, responsibility, and accountability being key. Co-designed vs evidence-informed Rapid and systematic evidence-building methodologies and co-design processes often move at different paces. The co-design process may require more time for elements such as the collective framing of open and exploratory questions, prioritising ideas and approaches, and consensus building and alignment [30, 43]. Conversely, systematic reviews necessitate more time for other elements, such as exploring definitions, answering narrowly defined questions, and considering inclusion and exclusion criteria [56]. While there were opportunities to align these processes more closely in the Kailo Deeper Discovery phase, it was challenging to do so while ensuring Kailo timelines were led by the pace of the Small Circles. This meant insights from the literature were not always readily available. Additionally, the co-design process involves frequent and regular exploration and reflection on various topics and elements as they are discussed in the Small Circles, from the stages of building conditions and discovery to designing and testing ideas [43]. In contrast, systematic reviews require a more in-depth focus on a single question for several months, covering stages from protocol development, screening, and analysis to synthesis [56, 57]. Challenges and Limitations Keeping designs focused on the Social Determinants A key aim of Kailo is to support local community partnerships in identifying locally relevant social determinants of CYP’s mental health and wellbeing and co-designing local responses. The Early Discovery phase of Kailo [17] created these initial foci across sites (e.g., exposure to violence and crime, lack of diverse employment opportunities, neighbourhoods, and networks of support). The Deeper Discovery and Co-Design phase aimed to further explore these social determinants and collaboratively design local responses to address them. The youth-centred approach and central involvement of CYP in the Small Circles was crucial in creating a rich and meaningful understanding of ‘what matters’ to CYP, in relation to the social determinants and influences on their mental health and wellbeing in their specific contexts [17]. However, given their position, knowledge, and experience, CYP were not always equipped or best placed to identify how specific social determinants might be structurally addressed or intervened with beyond an individually focused or service-level response, as this is their direct experience. Experiences across co-design teams and sites suggested that there were limits to the extent CYP could move beyond more practical, individually focused services and interventions to explore less tangible and more community-focused (and complex) options necessary for addressing structural change. As a result, the emerging co-designs developed in the Small Circle sessions, while valuable, more often resulted in individualised and service-oriented strategies or interventions rather than preventative or structural responses to the social determinants of mental health. One contributory explanation for this is that the social determinants CYP needed to focus on across the different OAs were not always explicitly framed or consistently reinforced through a social determinants lens. For instance, while Northern Devon’s prioritised OA2 was clearly defined and explicitly framed as a social determinant, OA1 was variably and imprecisely defined. It often strayed towards more individualistic facets (such as individual knowledge and understanding) rather than structural or social determinant facets (such as community and social infrastructures that create social norms). This underscores the importance of clear and consistent messaging and framing through a social determinants lens and the need for supporting training and tools to reinforce this focus. In addition, community engagements and discussions beyond the Small Circles also lacked a clear and consistent definition or framework for the social determinants, which could be shared among KST, KCP and those engaged in the Big Circle. Finally, co-design is messy [52] and the work often lacked clearly communicated boundaries around these determinants, reinforced at each stage of the co-designs development. Who is (not) in the room? Compounding the challenge of maintaining a focus on the social determinants of mental health is the question of who is—and who is not—participating in co-design activities. This issue relates to the aforementioned tension between being youth-centred and youth-led. Public system leaders and local policymakers, who arguably have the greatest power and influence to shape policies and interventions addressing social determinants, were, for the most part, only involved in the ‘Big Circles’. As such, their role and input were more limited to reviewing, inputting, and refining emerging designs and responses rather than fundamentally shaping their design. The role of parents and carers, who bring unique and specific experiences and perspectives on the social determinants of their CYP’s mental health and wellbeing and largely act as ‘gatekeepers’ and enablers of CYP’s involvement [58], was also limited in the Small Circles. More opportunities could have been created to meaningfully engage system leaders and those in positions of power and influence to inform co-designs that address the social and structural determinants under consideration, alongside parents and carers. This might have provided more opportunities for CYP to better understand the wider spheres of influence around them and the levers that could generate structural changes. There were various reasons why this was challenging, including capacity and availability issues, as well as the time and effort required to ensure individuals involved were able to engage with CYP in equal and meaningful ways during the co-design process [59]. Finally, community members involved in some of the Small Circles were often managing the tension between supporting the CYP in the room and contributing to the codesigns with their own ideas. The KST could have provided greater clarity on the scope of their role and responsibilities and/or alternative ways of participating. Implications Learning and experience to date underscore the critical value and importance of CYP in determining ‘what matters’ in relation to improving mental health and wellbeing within their own local contexts and communities, as aligns with the extant literature [60]. The fundamental importance of taking the necessary time to build trust and relationships with respected and embedded community partners, working with and across communities and local public systems, has also been highlighted [61]. However, pilot testing of the co-design approach suggests some important limitations, prompting adaptations for future iterations of Kailo in current and future sites. First, there is a need for the development of key learning and training inputs around the social determinants of CYP’s mental health and wellbeing, consistently reinforced throughout the Early Discovery, Deeper Discovery, and Co-Design phases. Second, there should be a reinforcement of a youth-centred (rather than solely youth-led) approach to co-design. This approach clearly identifies and centres the role of CYP in determining ‘what matters’ locally and later appraising the relevance and fit of what is co-designed for CYP. This should be balanced with wider active stakeholder participation in designing systemic responses, interventions, and strategies. This can be achieved through a combination of separate policy, system leadership, parent and professional co-design spaces, as well as carefully designed and facilitated combined sessions with CYP. Finally, to advance an evidence-informed approach to co-design, rather than having detached academic partners input rapid evidence reviews into the co-design process (which was not sufficiently timely or responsive), we will test the integration of local embedded researchers as an integral part of the Small Circle co-design teams. Ideally, these researchers will be recruited through local college or university settings. Conclusion This paper discusses the approach utilised in the Kailo Deeper Discovery process, which focused on the co-design of solutions to address the social determinants of CYP’s mental health and wellbeing through youth and community participation. The co-design approach adopted by the KSTs enabled community members (CYP and others) to explore various ideas and potential strategies. By adapting and flexing the co-design approach to community members' needs across the various Deeper Discovery Circles, the KST team facilitated meaningful conversations and supported community members in developing solutions, which will now move into the implementation phase of the Kailo programme. However, there were important limitations associated with navigating individual challenges and needs while simultaneously developing solutions to address mental health issues through a prevention and social determinants lens. This suggests careful consideration is required around where different groups of CYP with lived experience, as well as other groups of community members, are best placed to engage in the development of solutions to issues they are currently experiencing, as well as when and how (and what supports are required). This is particularly important in community participation efforts exploring complex issues such as mental health and wellbeing challenges and their associated social determinants. These insights are directly informing subsequent adaptations of the Kailo framework and design, contributing to the wider literature on how and where co-design works to lead or support the development of solutions to issues faced by CYP and other community members. Abbreviations CYP - Children and Young People KCP - Kailo Community Partners KCRD - Kailo Community Researchers and Designers KST- Kailo Sites Team OA - Opportunity Areas Declarations Ethical approval and consent to participate The methods undertaken in the Deeper Discovery phase of the Kailo Programme were approved by the UCL Research Ethics Committee (REC) ethics committee, Project ID: 18773/002. All community members and young people involved in the Small Circles of Co-design provided written informed consent, prior to Kailo Deeper Discovery workshops taking place, and the methods were performed in accordance with relevant guidelines and regulations. Written informed consent was also obtained from parents or legal guardians of participants under the age 18 years, also prior to their participation in the programme's workshops. Consent for publication Not applicable. The manuscript does not contain data from any individual person which would include individual details, images or videos. Availability of data and materials The data shall be made available upon request. Competing interests The authors declare that they have no competing interests. Funding This work is supported by the UK Prevention Research Partnership (UKPRP), which is funded by the British Heart Foundation, Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Health and Social Care Research and Development Division (Welsh Government), Medical Research Council, National Institute for Health Research, Natural Environment Research Council, Public Health Agency (Northern Ireland), The Health Foundation and Wellcome. Author Contributions Statement PF, TH, ESL. Leadership and oversight ESL, KP, NR, TH, PF. Conception and design ESL, CP. Wrote the main manuscript text ESL, KP, NR, SB Data collection ESL, KP, CP, NR, SB. Analysis and interpretation of data. TH, PF. Funding acquisition All authors - Substantively revised and reviewed it. Acknowledgements The authors acknowledge all of the young people and other community professionals in Northern Devon and Newham who were involved in the Kailo research and design programme, from May 2022 to August 2024, which made this paper possible. We also acknowledge those who will be involved in the future versions of this Kailo programme. This research was conducted as part of the Kailo programme, and we gratefully acknowledge the valuable input and discussions from the wider team that have informed this paper. This work is supported by the UK Prevention Research Partnership (UKPRP), which is funded by the British Heart Foundation, Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Health and Social Care Research and Development Division (Welsh Government), Medical Research Council, National Institute for Health Research, Natural Environment Research Council, Public Health Agency (Northern Ireland), The Health Foundation and Wellcome. Authors information Dartington Service Design Lab - Ediane Santana de Lima, Katie Potter, Cristina Preece and Tim Hobbs UCLPartners - Nirandeep Rehill, Sophie Bulmer Research Department of Clinical, Educational and Health Psychology, University College London (UCL) - Peter Fonagy University of Exeter Medical School - Kate Allen and Anna March References Foulkes L, Andrews JL. 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American Journal of Community Psychology [Internet]. 2010 Jun 4 [cited 2024 Aug 5];46(1-2):195–203. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1007/s10464-010-9324-y Bailey S, Boddy K, Briscoe S, Morris C. Involving Disabled Children and Young People as Partners in research: a Systematic Review. Child: Care, Health and Development [Internet]. 2014 Oct 16 [cited 2024 Aug 5];41(4):505–14. Available from: https://onlinelibrary.wiley.com/doi/10.1111/cch.12197 Tricco AC, Antony J, Zarin W, Strifler L, Ghassemi M, Ivory J, et al. A scoping review of rapid review methods. BMC Medicine [Internet]. 2015 Sep 16 [cited 2024 Jun 26];13(1). Available from: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-015-0465-6 Calderon Martinez E, Hernández Valdés J, Cuenca J, Murube J, Blanco RM, Jiménez J, et al. 10 steps to conduct a systematic review. Cureus [Internet]. 2023 Dec 31 [cited 2024 Jun 26];15(12). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10828625/ Youngminds. Involving Parents and Carers in Children and Young people’s Mental Health [Internet]. 2020 [cited 2024 Aug 5]. Available from: https://www.youngminds.org.uk/media/h4uexcw1/ym-parent-carer-toolkit-2020.pdf Wheeler G, Mills N, Ankeny U, Howsley P, Bartlett C, Elphick H, et al. Meaningful Involvement of Children and Young People in Health Technology Development. Journal of Medical Engineering & Technology [Internet]. 2022 Jul 19 [cited 2024 Aug 5];46(6):462–71. Available from: https://www.tandfonline.com/doi/full/10.1080/03091902.2022.2089252#abstract Kirk S, Fraser C, Evans N, Lane R, Crooks J, Naughton G, et al. Perceptions of the Key Components of effective, Acceptable and Accessible Services for Children and Young People Experiencing Common Mental Health problems: a Qualitative Study. BMC Health Services Research [Internet]. 2023 Apr 24 [cited 2024 Aug 5];23(1). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10123588/ Fitzpatrick SJ, Lamb H, Stewart E, Gulliver A, Morse AR, Giugni M, et al. Co‐ideation and Co‐design in Co‐creation research: Reflections from the “Co‐Creating Safe Spaces” Project. Health Expectations [Internet]. 2023 May 31 [cited 2024 Aug 5];26(4). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10349236/ Tables Tables 1 and 2 are not available with this version. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1.docx Additional File 1. docx AdditionalFile2.docx Additional File 2. docx AdditionalFile3.docx Additional File 3. docx AdditionalFile4.docx Additional File 4. docx AdditionalFile5revised.docx Additional File 5. docx AdditionalFile6.docx Additional File 6. docx AdditionalFile7.pptx Additional File 7. pptx AdditionalFile8.pptx Additional File 8. pptx AdditionalFile9.docx Additional File 9. docx 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Demand for specialist services has also increased over the past decade [3]. Mental health specialists offer various explanations for this trend, including changes in diagnostic criteria for mental disorders ('diagnostic inflation') [4]; an increase in experienced symptoms of poor mental health [2]; heightened awareness, recognition, and potential over-interpretation [1]; and the increased complexity of CYP’s lives, including new challenges associated with social media [5]. A crucial aspect to consider is the role of prevention in these discussions, aiming to address not only the manifestations of need and the outcomes of these challenges [6] but also the underlying systemic and structural drivers that perpetuate these issues [7]. Marmot et al [8, 9, 10] have also underscored the need for a focus on structural and contextual factors that influence health inequalities, and impact on population mental health.\u003c/p\u003e\n\u003cp\u003eThe social determinants literature provides a useful framework to explore how social, environmental, and behavioural risk factors [11, 12] and the conditions and contexts in which people are born and live influence their mental health and wellbeing outcomes [13]. To comprehensively support CYP, it is necessary to not only offer targeted and specialised services for those with diagnosed mental disorders but also to invest in prevention measures addressing these underlying social determinants, and provide early intervention to prevent needs from escalating [6, 14].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, the design and implementation of prevention and early intervention efforts must consider how these social determinants are experienced in varying local contexts and the implications for developing contextually relevant strategies to support CYP’s wellbeing and mental health needs, which may differ from national policy and strategies [15, 16]. For example, CYP in urban and rural areas may encounter similar social determinants such as poverty, racism, or limited employment opportunities, but the manifestations can vary significantly. While job insecurity and underemployment, both social determinants of health [11, 13], might affect both rural and urban areas, rural areas may suffer from a lack of local industries and transportation [17, 18], which might not be the primary issue in urban contexts. Overlooking contextual factors, such as demographics, leadership, history of the local area and socioeconomic conditions can lead to an underdeveloped understanding of needs and local influences [16], thereby undermining the design and implementation of suitably contextualised and nuanced strategies [19]. Such strategies often focus only on the surface-level manifestations of needs and individual understanding of mental health rather than addressing the underlying root drivers and wider system influence [16, 20].\u003c/p\u003e\n\u003cp\u003eThe meaningful participation of local CYP and other community members in the exploration, co-design, and implementation of strategies aimed at improving mental health and wellbeing, enhances the likelihood of these strategies reflecting local views and needs [21]. It also elucidates the complex and nuanced ways in which the social determinants of mental health are experienced by CYP in different contexts, thereby informing effective interventions [22]. Additionally, co-design and other participatory design methods can provide individual benefits to CYP involved in these activities, supporting their own wellbeing [23], and benefiting wider groups of CYP through the application of their lived experiences to strategy development [24]. However, recent literature indicates a gap in the evidence supporting the effectiveness of co-design methodologies in significantly improving CYP's mental health, calling for further research to enhance the evidence base [25, 26].\u003c/p\u003e\n\u003cp\u003eThis paper will: (1) describe the methods used to support the co-design of contextually relevant and prevention-oriented strategies for CYP mental health and wellbeing in two distinct areas; and (2) report the learning and recommendations derived from this youth-centred co-design approach to addressing the social determinants of mental health at the local level.\u003c/p\u003e\n\u003ch3\u003eAbout Kailo\u003c/h3\u003e\n\u003cp\u003eCo-design took place in two intentionally distinct communities in the UK as part of Kailo, a place-based research and design initiative aimed at addressing the social determinants of CYP's mental health in local contexts. The meaningful engagement of CYP and other community members in addressing inequalities and the social determinants of CYP’s mental health, are key features of Kailo's co-design process. The Kailo team was guided by the Kailo Pillars (Figure 1) and the Lundy model of child participation [27], focusing on four key areas: space, voice, audience, and influence. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Kailo framework is currently being tested and delivered in two initial sites: Northern Devon (a rural/coastal region in the South-West of England) and the London Borough of Newham (a densely populated and diverse inner-city area).\u003c/p\u003e\n\u003cp\u003eAs illustrated in Figure 2, Kailo has three phases [7]:\u0026nbsp;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eEarly Discovery\u003c/strong\u003e: This phase focuses on building trusted relationships with local partners, understanding what matters to local community members, and forming communities around shared priorities.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDeeper Discovery and Co-Design\u003c/strong\u003e: This phase is centred on co-designing strategies and interventions to address prioritised issues.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eImplementation\u003c/strong\u003e: This phase focuses on embedding and sustaining the strategies developed in the co-design phase.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe framework is currently being further developed and refined to embed and scale the approach in local areas.\u003c/p\u003e\n\u003ch4\u003eEarly Discovery Phase\u003c/h4\u003e\n\u003cp\u003eThe Early Discovery phase of Kailo in the initial two sites was conducted between May 2022 and May 2023. This phase involved qualitative engagements with over 500 individuals, including CYP and community professionals, across Northern Devon and Newham. The focus was on understanding what mattered to these groups in improving CYP’s mental health through a social determinants lens. Researchers and local partners collaborated with CYP and community professionals to narrow down and prioritise a set of contextually relevant areas of focus for the Deeper Discovery and Co-design phase of the program. These areas of focus, referred to as ‘Opportunity Areas’ (OA), were used to form committed local partnerships for engaging in co-design activities in the Deeper Discovery and Co-Design phase [17].\u003c/p\u003e\n\u003cp\u003eIn Northern Devon, the prioritised OAs identified were: (i) building stronger informal community support networks to promote mental health awareness and literacy (\u003cstrong\u003eOA1\u003c/strong\u003e); (ii) creating and enhancing access to more diverse opportunities for studies, employment, and recreation (\u003cstrong\u003eOA2\u003c/strong\u003e); and (iii) fostering a sense of identity and belonging (\u003cstrong\u003eOA3\u003c/strong\u003e) as a cross-cutting theme. In Newham, the prioritised OAs were: (i) reducing the impact of violence and crime and enhancing safety (\u003cstrong\u003eOA4\u003c/strong\u003e); and (ii) strengthening the role of local community infrastructure and activities for wellbeing (\u003cstrong\u003eOA5\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eThe primary aim of this paper is to describe and reflect on the methods used in the subsequent Deeper Discovery and Co-Design phase of Kailo. This provides context for a concurrent developmental and complex systems change evaluation [32]. The discussion in this paper reflects the experiences and learning of the design and implementation teams, informed in part by emerging insights from these accompanying evaluation activities. The third and final phase of Kailo, Implementation, will be discussed in future outputs.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis section describes the Deeper Discovery and Co-Design phase of Kailo and its associated methods and implementation in the two pilot sites: Northern Devon and Newham.\u003c/p\u003e\n\u003cp\u003eDeeper Discovery and Co-Design phase overview\u003c/p\u003e\n\u003cp\u003eUsing co-design and group model-building approaches, the Deeper Discovery and Co-Design phase of Kailo aims to:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eBuild on Early Discovery work and undertake deeper research around OAs identified and prioritised in the Early Discovery phase \u003cstrong\u003eto identify root causes and systemic drivers\u003c/strong\u003eof CYP’s mental health and wellbeing in the local context.\u003cul\u003e\n \u003cli\u003eDevelop a more nuanced understanding of the prioritised OAs as defined and experienced by CYP and the broader local communities.\u003c/li\u003e\n \u003cli\u003eGain a comprehensive understanding of the systemic behaviours driving the identified OAs and pinpoint leverage or intervention points for impactful change.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eGenerate ideas and co-design responses\u0026nbsp;\u003c/strong\u003earound these OAs to support CYP’s mental health and wellbeing within the Kailo pilot sites.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEngage and collaborate\u003c/strong\u003e with key stakeholders and actors related to the identified OAs, including CYP, youth and community organisations, local commissioners, and other critical actors.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFoster local partnerships' capacity\u003c/strong\u003e to engage in the Deeper Discovery and Co-Design phase by gradually transitioning ownership from the Kailo team to these partnerships, ensuring the process is community-led and owned.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAddress gaps in engagement and knowledge\u003c/strong\u003e identified during the Early Discovery phase.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis is achieved by forming and bringing together Kailo Site Teams (KST), Kailo Community Partners (KCP), Kailo Community Researchers and Designers (KCRD), Wider Kailo Consortium (WKC) and other community members to develop local strategies and interventions (See Additional File 1). These groups played crucial roles in the effective implementation and sustainability of the co-design efforts, ensuring that the process remained community-led and focused on the specific needs and contexts of the participating areas. These efforts contribute to addressing locally relevant social determinants of CYP’s mental health and wellbeing as part of a wider, portfolio-based approach [28].\u003c/p\u003e\n\u003ch4\u003eCore elements of Deeper Discovery and Co-Design phase\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003eThe Deeper Discovery and Co-Design process is grounded in the use and integration of two broad methodologies: co-design and group model building, supported by considerations of the extant literature and evidence integration.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCo-design:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCo-design, as defined by Blomkamp [29], signifies the active involvement of a diverse range of participants in exploring, developing, and testing responses to shared challenges. This approach enables strategy and intervention design efforts to centre the voices of CYP in shaping and defining supports, interventions, and strategies that are specific and appropriate to their mental health needs [21, 30]. The intent is to produce strategies that are more likely to address pertinent and relevant needs while enhancing engagement and traction with the intended audiences, which is a critical prerequisite for impact. Additionally, participating in co-design can offer wellbeing benefits for CYP, including feelings of pride, achievement, and enjoyment, as well as the opportunity to learn and use skills such as teamwork and collaborative working [24].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eGroup model building:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGroup model building is a participatory approach developed within the field of system dynamics to facilitate group decision-making and problem structuring [31]. It allows for the consideration and better understanding of complex problems through mapping and modelling process that capture underrepresented perspectives and emphasise consensus building, which is critical for sustainable community-led change [33]. Group model building was integrated into the co-design process. Further details and protocols for this element of the Kailo design process are described by Keenan et al [34].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEvidence integration:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIncorporating and using knowledge from the extant research literature around areas of focus was interspersed throughout the Deeper Discovery and Co-Design process. This pragmatic, rapid, and non-systematic approach aimed to: (a) offer insight into the current state of academic evidence [35] around the topics explored in the Deeper Discovery Circles; (b) surface insights not otherwise considered; and (c) provide a generalised consideration of what prior research indicates is impactful, ineffective, or harmful, which may be considered in relation to the local context, knowledge, and lived experience of co-design teams [35]. As discussed later, integrating such forms of knowledge into a rapid, adaptive, and emergent design process presented challenges. Two Small Circles benefited from an Evidence Brief, conducted by one of the Kailo Consortiums partner universities.\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eCo-Design team formation and wider supporters\u003c/h4\u003e\n\u003cp\u003eAs illustrated in Figure 3, the Deeper Discovery and Co-Design phase comprises three main groups:\u0026nbsp;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eThe ‘Small Circle’: This group leads the co-design work, with varying levels of participation and commitment to accommodate their preferences, specific needs, and availability [30].\u003c/li\u003e\n \u003cli\u003eThe ‘Circle of Research’: This group undertakes supplementary community research as required by the Small Circle.\u003c/li\u003e\n \u003cli\u003eThe ‘Big Circle’: This group comprises local policy, commissioning, and practice leaders and professionals who provide regular review, input, connection to related work, and championing efforts.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eAll Deeper Discovery and Co-Design Circles’ members have a role - directly or indirectly - in supporting CYP’s mental health and wellbeing within local community areas.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe formation and activities of these circles were supported and facilitated by Kailo Site Teams (KSTs) and Kailo Community Partners (KCPs), who also enabled accompanying community research.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eParticipants in the Deeper Discovery and Co-Design phase\u003c/strong\u003e\u003c/h3\u003e\n\u003ch3\u003eSampling and recruitment\u003c/h3\u003e\n\u003cp\u003e\u003cem\u003eSmall Circle of co-design\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eKailo places a particular focus on engaging CYP who are most impacted and often less heard regarding the OAs identified in each site. The KST recruitment strategy and sampling was informed by insights around engagement gaps from the Early Discovery phase and the experiences of KCP.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough KST members were committed to engaging a diverse range of CYP, certain groups were not sufficiently engaged during the Early Discovery phase [17]. These groups varied across the sites and included neurodivergent CYP, those identifying as LGBTQIA+, and those living in rurally isolated areas in Northern Devon, and CYP from racially and ethnically minoritised groups in Newham. In response to these gaps, the recruitment criteria during the codesign phase focused on individuals belonging to these underrepresented groups and others with relevant lived experiences of the OAs prioritised in the Early Discovery phase. To aid this recruitment, the KST created a guide based on insights from the Early Discovery phase and KCP’s experiences, which included questions and prompts to support conversations with CYP. This was used to assess their comfort in the co-design sessions and identify any reasonable adaptations needed to improve session accessibility (See Additional File 2, 3, 4). To access a broader network of diverse groups\u003cins cite=\"mailto:March,%20Anna\" datetime=\"2024-07-30T09:39\"\u003e,\u003c/ins\u003e CYP were recruited through KCP, who approached individuals they had had existing relationships with and/or those they felt would be able to engage in the project in a group setting.\u003c/p\u003e\n\u003cp\u003eAdults participating in the Small Circles were recruited by KCP and KST, all subject to safeguarding checks and protocols. Both CYP and adults regularly involved in the Small Circles were compensated for their participation in line with the National Living Wage rate [36].\u003c/p\u003e\n\u003cp\u003eThese groups of CYP and community members were supported and facilitated by the KST. In Northern Devon, this included one Site Lead (Designer), one Researcher, two Community Researchers, and three to five individuals from KCP organisations in each circle. In Newham, this included one Site Lead (Public Health Specialist), two Researchers, and one to two individuals from KCP organisations. These trusted local community members played roles in supporting CYP’s mental health and wellbeing (either directly or indirectly), in each site. Some community members and professionals also played safeguarding roles and provided additional support for particular CYP attending the sessions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCircle of Research\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn addition to the core ‘Small’ and ‘Big’ circle members, at specific points in the co-design process, the Small Circle, KST, and KCPs consulted wider members of the local community. This included CYP, community members, or other local organisations or partnerships to undertake ad-hoc outreach, engagements, or community research to inform aspects of co-design. Methods such as rapid literature searches, surveys of CYP and other community members, and focus groups were employed to inform prioritisation or design decisions in the Small Circle co-design sessions.\u003c/p\u003e\n\u003cp\u003eThe intention was that these efforts by the Circle of Research ensured that the co-design process was informed by a broader spectrum of community input, enhancing the relevance and impact of the design decisions made by the Small Circle.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBig Circle\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBig Circle recruitment aimed to represent local systems leadership [37], and \"local people who represent and speak for their community\" [38], which included local community leaders, youth and community organisational representatives, public systems leaders, funders and commissioners, education providers, and academics.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMembers of the Big Circle were identified and engaged through the Early Discovery phase [17], via snowballing recommendations from existing Big Circle members and KCPs, or through invitations to specific Kailo forums or via presentations or inputs to pre-existing public sector forums, such as local authority or health system boards. Participants were typically individuals or representatives from organisations with power, specialism, or influence regarding the specific OA themes or broader CYP mental health.\u003c/p\u003e\n\u003ch3\u003eCo-Design Process and Analysis\u003c/h3\u003e\n\u003ch4\u003eSettings and delivery\u003c/h4\u003e\n\u003cp\u003eOverall, 34 Small Circle co-design workshop sessions were held between July 2023 and June 2024 across the two Kailo pilot sites; Northern Devon held 17 sessions for both their small circles, and 1 joint session where the two circles came together, and Newham held 15 and 17 sessions across its two small circles. In Northern Devon, sessions were facilitated in person at a local charity building that offers therapeutic support for CYP and their families, as well as at a local youth centre. In Newham, sessions were facilitated across two youth centres and a community centre. Sessions occurred weekly or fortnightly, depending on participant availability. These activities were facilitated by KST members and Community Researchers, with support from KCPs.\u003c/p\u003e\n\u003cp\u003eBig Circle group sessions were conducted online, supplemented by additional one-on-one conversations with Big Circle and members who were either unable to attend sessions or wished to support or engage further. These activities were facilitated by KST members, supported by KCRs. Lastly, the Circle of Research engagements were facilitated online through surveys or in-person through focus groups when appropriate across the sites.\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eCo-design delivery and analysis\u003c/h4\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional File 5\u0026nbsp;\u003c/strong\u003eillustrates the various Small Circle co-design sessions facilitated by the KST. Although there was some variation in the sessions, most included the elements described below. These sessions were designed to build on one another rather than being standalone events, whilst also ensuring flexibility to the needs of each group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe KST led engagements such as Kailo Deeper Discovery Circles sessions, one-on-ones with specific community organisations, and surveys, involving data collection and analysis across the circles. Simple and interactive tools such as posters, cards, voice notes/recordings, LEGO ©, arts, crafts, and sticky notes were used to facilitate discussions and collect information within Small Circle sessions, encouraging CYP and community members to be reflective and creative. The information collected during these sessions was transferred into a digital whiteboard by the KST, acting as a collaborative workspace for data collection, remote collaboration, and communication.\u003c/p\u003e\n\u003cp\u003eAfter each co-design session, various methods were used to analyse and summarise outputs, supporting Small Circle members in building on their discussions and learning. These approaches included clustering and thematic analysis [39]. Additionally, in many sessions, subsequent refinement was carried out by the KST as the sessions focused on producing specific outputs such as systems maps, personas, and empathy or journey maps.\u003c/p\u003e\n\u003cp\u003eThroughout the process, findings were presented back to the Big Circle, either through regularly scheduled online sessions or via ad-hoc sessions as required. This enabled sense-checking, feedback, and review. Big Circle members had the opportunity to contribute their reflections via virtual whiteboards and/or discussions, which were incorporated into the Small Circle insights and outputs. These insights and outputs were then presented back to the Small Circle members in subsequent sessions, allowing for multiple cycles of sensemaking and feedback. Prioritisation exercises were also facilitated within the Small Circle sessions (either during the sessions or following the thematic analysis) to identify areas of focus at different stages of the process. These activities were informed by wider community research, rapid engagements with research literature, surveys, and focus groups, allowing for external input and diverse knowledge and expertise to be incorporated into the prioritisation exercises.\u003c/p\u003e\n\u003cp\u003eFurthermore, throughout the Deeper Discovery and Co-Design phase, the delivery and support teams engaged in regular cycles of review and reflection to analyse outputs and discuss adaptations to the approaches based on CYP’s views and the observations of the delivery and support teams. KCPs were involved in co-facilitating Small Circle sessions with KSTs, as well as reviewing insights and findings from Small and Big Circle sessions.\u003c/p\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003eEthical approval for the study and associated co-design activities was obtained from the University College London (UCL) Research Ethics Committee (REC). Project ID/Title 18773/002.\u003c/p\u003e"},{"header":"Results","content":"\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSmall Circle\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe recruitment process resulted in the involvement of 44 CYP aged 12-25 living in the Kailo pilot site communities, with an average of 22 CYP being recruited in each site. These CYP came from diverse groups including those from low-income households (Northern Devon and Newham), those from white and mixed backgrounds (Northern Devon and Newham), and those from Muslim and Christian faiths (Newham). On average, three community members attended each Small Circle across the pilot sites, including local youth workers, parents, counsellors, and practitioners. Additionally, in Northern Devon, eight practitioners joined later stages of one of the Small Circles to contribute to further refinement of the co-design process.\u003c/p\u003e\n\u003cp\u003eIn Northern Devon and Newham an average of eight CYP were regularly engaged in each Small Circle co-design session. In other words, an average of 32 young participated in all Small Circle sessions across both pilot sites. However, in Newham attendance fluctuated and new members had to be recruited at various stages of the process.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKey barriers to initial and regular participation in sessions identified by the KST and KCP (parentheses include the strategies used by the KST team to mitigate or address these challenges):\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAccess to reliable and affordable transport (CYP had access to taxis and full contribution towards transport)\u003c/li\u003e\n \u003cli\u003eEvening sessions in communities where violence and crime and personal safety was a concern (Session times were changed to fit CYP’s needs and safeguarding, taxis were also offered to enable CYP to safely access session’s location)\u003c/li\u003e\n \u003cli\u003eOther commitments (e.g., school, college and work)\u003c/li\u003e\n \u003cli\u003ePerceptions of the place where the sessions were happening (Sessions were held in youth and community centres i.e., places that CYP knew and felt comfortable in).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eKey barriers to participation within sessions identified by the KST and KCP:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eMeeting the needs of neurodiverse groups of CYP (Session plans were adapted to neurodiverse and neurotypical needs)\u003c/li\u003e\n \u003cli\u003eCurrent experience of mental health symptoms (CYP were supported through KCP, and other local professionals)\u003c/li\u003e\n \u003cli\u003eUnderlying motivations (e.g., engaging to spend time with their friends, engaging because they needed the money offered for participation) (CYP were invited to reassess their motivation to participate and develop group agreements and aims within sessions. Reflection spaces were also facilitated with the purpose of regularly reviewing these)\u003c/li\u003e\n \u003cli\u003eCompeting individual priorities and needs between different groups of CYP in the sessions (e.g., neurodiverse and neurotypical in Northern Devon, white and ethnic diverse groups in Newham)\u003c/li\u003e\n \u003cli\u003eLack of experience or knowledge of how the systems supporting/hinder CYP’s mental health. However, CYP were expected to only have a minimum understanding of this, as other community members with more relevant knowledge and experience were involved in contributing to insights (using youth friendly language to explain complex terms, concepts and systems. Simultaneously, ensuring Big Circle inputs were shared within sessions with Small Circles).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBig Circle\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, over 57 people participated in the Big Circles workshops across the pilot sites (47 participated in Northern Devon, and 10 in Newham (percentage breakdown of organisation type in Table 3). Additionally, some Big Circle members were engaged in other types of engagements including 1:1 conversations with Kailo partners, invitation and participation at Kailo-hosted online and in-person events and workshops, or by inviting Kailo partners to present at pre-existing forum, such as local authority, health boards, or associated governance structures. These participants included local or regional commissioners and policymakers, elected members, public or mental health specialists, practitioners, academics and others.\u003c/p\u003e\n\u003cp\u003eTable 3: Organisations involved in the Kailo Big Circles\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.63636363636364%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of organisation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e% Across the two sites\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.63636363636364%\" valign=\"top\"\u003e\n \u003cp\u003eHealth (includes primary care, mental health, specialist services, both charities and NHS services)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.63636363636364%\" valign=\"top\"\u003e\n \u003cp\u003eDelivery organisations working directly with CYP and families (including youth work organisations, family support charities, organisations supporting SEN and neurodiverse CYP, and organisations supporting CYP's mental health needs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.63636363636364%\" valign=\"top\"\u003e\n \u003cp\u003eCommunity organisations (includes organisations working within sectors such as local heritage, environment, and community networks)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.63636363636364%\" valign=\"top\"\u003e\n \u003cp\u003eFunders and commissioners (including clinical commissioning groups of local health services)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.63636363636364%\" valign=\"top\"\u003e\n \u003cp\u003eVoluntary services (organisations supporting and providing advice to charities to represent, support and champion community action within their local area)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.63636363636364%\" valign=\"top\"\u003e\n \u003cp\u003eLocal businesses (including cafes, activity centres, music and theatre companies)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.63636363636364%\" valign=\"top\"\u003e\n \u003cp\u003eResearch organisations (universities, independent research organisations)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.63636363636364%\" valign=\"top\"\u003e\n \u003cp\u003eEducation (primary, secondary, further and higher education providers)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.63636363636364%\" valign=\"top\"\u003e\n \u003cp\u003eLocal government and council members (public health, community engagement, economic development)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.63636363636364%\" valign=\"top\"\u003e\n \u003cp\u003eStatutory services\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.363636363636363%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBig Circle community members were involved in three online workshops in Northern Devon and one in-person event in Northern Devon, and one online workshop in Newham (Example workshop plan shown in Additional File 6).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKey barriers to participation within sessions identified by the KST and KCP:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eTime and capacity to engage in a meaningful way (Community members were given opportunities to join the Big Circles session or have 1:1s conversations)\u003c/li\u003e\n \u003cli\u003ePerceived lack of alignment with their current priorities (Part of KST work around managing relationships involved regular engagements to better understand wider community members current priorities)\u003c/li\u003e\n \u003cli\u003eInitial lack of clarity around how their role would contribute to the Small Circle outputs and Implementation (Focused 1:1s with community members who could play a specific role in the development and implementation of Small Circles co-designs).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eKey enablers identified by the KST and KCP:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAlignment with their current priorities\u003c/li\u003e\n \u003cli\u003eCommitment to youth voice and participation\u003c/li\u003e\n \u003cli\u003eCommitment to systems change\u003c/li\u003e\n \u003cli\u003eOpportunities to engage in different ways (e.g., group conversation, 1:1s etc)\u003c/li\u003e\n \u003cli\u003eFeeling heard and listened to\u003c/li\u003e\n \u003cli\u003eWillingness and availability to adapt approaches and sessions\u003c/li\u003e\n \u003cli\u003eConnected and joined ways of working.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCircle of Research\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn Northern Devon, a survey was used to support prioritisation of design opportunities between Small Circle sessions 7-8. The Survey was shared on social media, in schools, and at local events, and responses were taken back into the Small Circles; 68 community members responded to the survey pertaining to the Northern Devon OA1 and 75 to the OA2. In Newham, a survey was conducted between sessions 7-8 (for both OA’s) to assess areas of impact and potential change related to the themes of co-design explored in Small Circle sessions. The Survey was also shared on social media and schools; 44 community members responded to the survey.\u003c/p\u003e\n\u003cp\u003eThere was great variation in attendance of the Big Circle and engagement in survey across the pilot two sites. It is possible that this variation was a result of how crowded (with other initiatives, research projects, interventions, etc) each context was before Kailo was adopted or variations in the approaches utilised by researchers and designers across the two sites, which led to variable engagement. A developmental evaluation has been conducted which will explore this further.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eResulting maps from deeper research group model building\u003c/h3\u003e\n\u003cp\u003eSystems Maps were developed in the Group Model Building Small Circles sessions across the two pilot sites (and reviewed in the Big Circles). These maps translated CYP’s lived experience and view of the systems around them. All the maps were centred on the OAs the Small Circles were exploring and the social determinants related to them such as unemployment, violence and crime and community/neighbourhood supports. Simultaneously, the maps showed how the issues explored in the OAs were not isolated but related to other social determinants, as they had the same mediating factors or led to each other. For instance, some CYP were able to see the relationship between their experiences of poverty, unemployment and exclusion. In the maps, poverty was interrelated with and amplified by limited opportunities for employment, inequalities in educational opportunities and school exclusion, and family pressures, all of which are social determinants of mental wellbeing for CYP. See \u003cstrong\u003eAdditional File 7\u003c/strong\u003e (Newham) and \u003cstrong\u003eAdditional File 8\u003c/strong\u003e (Northern Devon) for maps and their accompanying narratives.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eResulting Co-Design Strategies\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThe ideas, interventions, and strategies explored and designed by Small Circles in the Deeper Discovery and Co-Design phase were diverse. This paper does not aim to describe these in detail, as they are expected to be iterated upon while host/delivery partners are identified and they are piloted/implemented. Nonetheless, brief overviews are provided in Additional File 9.\u003c/p\u003e\n\u003cp\u003eSome Small Circle teams created well-developed strategies, including detailed blueprints, stakeholder involvement details, and associated implementation plans. Others developed early-stage ideas and user maps, but not fully formed strategies. These initial concepts are not yet sufficiently developed for the implementation stage of Kailo but may be further refined in the future.\u003c/p\u003e\n\u003cp\u003eIn both sites, the design orientation focused on several key similarities:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eReducing unemployment by upskilling CYP through life skills, formal and alternative education, and learning, providing them with the knowledge and skills to pursue diverse career goals\u003c/li\u003e\n \u003cli\u003eEmphasising the importance of signposting and increasing awareness of existing local community resources for CYP\u003c/li\u003e\n \u003cli\u003eAddressing experiences of discrimination and their impacts on CYP's mental health and wellbeing, with a particular emphasis on promoting inclusion, encouraging participation, and extending reach\u003c/li\u003e\n \u003cli\u003eCollaborating with professionals and service providers within the local areas to deliver services and supports that meet the needs and wants of local CYP, such as youth clubs, youth workers, and existing services\u003c/li\u003e\n \u003cli\u003eUtilising peer support and its benefits for CYP's mental health and wellbeing.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eDifferences between the sites were also evident in the design process. In the urban site (Newham), there was a specific emphasis on the impacts of violence or trauma within the local community, as well as CYP's experiences of discrimination due to their race and ethnicity. This differed from the rural Northern Devon context, where, although the impacts of discrimination were still considered important, there was a greater focus on the experiences of neurodiverse CYP and those from LGBTQIA+ groups.\u003c/p\u003e\n\u003cp\u003eAdditionally, while both sites acknowledged the importance of promoting and developing mental health literacy within the local community, the emphasis on where this fitted within the co-designs differed. In the rural site, mental health literacy was seen as a specific issue needing focus and was thus framed as an OA, leading to the development of co-designs around this. In contrast, in the urban site, mental health literacy promotion and development were not a specific focus or OA but were instead incorporated into co-designs developed to tackle other challenges and issues.\u003c/p\u003e\n\u003cp\u003eThe KST is currently working with co-design teams and KCPs to refine these co-designs, as well as engaging in conversations with community members and system leaders to discuss and assess the next steps and local piloting and implementation plans.\u003c/p\u003e\n\u003cp\u003eEvidence integration\u003c/p\u003e\n\u003cp\u003eEvidence briefs were produced for one of the Small Circles in each site (OA2 in Northern Devon, and OA5 in Newham). These briefs were used differently by each site, depending on the ongoing process in the Small Circles at the time of their completion (See Table 2 Small Circles Timeline). Additionally, Evidence Reviews were planned for the other two Small Circles in each site. However, due to difficulties in aligning research and co-design timelines and priorities, these plans were abandoned.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis paper aims to describe and discuss the methods employed in Kailo’s Deeper Discovery phase, and learning in relation to the extent to which the process supported Kailo’s overarching aims and ambitions of designing local responses that address the social determinants of CYP’s mental health and wellbeing in each area. It is not the intention or focus of this paper to consider the efficacy or effectiveness of the resulting co-designs.\u003c/p\u003e\n\u003cp\u003eThe following discussion represents reflections and learning from the KST, some of\u0026nbsp;which have been informed by iterative insight generation from an accompanying developmental evaluation [32]. This evaluation will report further on learning about\u0026nbsp;the wider Kailo framework design and delivery.\u003c/p\u003e\n\u003ch3\u003eWhat worked well?\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eCommunity Partner involvement throughout\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInvolving community organisations, community researchers, and CYP in the recruitment, refinement, and delivery of the Kailo Deeper Discovery Circles was crucial in ensuring that diverse perspectives and needs were heard and addressed throughout the co-design process and within the co-designs developed [40]. The trust and relationships that CYP had with KCPs enabled them to openly discuss, question, and explore the Kailo activities, the parameters of their participation, the types of support required to make meaningful contributions (e.g., adult support within sessions, taxis, breaks from sessions), and to engage in decision-making within the sessions. Local organisations are experts in the local context and provide the knowledge of where and how to engage CYP who may otherwise have experienced inequalities in inclusion [41].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis contributed to adaptations which were tailored to meet the individual needs of those participating, so they were able to engage in a way that best suited them. Thus, involving local organisations in the recruitment and induction process for the CYP enabled the process to be conducted in less extractive ways, providing CYP with autonomy within the research process [42].\u003c/p\u003e\n\u003cp\u003eFurthermore, despite limitations, the engagement with the Big Circle ensured there was an audience to listen to the Small Circle members' views and a commitment to work towards ensuring they are acted upon during the implementation phase of Kailo [27].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFocusing on what matters\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe process and outputs of the Deeper Discovery phase suggest that the CYP participating in the Small Circles of co-design in Newham and Northern Devon had the necessary tools, support, skills, and lived experience to identify key factors, barriers, enablers, desirable outcomes, and impacts related to the OAs prioritised in the Early Discovery phase. The strong emphasis on CYP’s knowledge, experience, and understanding of the issues affecting their own lives, mental health, and wellbeing, as well as those of others in their local context, was critically important for informing the subsequent design of responses that are meaningful and contextually relevant [29].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCentring Youth and Community Voice through a Flexible and Adaptive Approach\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCentral to the co-design process was creating conditions for centring youth voices by providing diverse groups of CYP and other community members with various ways to be meaningfully involved in exploring ideas and strategies to support CYP’s mental health and wellbeing in their communities [43]. This was achieved by adapting the co-design approach (pace, tools, and facilitation style) based on the types of potential co-designs identified, group dynamics (influenced by size and composition), and CYP's needs [44, 45]. For example, accommodating the needs of neurodiverse and neurotypical group members, or pausing circle sessions for CYP in Newham during Ramadan.\u003c/p\u003e\n\u003cp\u003eThe literature highlights the importance of flexibility when utilising co-design principles and approaches with CYP [46]. Methods need to be adapted to the unique skills and experiences of the group [44], enabling individuals to develop the confidence to share their experiences [47] and encouraging engagement in reflective practice [48]. Through this flexible approach and by addressing power imbalances between different groups of CYP and adults within the sessions, Small Circle members were able to have nuanced conversations and collaboratively develop various potential solutions to support diverse groups of CYP and their mental health.\u003c/p\u003e\n\u003cp\u003eInherent tensions\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFlexibility vs pace\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere can be inherent tensions between building and maintaining pace and momentum and ensuring flexibility and adaptation in a codesign process [49]. Pace and momentum were achieved by scheduling approximately 16 co-design sessions in advance, along with relevant planning and content adaptation. However, to accommodate the varying and emerging needs of CYP, as well as new lines of inquiry in the co-design process, the focus or delivery of planned sessions often needed to change. This resulted in a trade-off with momentum and pace. This underscores the importance of building in sufficient time, flexibility, and resources so the process can reach its potential without being unduly rushed or pressured by fixed timelines [24]. However, this emergent approach does not always align with the timescales or expectations of research projects, funders and wider community members [50].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eYouth-led vs Youth-centred\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA key challenge KSTs had to manage across all co-design circles was the tension between being youth-centred, where CYP work collaboratively with researchers as equals [53], and being explicitly youth-led, where CYP instigate potential solutions to a problem, often one they have identified or defined themselves, and take responsibility for developing and implementing a solution [51]. However, in the context of designing responses to address the social determinants of mental health and discussing sensitive topics, this created challenges in maintaining sufficient focus on the social determinants of mental health, respecting CYP’s boundaries, and managing who was in the room.\u003c/p\u003e\n\u003cp\u003eThe co-design experience highlighted that being overly youth-led risks inappropriately or disproportionately burdening some CYP and excluding others who did not feel equipped to develop particular types of solutions or were managing complex challenges in their personal lives. This underscores the importance of planning for and providing appropriate support and training for CYP and co-design participants [24], as well as preparation time and support to build the knowledge and skills required to develop and implement particular types of solutions [52]. In some cases, the KST and CYP recognised that the responsibility and capabilities required to further develop and lead the implementation of particular co-designs needed to be with other individuals, organisations, and communities (particularly those involving the roles and responsibilities of adult users), thus preventing the overburdening of CYP [54, 55]. \u0026nbsp;Across different Small Circle teams, these roles were variably held by KST, KCPs, or wider individuals, organisations, and communities around CYP, with clarity on role, responsibility, and accountability being key.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCo-designed vs evidence-informed\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRapid and systematic evidence-building methodologies and co-design processes often move at different paces. The co-design process may require more time for elements such as the collective framing of open and exploratory questions, prioritising ideas and approaches, and consensus building and alignment [30, 43]. Conversely, systematic reviews necessitate more time for other elements, such as exploring definitions, answering narrowly defined questions, and considering inclusion and exclusion criteria [56]. While there were opportunities to align these processes more closely in the Kailo Deeper Discovery phase, it was challenging to do so while ensuring Kailo timelines were led by the pace of the Small Circles. This meant insights from the literature were not always readily available.\u003c/p\u003e\n\u003cp\u003eAdditionally, the co-design process involves frequent and regular exploration and reflection on various topics and elements as they are discussed in the Small Circles, from the stages of building conditions and discovery to designing and testing ideas [43]. In contrast, systematic reviews require a more in-depth focus on a single question for several months, covering stages from protocol development, screening, and analysis to synthesis [56, 57].\u003c/p\u003e\n\u003ch3\u003eChallenges and Limitations\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eKeeping designs focused on the Social Determinants\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA key aim of Kailo is to support local community partnerships in identifying locally relevant social determinants of CYP’s mental health and wellbeing and co-designing local responses. The Early Discovery phase of Kailo [17] created these initial foci across sites (e.g., exposure to violence and crime, lack of diverse employment opportunities, neighbourhoods, and networks of support). The Deeper Discovery and Co-Design phase aimed to further explore these social determinants and collaboratively design local responses to address them.\u003c/p\u003e\n\u003cp\u003eThe youth-centred approach and central involvement of CYP in the Small Circles was crucial in creating a rich and meaningful understanding of ‘what matters’ to CYP, in relation to the social determinants and influences on their mental health and wellbeing in their specific contexts [17]. However, given their position, knowledge, and experience, CYP were not always equipped or best placed to identify how specific social determinants might be structurally addressed or intervened with beyond an individually focused or service-level response, as this is their direct experience. Experiences across co-design teams and sites suggested that there were limits to the extent CYP could move beyond more practical, individually focused services and interventions to explore less tangible and more community-focused (and complex) options necessary for addressing structural change.\u003c/p\u003e\n\u003cp\u003eAs a result, the emerging co-designs developed in the Small Circle sessions, while valuable, more often resulted in individualised and service-oriented strategies or interventions rather than preventative or structural responses to the social determinants of mental health.\u003c/p\u003e\n\u003cp\u003eOne contributory explanation for this is that the social determinants CYP needed to focus on across the different OAs were not always explicitly framed or consistently reinforced through a social determinants lens. For instance, while Northern Devon’s prioritised OA2 was clearly defined and explicitly framed as a social determinant, OA1 was variably and imprecisely defined. It often strayed towards more individualistic facets (such as individual knowledge and understanding) rather than structural or social determinant facets (such as community and social infrastructures that create social norms). This underscores the importance of clear and consistent messaging and framing through a social determinants lens and the need for supporting training and tools to reinforce this focus. In addition, community engagements and discussions beyond the Small Circles also lacked a clear and consistent definition or framework for the social determinants, which could be shared among KST, KCP and those engaged in the Big Circle. Finally, co-design is messy [52] and the work often lacked clearly communicated boundaries around these determinants, reinforced at each stage of the co-designs development.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eWho is (not) in the room?\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCompounding the challenge of maintaining a focus on the social determinants of mental health is the question of who is—and who is not—participating in co-design activities. This issue relates to the aforementioned tension between being youth-centred and youth-led. Public system leaders and local policymakers, who arguably have the greatest power and influence to shape policies and interventions addressing social determinants, were, for the most part, only involved in the ‘Big Circles’. As such, their role and input were more limited to reviewing, inputting, and refining emerging designs and responses rather than fundamentally shaping their design.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe role of parents and carers, who bring unique and specific experiences and perspectives on the social determinants of their CYP’s mental health and wellbeing and largely act as ‘gatekeepers’ and enablers of CYP’s involvement [58], was also limited in the Small Circles. More opportunities could have been created to meaningfully engage system leaders and those in positions of power and influence to inform co-designs that address the social and structural determinants under consideration, alongside parents and carers. This might have provided more opportunities for CYP to better understand the wider spheres of influence around them and the levers that could generate structural changes. There were various reasons why this was challenging, including capacity and availability issues, as well as the time and effort required to ensure individuals involved were able to engage with CYP in equal and meaningful ways during the co-design process [59].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, community members involved in some of the Small Circles were often managing the tension between supporting the CYP in the room and contributing to the codesigns with their own ideas. The KST could have provided greater clarity on the scope of their role and responsibilities and/or alternative ways of participating.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eImplications\u003c/h3\u003e\n\u003cp\u003eLearning and experience to date underscore the critical value and importance of CYP in determining ‘what matters’ in relation to improving mental health and wellbeing within their own local contexts and communities, as aligns with the extant literature [60]. The fundamental importance of taking the necessary time to build trust and relationships with respected and embedded community partners, working with and across communities and local public systems, has also been highlighted [61]. However, pilot testing of the co-design approach suggests some important limitations, prompting adaptations for future iterations of Kailo in current and future sites.\u003c/p\u003e\n\u003cp\u003eFirst, there is a need for the development of key learning and training inputs around the social determinants of CYP’s mental health and wellbeing, consistently reinforced throughout the Early Discovery, Deeper Discovery, and Co-Design phases. Second, there should be a reinforcement of a youth-centred (rather than solely youth-led) approach to co-design. This approach clearly identifies and centres the role of CYP in determining ‘what matters’ locally and later appraising the relevance and fit of what is co-designed for CYP. This should be balanced with wider active stakeholder participation in designing systemic responses, interventions, and strategies. This can be achieved through a combination of separate policy, system leadership, parent and professional co-design spaces, as well as carefully designed and facilitated combined sessions with CYP.\u003c/p\u003e\n\u003cp\u003eFinally, to advance an evidence-informed approach to co-design, rather than having detached academic partners input rapid evidence reviews into the co-design process (which was not sufficiently timely or responsive), we will test the integration of local embedded researchers as an integral part of the Small Circle co-design teams. Ideally, these researchers will be recruited through local college or university settings.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis paper discusses the approach utilised in the Kailo Deeper Discovery process, which focused on the co-design of solutions to address the social determinants of CYP\u0026rsquo;s mental health and wellbeing through youth and community participation. The co-design approach adopted by the KSTs enabled community members (CYP and others) to explore various ideas and potential strategies. By adapting and flexing the co-design approach to community members' needs across the various Deeper Discovery Circles, the KST team facilitated meaningful conversations and supported community members in developing solutions, which will now move into the implementation phase of the Kailo programme.\u003c/p\u003e \u003cp\u003eHowever, there were important limitations associated with navigating individual challenges and needs while simultaneously developing solutions to address mental health issues through a prevention and social determinants lens. This suggests careful consideration is required around where different groups of CYP with lived experience, as well as other groups of community members, are best placed to engage in the development of solutions to issues they are currently experiencing, as well as when and how (and what supports are required). This is particularly important in community participation efforts exploring complex issues such as mental health and wellbeing challenges and their associated social determinants.\u003c/p\u003e \u003cp\u003eThese insights are directly informing subsequent adaptations of the Kailo framework and design, contributing to the wider literature on how and where co-design works to lead or support the development of solutions to issues faced by CYP and other community members.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCYP - Children and Young People\u003c/p\u003e\n\u003cp\u003eKCP - Kailo Community Partners\u003c/p\u003e\n\u003cp\u003eKCRD - Kailo Community Researchers and Designers\u003c/p\u003e\n\u003cp\u003eKST- Kailo Sites Team\u003c/p\u003e\n\u003cp\u003eOA - Opportunity Areas\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthical approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThe methods undertaken in the Deeper Discovery phase of the Kailo Programme were approved by the UCL Research Ethics Committee (REC) ethics committee, Project ID: 18773/002. All community members and young people involved in the Small Circles of Co-design provided written informed consent, prior to Kailo Deeper Discovery workshops taking place, and the methods were performed in accordance with relevant guidelines and regulations. Written informed consent was also obtained from parents or legal guardians of participants under the age 18 years, also prior to their participation in the programme's workshops.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable. The manuscript does not contain data from any individual person which would include individual details, images or videos.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe data shall be made available upon request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThis work is supported by the UK Prevention Research Partnership (UKPRP), which is funded by the British Heart Foundation, Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Health and Social Care Research and Development Division (Welsh Government), Medical Research Council, National Institute for Health Research, Natural Environment Research Council, Public Health Agency (Northern Ireland), The Health Foundation and Wellcome.\u003c/p\u003e\n\u003ch2\u003eAuthor Contributions Statement\u003c/h2\u003e\n\u003cp\u003ePF, TH, ESL. Leadership and oversight\u003c/p\u003e\n\u003cp\u003eESL, KP, NR, TH, PF. Conception and design\u003c/p\u003e\n\u003cp\u003eESL, CP. Wrote the main manuscript text\u003c/p\u003e\n\u003cp\u003eESL, KP, NR, SB Data collection\u003c/p\u003e\n\u003cp\u003eESL, KP, CP, NR, SB. Analysis and interpretation of data.\u003c/p\u003e\n\u003cp\u003eTH, PF. Funding acquisition\u003c/p\u003e\n\u003cp\u003eAll authors - Substantively revised and reviewed it.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe authors acknowledge all of the young people and other community professionals in Northern Devon and Newham who were involved in the Kailo research and design programme, from May 2022 to August 2024, which made this paper possible. We also acknowledge those who will be involved in the future versions of this Kailo programme. This research was conducted as part of the Kailo programme, and we gratefully acknowledge the valuable input and discussions from the wider team that have informed this paper.\u003c/p\u003e\n\u003cp\u003eThis work is supported by the UK Prevention Research Partnership (UKPRP), which is funded by the British Heart Foundation, Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Health and Social Care Research and Development Division (Welsh Government), Medical Research Council, National Institute for Health Research, Natural Environment Research Council, Public Health Agency (Northern Ireland), The Health Foundation and Wellcome.\u003c/p\u003e\n\u003ch2\u003eAuthors information\u003c/h2\u003e\n\u003cp\u003eDartington Service Design Lab - Ediane Santana de Lima, Katie Potter, Cristina Preece and Tim Hobbs\u003c/p\u003e\n\u003cp\u003eUCLPartners - Nirandeep Rehill, Sophie Bulmer\u003c/p\u003e\n\u003cp\u003eResearch Department of Clinical, Educational and Health Psychology, University College London (UCL) - Peter Fonagy\u003c/p\u003e\n\u003cp\u003eUniversity of Exeter Medical School - Kate Allen and Anna March\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eFoulkes L, Andrews JL. 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Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10349236/\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are not available with this version.\u003c/p\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, Co-Design, Community-Based Participatory Research, Group Model Building, Systems Thinking, Social Determinants and Participatory Design.","lastPublishedDoi":"10.21203/rs.3.rs-4901621/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4901621/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Rates of poor mental health among children and young people (CYP) are increasing and wellbeing is declining, despite rising investment in treatment services. The argument for greater investments in prevention is well-established, with growing calls to address the social determinants of CYP’s mental health. However, there is a gap between this rhetoric and the knowledge required to design and implement such approaches locally. \u003cstrong\u003eMethods\u003c/strong\u003e: This paper outlines the methods and approaches used in two distinct local communities where CYP, community partners, and system leaders collaborate to co-design contextually relevant and prevention-focused solutions to improve CYP’s mental health and wellbeing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults and Conclusions\u003c/strong\u003e: This paper examines the benefits, inherent tensions, and limitations of this approach. Youth-centred co-design approaches have value and potential, but to address the social determinants of mental health, it is crucial to maintain this focus and ensure that those with the power to effect structural and systemic change are integral members of co-design teams.\u003c/p\u003e","manuscriptTitle":"Co-designing strategies to support children and young people’s mental health in Newham and Northern Devon","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-11 05:00:49","doi":"10.21203/rs.3.rs-4901621/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":"878233de-9632-444c-a087-a3f74b9e5dab","owner":[],"postedDate":"October 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-11-05T06:24:30+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-11 05:00:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4901621","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4901621","identity":"rs-4901621","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}