Barriers and facilitators to implementation of a community wellbeing service for black, Asian and minoritised young people

Participants

Eligible study participants were the four practitioners delivering the service and all the minoritised CYP aged 11–17 registered at the centre attending the service. We aimed to purposefully sample CYP of varying age and gender for interviews. A £10 shopping voucher was given to CYP who participated in interviews. 94 CYP attended at least one wellbeing session during the course of the study. All of them were shown study flyers and leaflets and approached for participation in the study. Six CYP and all four service providers from the centre were interviewed. Their characteristics are not described to avoid identification.

The providers were a youth worker and a manager, and two mental health practitioners. They visited the centre weekly to deliver the service. All four were interviewed on three occasions between December 2022 and March 2024; at the start of service implementation, then after seven, and 12 months. Interviews lasted one hour on average (range 37–74 min). Five interviews were conducted face-to-face, at the youth centre or at the mental health organisation’s office, and seven were conducted by phone.

CYP were reluctant to participate in the evaluation and only three paired interviews were conducted. The six young people interviewed were between 11 and 15 years (Median age 13 years), included both boys and girls and represented a range of minoritised ethnic backgrounds. These interviews lasted, on average, 30 minutes and were held in a private room at the centre between May and November 2023.

Procedure and measures

The new service was set in a community youth centre located in a deprived urban area with a diverse population (30–35% ethnic minority)²¹. The ethnic makeup of the youth centre attendees was varied, including CYP with Black, Asian and mixed heritages in majority.

The service hub was a 2-hour, weekly, youth activity session run for 11- to 17-year-old CYP in the youth centre where mental health practitioners were present. The aims of the new service were broad, so the specific design and professional activities of the service were not decided a priori and were developed as service was implemented. It was co-developed and facilitated by two youth practitioners from the community centre and two specialist mental health practitioners from the mental health organisation (the service ‘providers’). Majority of the youth and mental health practitioners were from the same community and of Black Asian or Mixed ethnicity. The practitioners discussed and agreed on what the service would comprise of and developed it together, based on their knowledge and experience of looking after minoritised CYP and their own lived experience of being from minoritised communities. They therefore understood the reluctance and sensitivity around mental health.

We held in person and online conversations prior to and during the study with parents and guardians of children attending the youth centre to inform them about the study and enhance the reach. These conversations indicated that parents trusted the setting providers for looking after their children because of their longstanding presence in the community and shared values.

One author (SS), a senior research associate experienced in qualitative methods and with a master’s in public health, visited the centre and met with practitioners prior to evaluation starting. She was from an ethnic minority background, as suggested by our Public and Patient Involvement work (see below in section titled Public and Patient Involvement). Participants were told that SS was the researcher employed on the study to conduct the qualitative work. She attended all the sessions where all providers (two centre staff and two mental health practitioners) were present, and when the centre was open to CYP aged 11 to 17. During these visits, SS took fieldnotes based on what she observed, such as physical description of the community centre and the activities carried out. These notes provided contextual data for the providers’ and young people’s accounts.

Throughout the evaluation, SS invited providers and the CYP attending the activity session to interviews, to explore their views and experiences of the service. Individuals approached for interview were given an information sheet that described the aim of the study and what taking part would entail. Individuals could read this sheet at their leisure and ask questions about the study. SS secured written informed consent prior to interview and conducted all the interviews. When the participant was under 16 years of age, consent was obtained from the guardians or parents of the CYP, as well as the CYP themselves.

For interviews with service providers, a topic guide was used to ensure consistency across the interviews. The same guide was used at each of the three time points. It was based on the purpose of the interviews and informed by relevant literature, knowledge of the planned intervention and discussions within the research team. It included open-ended questions to elicit details and description from the participants about the service, its implementation, and the barriers and facilitators to service delivery. The interviews were held at a private location in the centre or via phone, at a time convenient to the participant.

For interviews with young people, a flexible and open-ended topic guide was designed to explore their awareness and experiences with the service. This guide was also refined in conjunction with our young people’s research advisory group (see under Patient and Public Involvement). The topic guide included open questions about their perception of mental health and of the new service. A guide was also developed for the interviews with CYP who were referred for mentoring or additional mental health support. It included questions about young person’s perceptions of the additional support and referral components, and processes and how it could be improved in future. (see Supplementary data for all topic guides²²).

Data management and analysis

The interviews were audio-recorded and fully transcribed professionally. All audio recordings were deleted within three months of interview. The transcripts will be kept securely for 10 years. All information is stored safely and securely by the University of Bristol – in line with the General Data Protection Regulations and the University of Bristol’s Data Protection policy.

In terms of analysing the interview data, following the principles of grounded theory²³, data collection and analysis proceeded in parallel, so that findings from earlier interviews informed the focus of later data collection. The interview transcripts were analysed thematically, using the approach suggested Braun and Clarke²⁴. Data collection and analysis proceeded in parallel, so that findings from earlier interviews informed the focus of later data collection. This entailed a subsample of all transcripts being independently read and manually coded by SS and KT, who then met to discuss their coding and interpretation of the data, and to develop a coding frame which reflected themes identified in the data. Once the coding frame had been agreed, transcripts were uploaded into NVivo v14²⁵ and electronically coded. As data collection progressed, new codes were added to the coding frame and transcripts that had previously been coded were re-coded where necessary. Finally, codes were grouped together to develop categories and collated into potential themes and sub-categories. This inductive approach to the analysis ensured findings were based on participants’ accounts and not coded according to the researchers’ pre-existing assumptions or priorities. Researcher bias was also controlled for through the double coding of transcripts and regular discussion between SS and KT about how findings related to the data set. In addition, during data collection, SS discussed interim findings with providers to check our interpretation of the data. Whilst it was felt SS’s ethnicity had facilitated access to the centre and the interviews with providers, it was also felt her gender had hindered the extent to which young men, particularly the 16- and 17-year-olds, using the centre were willing to take part in the research.

In terms of analysing the quantitative data collected by the providers on CYP’s attendance at wellbeing sessions, and referrals to other services over the 12 months, these data were analysed descriptively using Excel.

Ethical approval

Ethical approval was granted by the University of Bristol Faculty of Health Sciences Research Ethics Committee on 30^th Nov 2022 (application ID13984).

Public and Patient Involvement

We worked with the service providers and an independent young people’s research advisory group (YPAG) prior to evaluation and throughout the study. They helped us in developing participant information materials, choosing outcomes and interpreting the findings. A YPAG is a group of volunteer young people who advise on research concerning young people using their lived experience and age specific views. Members of the YPAG consulted were all from minoritised ethnic backgrounds.

The centre

Providers explained the centre had been offering community-based services for 40 years, serving multiple generations of local families, primarily from minoritised ethnic backgrounds. The centre already offered a variety of skill-building activities, such as sports, music production, games, movies, cooking, arts, and crafts. Activities were overseen by youth practitioners, most of whom were from minoritised ethnic backgrounds. The CYP interviewed recalled engaging in activities, and described them as soothing and as building their skills and confidence.

Participation in activities was not mandatory and CYP could move freely within the space, using it predominantly to socialise with their peers and friends. CYP described how this meant the centre provided them with a space to relax and feel safe:

Service content

The providers stated that the aim of the service was to ensure a referral pathway for CYP to access mental health services and to normalise mental health and wellbeing conversations among centre attendees. Providers explained the service was being developed iteratively, on-site, over several months, and included four components:

Service implementation

Service implementation was slow. Providers explained this was because it was a novel offering and that they had limited experience of such service implementation. They noted additional time was needed to build mutual understanding and trust between the youth workers and mental health practitioners, who had not previously worked together. They also felt the service needed to be developed naturally, through trial and error, so that it fitted within the constraints of the setting and was tailored to the CYP’s needs.

Facilitators to service implementation

Facilitators to implementation included building trust and relationships with service users and between organisations, and tailoring activities to context.

Fostering trust and building relationships. Providers stated building trust and relationships was crucial to successful service implementation. They mentioned that their expertise and lived experience helped them recognise the stigma and apprehension surrounding mental health in minoritised communities, and be responsive to the needs of these communities:

Providers explained their approach transcended the traditional therapist-client dynamic, aiming to cultivate informal, youth-friendly relationships akin to youth workers, to mitigate power imbalances and cultivate meaningful connections with the CYP:

Initially, the mental health practitioners did not introduce themselves as such to the CYP, in case this label discouraged communication:

Additionally, mental health practitioners mentioned their positive relationship with centre staff facilitated the process of them being accepted by the CYP.

Trust building between the organisations. Ongoing engagement, knowledge-sharing, and training (of youth centre staff by the practitioners from mental health organisation) facilitated the development of a collaborative relationship between the two organisations. This fostered mutual understanding and trust, enabling staff at the centre to seek guidance in addressing specific challenges related to safeguarding, engaging disengaged young people, and responding to young people’s mental health needs.

Tailoring activities to the context. Providers explained that centre activities were determined by CYP interests and participation was optional. This meant that while the providers wanted to implement structured educational activities, uptake depended on the CYP’s willingness to engage.

For this reason, providers opportunistically incorporated mental health conversations and activities into their usual interactions with CYP. Examples included regularly checking in with CYP about how they were feeling and encouraging them to discuss something positive or challenging that happened during their day. This was also reflected in the CYP interviews. Although CYP could not recall any specific mental health activities, they mentioned providers checking-in on them, having conversations about their emotions, and discussing positive and challenging events. It was also evident that they felt the providers genuinely cared.

Barriers to service implementation

Barriers to implementation mentioned by providers included inconsistent attendance of CYP, the unstructured nature of activities delivered in the centre, slow intervention delivery, and the CYP’s reluctance to engage in wellbeing services or conversations.

Inconsistent attendance. CYP’s inconsistent attendance hindered the development of trust and rapport with the providers, and also affected the continuity of service delivery.

Informal and relaxed structure. Providers repeatedly highlighted a ‘tension’ between the formality of the service and the informality of the community setting. To engage effectively with CYP, providers had to navigate around the habitual actions and expectations of CYP attending the activities:

Slow pace of service delivery. All providers acknowledged that service implementation was slower than anticipated. This was partly due to the service being developed through trial and error. Implementation was also slow because the centre needed to develop the safety procedures required when providing a mental health service. It took 12 months for all four service components to become operational. This delay contributed to providers being unsure of their roles within the service. As all the CYP we interviewed were not aware of the new service, this operational delay likely contributed to a lack of service visibility to CYP.

Hesitancy in engaging with service and providers. Providers mentioned that CYP did not want to discuss mental health or access further support when it was offered. They suggested that, in the early phases of the service, this might have been because they were not familiar with the mental health practitioners. They also commented that it could be due to the perception that participating could signal that CYP had problems, underscoring the need for practitioners to approach them with care and sensitivity.

CYP accounts suggested that their reluctance to engage could also be because they were unsure what was meant by 'mental wellbeing' or 'emotions', and what service and activities were being offered. They also mentioned not seeing the service as relevant to them, as they considered their mental health was fine. CYP were also unsure how to discuss their mental health and explain how they felt.