Kate Allen

Background: Despite increasing efforts to provide support for children and young people’s mental health and wellbeing, rates of poor wellbeing and probable mental health disorders continue to rise. This underscores the need for approaches that target the root causes and social determinants underlying these issues. This paper offers reflections on efforts to address these determinants at the local level, drawing on learning from the co-design phase of Kailo, a research and design initiative that works with young people and communities to shift the underlying conditions sustaining poor mental health and wellbeing, including resources, policies, relationships, and mindsets. Methods: Across two pilot sites, Northern Devon and Newham, the Kailo programme used a community-based co-design methodology and a structured process for reflective, iterative learning. Participants included young people, community partner organisations, local professionals, academics, researchers, and designers. The co-design process was integrated with research synthesis and systems mapping to ensure that emerging strategies were informed by lived experience, empirical evidence, and a systemic lens. Results: Four co-design strategies were developed through this process, involving over 300 young people and community members across the two pilot sites. While the intention was to support upstream prevention and systems-level transformation, most strategies ultimately focused on individual-level interventions. Nonetheless, the process generated important learning about the barriers and enablers to developing systems change approaches targeting social determinants and preventative action. Conclusion: Systemic co-design offers potential for developing youth-centred, locally situated policy and practice interventions. However, careful attention must be paid to the composition of co-design teams and in relation to who is included, who is more broadly engaged, and who is kept informed. This is particularly crucial when exploring system-wide solutions, rather than focusing solely on the immediate experiences of participants. While the significance of addressing social determinants was acknowledged and explored during the initial phases of problem identification and understanding, effective action in this area requires sustained collaboration, not only with young people, but also with other community members who hold valuable knowledge and experience regarding the use of, and opportunities within, systemic levers necessary to support transformative change.

Background: Co-design approaches are increasingly used in efforts to address complex challenges, such as adolescent mental health. Benefits of these approaches are multifaceted and include strategies that better reflect local perspectives and needs, as well as the potential for improved outcomes for those involved. However, the literature has highlighted challenges and unintended consequences of co-design, such as issues with inclusivity and undue burden being placed on participants. This paper examines the methods used in the ‘Deeper Discovery and Co-design phase’ of Kailo, a place-based research and design initiative aimed at tackling the social determinants of children’s and young people’s (CYP) mental health in their local communities. Methods: Over approximately nine months, a co-design approach was used across two pilot sites. This involved more than 69 workshops and several ad hoc engagements with CYP and other community members. The goal was to explore structural challenges and develop strategies to address CYP mental health and wellbeing in their local context. The co-design work also aimed to bring together community knowledge and expertise, systems mapping and academic evidence. Results: Over 300 local CYP, community members, professionals and practitioners participated or contributed to Kailo’s Deeper Discovery phase across the two pilot sites, via group sessions, individual feedback or surveys. The study identified key barriers (e.g. logistical constraints, limitations in accessibility of processes and participation, safeguarding and participant wellbeing concerns) and enablers (e.g. flexible and accessible participation, inclusive and adaptive facilitation, and participation and influence) that shaped conditions for implementation. Moreover, it explored the requirements and tensions for methodological implementation whilst maintaining a flexible and adaptive approach, centring CYP needs and voices, and integrating different methods into the co-design process. Conclusions: The Kailo programme prioritised the contributions of CYP and their communities, aiming to foster inclusive and diverse engagement through a distinctive, adaptive, youth-centred approach. This paper outlines the co-design methodology used to support the development of locally relevant strategies addressing the social determinants of mental health. However, balancing flexibility and adaptability and centring CYP needs, voices and agency, whilst maintaining a focus on broader structural issues, remains a challenge.

Kailo is a prevention framework that supports local communities to co-design evidence-informed strategies to address the social determinants of adolescent mental health and wellbeing. Similar place-based initiatives exist internationally but research into the mechanisms of change and contextual drivers is limited. Understanding how and why Kailo functions is crucial for refining the framework before it is implemented in different contexts and for informing the focus of an impact evaluation. We conducted a developmental, realist-informed evaluation to investigate how and why the Kailo framework functions, for whom and under what circumstances. The first phase of the evaluation involved a rapid realist review, observations of key processes, key informant interviews, and document analysis. These methods informed the development of a series of initial programme theories. The second phase involved testing and refining these initial programme theories through further interviews and focus groups with key informants. A realist dialogic approach was used throughout, and our work was supported by two Young People’s Advisory Groups who provided input on both the approach and theory generation. We generated a series of programme theories that shed light on the underlying mechanisms through which the Kailo framework works, the ways in which context acts as a catalyst for change, and the outcomes prioritised. These programme theories fall into six themes: 1) Alignment; 2) Time; 3) Credibility; 4) Accessible Spaces; 5) Building a Shared Understanding/Mission; and 6) Creating Hope that Change is Possible. Our study has informed the further development of the Kailo framework and lays the groundwork for a subsequent contributory impact evaluation to assess how Kailo contributes to system-level change and, ultimately, improvements in adolescent mental health and wellbeing. The programme theories generated also contribute to a wider understanding of how complex place-based approaches may function.

Objectives: To explore commissioners’ experiences of commissioning services for child and adolescent mental health, their perspectives on the needs of their populations, the challenges they face and their needs for support and data. Design: Qualitative study involving semi-structured interviews. All interviews were audio-recorded and transcribed verbatim. Data were analysed using framework analysis. Setting: England, UK. Participants: 12 integrated care board commissioners, responsible for commissioning NHS England Child and Adolescent Mental Health Services (CAMHS). Results: We identified five themes: ‘reflections on role’; ‘priorities and tensions: working in a complex and evolving integrated care system’; ‘insights and evidence: the role and use of data and informants’; ‘children’s mental health in the limelight: influences and expectations’ ; and ‘responding to need "CAMHS as the answer to everything" ’. Combined, these themes highlight the integral role commissioners play in providing oversight over the local system and challenges to this role including disproportionate funding for services for child and adolescent mental health, different use and value ascribed to ‘qualitative’ and ‘quantitative’ data, rises in demand and the limited focus on early intervention and prevention. Conclusions: CAMHS commissioners are currently negotiating a complex and changing political, social and economic environment with competing priorities and pressures. Our research indicates that commissioners require greater support as their roles continue to evolve.

Background Kailo is a community-centred research and design initiative that aims to improve adolescent mental health by addressing its wider social determinants. Unlike conventional interventions that often neglect systemic factors, Kailo employs a complex systems approach to identify and address the social causes of poor adolescent mental health in two pilot sites. This protocol outlines a developmental realist-informed evaluation that will develop, test, and refine the programme theory underpinning the Kailo framework. This evaluation will generate recommendations for the enhancement of Kailo before it is implemented in additional sites. Methods A developmental realist-informed evaluation will be conducted to investigate how and why Kailo works, for whom, and under what circumstances. This mixed-methods evaluation will engage key members of the Kailo consortium, local stakeholders, and young people who have interacted with Kailo. The initial phase incorporates a rapid realist synthesis, interviews with key informants, observations, and document analyses to formulate the initial programme theory. The second phase will employ semi-structured interviews, focus group discussions, observations, and analyses of routinely collected data to test the initial programme theory. The final phase will use focus group discussions to refine and consolidate the initial programme theory. Given the developmental nature of this evaluation, this programme theory will refine the implementation of the intervention in the pilot sites and generate recommendations to improve future versions of the Kailo framework. Discussion This study will explore the mechanisms by which the implementation of Kailo improves adolescent mental health by facilitating place-based systems change in the two pilot locations. This theory-based evaluation will illuminate the primary contextual conditions and mechanisms which produce intended (and unintended) outcomes to inform the future development of the Kailo framework. Moreover, the methodological approach used may contribute to broader understanding of how to implement and evaluate complex interventions designed to improve public health.

Background: Parental domestic violence and abuse (DVA), mental ill-health (MH), and substance misuse (SU) can have a negative impact on both parents and children. However, it remains unclear if and how parental DVA, MH, and SU cluster and the impacts this clustering might have. We examined how parental DVA, MH, and SU cluster during early childhood, the demographic/contextual profiles of these clusters, and how these clusters relate to child MH trajectories. Methods: We examined data from 15,377 families in the UK Millennium Cohort Study. We used: (1) latent class analysis to create groups differentially exposed to parental DVA, MH, and SU at age three; (2) latent growth curve modelling to create latent trajectories of child MH from ages 3–17; and (3) a case-weight approach to relate latent classes to child MH trajectories. Results: We identified three latent classes: high-frequency alcohol use (11.9%), elevated adversity (3.5%), and low-level adversity (84.6%). Children in the elevated adversity class had higher probabilities of being from low-socioeconomic backgrounds and having White, younger parents. Children exposed to elevated adversity displayed worse MH at age three (intercept = 2.274; p < 0.001) compared the low-level adversity (intercept = 2.228; p < 0.001) and high-frequency alcohol use class (intercept = 2.068; p < 0.001). However, latent growth factors (linear and quadratic terms) of child MH did not differ by latent class. Conclusions: Parental DVA, MH, and SU cluster during early childhood and this has a negative impact on children’s MH at age three, leading to similar levels of poor MH across time. Intervening early to prevent the initial deterioration, using a syndemic-approach is essential.

The mental health and wellbeing of children and young people is deteriorating. It is increasingly recognised that mental health is a systemic issue, with a wide range of contributing and interacting factors. However, the vast majority of attention and resources are focused on the identification and treatment of mental health disorders, with relatively scant attention on the social determinants of mental health and wellbeing and investment in preventative approaches. Furthermore, there is little attention on how the social determinants manifest or may be influenced at the local level, impeding the design of contextually nuanced preventative approaches. This paper describes a major research and design initiative called Kailo that aims to support the design and implementation of local and contextually nuanced preventative strategies to improve children's and young people’s mental health and wellbeing. The Kailo Framework involves structured engagement with a wide range of local partners and stakeholders - including young people, community partners, practitioners and local system leaders - to better understand local systemic influences and support programmes of youth-centred and evidence-informed co-design, prototyping and testing. It is hypothesised that integrating different sources of knowledge, experience, insight and evidence will result in better embedded, more sustainable and more impactful strategies that address the social determinants of young people’s mental health and wellbeing at the local level.

Parental domestic violence and abuse (DVA), mental ill-health (MH), and substance misuse (SU) are three public health issues that tend to cluster within families, risking negative impacts for both parents and children. Despite this, service provision for these issues has been historically siloed, increasing the barriers families face to accessing support. Our review aimed to identify family focused interventions that have combined impacts on parental DVA, MH, and/or SU. We searched 10 databases (MEDLINE, PsycINFO, Embase, CINAHL, Education Research Information Centre, Sociological Abstracts, Applied Social Sciences Index & Abstracts, ProQuest Dissertations and Theses Global, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials) from inception to July 2021 for randomised controlled trials examining the effectiveness of family focused, psychosocial, preventive interventions targeting parents/carers at risk of, or experiencing, DVA, MH, and/or SU. Studies were included if they measured impacts on two or more of these issues. The Cochrane Risk of Bias Tool 2 was used to quality appraise studies, which were synthesised narratively, grouped in relation to the combination of DVA, MH, and/or SU outcomes measured. Harvest plots were used to illustrate the findings. Thirty-seven unique studies were identified for inclusion. Of these, none had a combined positive impact on all three outcomes and only one study demonstrated a combined positive impact on two outcomes. We also found studies that had combined adverse, mixed, or singular impacts. Most studies were based in the U.S., targeted mothers, and were rated as ‘some concerns’ or ‘high risk’ of bias. The results highlight the distinct lack of evidence for, and no ‘best bet’, family focused interventions targeting these often-clustered risks. This may, in part, be due to the ways interventions are currently conceptualised or designed to influence the relationships between DVA, MH, and/or SU. Trial registration: PROSPERO registration: CRD42020210350.