‘Multi-stressed’: A qualitative study exploring the impact of the social determinants of health on access to digital mental health for youth and young adults in Alberta

Abstract

Background

Mental illness among youth (ages 15–24) is a critical and global public health issue. Youth's pathways to accessing mental healthcare are complex, non-linear, and mediated by the social determinants of health – including social, economic, environmental, and systemic factors. Digital mental health is recognised as a potential solution to address inequitable access to mental healthcare among youth. However, concerns have been raised regarding access to digital mental health for youth who are underserved and excluded by current mental healthcare systems. Access to digital mental health is a matter of mental health equity requiring urgent attention.

Methods

This study explores mental healthcare providers’ perspectives of how the social determinants of health affect access to digital mental health for youth in Alberta, Canada. A qualitative descriptive methodology was utilised to analyse focus group data and identify pertinent themes.

Results

Twenty-three focus groups were conducted with 168 participants from schools, specialised mental health services, primary care networks, and community-based mental health service settings. Findings show that youth's access to digital mental health is impacted by three overarching and intersecting themes: (1) social influences, (2) socio-economic circumstances, and (3) community contextual and systemic factors.

Conclusions

The three themes indicate that the social determinants of health do not occur in isolation and may combine to produce multiple forms of disadvantage. Practical considerations and recommendations emphasise the need to address the social determinants of health to ensure that all youth benefit equitably from emerging digital solutions.

Keywords

Digital mental health measurement-based care mental healthcare mental healthcare access social determinants of health mental health equity systemic barriers youth implementation science clinical perceptions

Background

Mental illness among youth is a critical and global public health issue.¹ Worldwide, psychological disorders (e.g., anxiety disorders, eating disorders, substance use disorders) tend to emerge before age 25² during periods of physical, psychological, and social development and transition.³ A recent epidemiological meta-analysis found peak and median ages at onset of any mental illness to be 14.5 and 18 years of age, respectively.² In Canada, research demonstrates an increasing prevalence of diagnosed mood disorders, anxiety disorders, and suicidality among youth between 2011 and 2018⁴ – and worsening mental health concerns due to the COVID-19 pandemic.⁵ Experiences of poor mental health in youth and young adulthood are associated with physical and psychiatric comorbidity,⁶ self-harm,⁷ suicidality,⁸ and mortality.⁹ Moreover, youth with untreated mental illness are vulnerable to disadvantage and impairment in functioning in adulthood.⁶

The prevalence and adverse impact of mental illness indicates a need for timely, accessible, and comprehensive assessment and psychosocial interventions. However, youth's pathways to accessing mental healthcare are complex, non-linear,^10,11 and mediated by interacting social, economic, environmental, and systemic influences.¹² Social barriers to mental healthcare access and engagement include stigma towards mental health and help-seeking,^12–14 limited support from family or peers,^12,14 and negative experiences with systems and providers¹⁴ (e.g., psychologists, physicians). Outside publicly funded services, cost may preclude youth with acute and complex needs from receiving specialised support.^10,12–15 Rural areas face a vicious dynamic between the high burden of mental health crises¹⁶ and the lack of general and specialised mental health services in rural communities.¹² Additionally, economic barriers are exacerbated by geographic location¹² due to travel costs to access resources in cities. System-level barriers such as wait times,^10,12–14 fragmented age-based transitions, and restrictive eligibility criteria dependent on age, diagnosis, or perceived severity¹⁰ also hinder youth's treatment access.

Importantly, disparities in access to mental healthcare among population groups occur at a systemic level^15,17,18 and interact with social, economic, environmental, and additional systemic factors.¹² Inequitable access is not inherent to certain populations¹⁹; rather, longstanding systems of oppression^15,18–20 related to race, ethnicity,^{12,15,17,18,21–23} gender, gender identity, sexual orientation,^12,17,18,21 and other aspects of intersectional identity^18,23 impact youth's access to and experience with mental healthcare. Examples include societal and community stigmatisation and marginalisation that impedes help-seeking,²² harmful interactions with providers,^17,21,22 longer wait times, and adverse pathways to mental healthcare via hospitalisation or the justice system.²² In addition, Canada lacks access to linguistically and culturally diverse providers^15,22 and culturally safe services to meet the heterogenous needs of Black youth,²² Indigenous youth, and other youth who are racialized.^12,23

Social determinants of health (SDH) frameworks (i.e., the Conceptual Framework for Action on the Social Determinants of Health²⁴) provide a valuable structure for understanding pathways to accessing mental healthcare. The SDH encompass the non-medical²⁵ social, economic, environmental, and systemic factors influencing health, both proximal and distal.²⁶ Proximal determinants include the ‘visible circumstances’^27(p1) in which individuals live, such as geographic location,²⁸ access to health systems,^3,29 schools, housing, and family and peer relationships.²⁶ Immediate circumstances are, in turn, shaped by distal historic, political, social, and economic contexts.²⁷ The resultant health-promoting or health-damaging experiences manifest inequitably across intersecting identities^27,30 (e.g., ethnicity, ability). Regarding mental health, the SDH affect both risk of disorder²⁸ and access to support.³¹ Youth exposed to greater social adversity experience greater accumulative stress,²⁸ are at greater risk of mental ill-health,^3,28 and face pronounced barriers along their access-to-care pathway.³¹ Interactions between the SDH, mental health, and access to mental healthcare during youth and young adulthood have lasting, cumulative implications for mental health and wellbeing.

Expanding access to mental healthcare: Overview of digital mental health

Given that access to health systems is in itself a determinant of mental health outcomes,³ there exists a need to address inequitable access to mental healthcare driven by the SDH. The digital delivery of mental health assessment and treatment is recognised as a means to mitigate social, economic, environmental, and systemic barriers^32,33 – and thereby advance mental health equity for the youth demographic.³³ Among various forms, digital mental health (dMH) includes web-based platforms, apps,^33,34 supportive text messaging,^34,35 telemental health,³⁶ virtual reality,³⁴ and wearable devices,³⁷ that may be embedded in existing systems or used in place of in-person services. dMH may increase access to mental healthcare by providing flexible access to support,³³ enabling anonymity^34,38 and reducing perceived stigma (if used independently),³³ offering cost-effective alternates to specialised and private treatment,^33,39 reaching individuals in rural and under-resourced areas,^33,40,41 and avoiding waitlists.³⁹ If co-designed through participatory community engagement, dMH may increase tailored and culturally relevant care options^42–44 and improve language accessibility.⁴² A secondary advantage to dMH is its ability to connect youth to local resources⁴⁵ that address the SDH – such as food banks, housing support, and employment centres.

Despite potential benefits, concerns have been raised regarding equitable access to dMH among youth experiencing barriers to accessing traditional mental healthcare.^33,40 Existing studies suggest that the social,^46–48 economic,^29,33,46 environmental,^33,49 and systemic factors⁴⁹ impeding access to in-person services may comparably affect access to dMH. For instance, youth may experience stigma toward using dMH,⁴⁶ economic barriers to owning digital devices, unstable Internet,³³ and limited community resources⁵⁰ that implement or raise awareness about digital offerings. Embedding dMH within existing systems also incites considerations for youth who are disproportionately negatively affected by the SDH, and consequently underserved and excluded by current mental healthcare pathways.

Study purpose

Challenges to accessing dMH require urgent attention so that all youth may benefit equitably from emerging digital solutions. However, to our knowledge, minimal literature intentionally explores the relationship between multiple SDH and access to dMH among youth. This qualitative thematic analysis therefore intended to describe the perspectives of providers working with youth through the following research question: How might the SDH, including social, economic, environmental, and systemic factors, affect access to dMH for youth in Alberta, Canada?

The present study is part of a larger implementation science project evaluating the implementation of a dMH platform in schools, specialised mental health services, primary care networks (PCNs), and community-based mental health service settings in rural and urban communities across Alberta (2020–2026). By implementing dMH, the Alberta health system and researchers aim to address the high prevalence of mental health issues and insufficient mental health resources that meet youth's needs. dMH provides a supplementary approach to existing services and may expand the health system's capacity for prevention, early detection, and early intervention. Among its outcome objectives, the project will assess the impact of dMH on system cost-effectiveness, wait times for mental health services, emergency department use, and youth mental health.

Methods

Project intervention: The Innowell dMH platform

A platform decision-making group selected Innowell⁵¹ as the project intervention based on its evidence base, user experience, safety and security, and ability to be customised to the Alberta context. Through participatory research with health professionals and individuals with lived experience, Innowell was co-designed to enable collaborative measurement-based care (MBC) in a web-based interface.^51–54 MBC traditionally involves the systematic assessment of symptoms and sharing of results between providers and patients to guide personalised treatment and monitor progress.^51,55–57 By gathering and acting upon individual data,⁵⁵ MBC may increase shared decision-making and patient engagement^55,57 and improve clinical outcomes.⁵⁷ Innowell delivers MBC in a digital, accessible format for youth and providers.

The platform contains a multidimensional assessment package of standardised measures across 20 biopsychosocial domains: psychological distress, suicidal thoughts and behaviours, psychosis-like experiences, mania-like experiences, social and occupational function, self-harm, tobacco use, alcohol use, social connectedness, depressed mood, anxiety, physical health, sleep-wake cycle, post-traumatic stress, eating behaviours and body image, cannabis use, grief and loss, spiritual health, cultural connectedness, and resilience.⁵⁸ Youth complete the assessment package continuously or as-needed; their results are immediately shared (with youth, their provider(s), and optional supportive others) via a personalised dashboard that identifies the severity of domains, reflects improvement or decline over time, and suggests relevant and vetted mental health apps and e-tools. Additionally, the platform integrates an automated suicide escalation protocol that alerts providers if youth score high for suicidal thoughts and behaviours⁵² and provides youth with community-specific crisis resources.⁵¹ Providers may engage in MBC by using information about youth's functioning and change processes to augment treatment planning and guide patient goals.

To use Innowell in the context of the research project, youth required access to a service setting implementing dMH and parental/guardian consent for minors (<18 years).

Participant recruitment

We used purposive sampling to recruit participants working in communities and service settings that had agreed to implement Innowell with youth ages 15 to 24.^58,59 In each community, the research team assigned an implementation lead who liaised between researchers and service setting administrators/leadership. The implementation lead disseminated recruitment materials to administrators/leadership who aided in identifying potential participants. To participate, inclusion criteria included (1) employment as a provider (e.g., social worker, administrator, nurse) in an involved service setting, (2) proficiency in written and spoken English, and (3) access to and ability to use web-based technologies on a computer, laptop, tablet, or smartphone. Potential participants who did not meet inclusion criteria were excluded.

Ethical considerations

This study was approved by the Conjoint Health Research Ethics Board at the University of Calgary (REB20-1137). Prior to participation, informed consent and demographic data were collected using Research Electronic Data Capture (REDCap) secure software hosted at the University of Calgary. Consent for audio-recording of focus groups was included in consent forms. Monetary compensation was not provided to participants; service settings implementing dMH considered implementation and research activities part of participants’ regular clinical duties, and focus groups occurred during participants’ working hours.

Data collection

Data was collected during the pre-implementation phase of the project (2020–2022). The research and implementation team developed a semi-structured interview guide to examine specific topics, and encourage flexibility to pursue unforeseen matters raised by participants.^58,59 To structure the guide and inform its questions, the Theoretical Domains Framework (TDF)⁶⁰ was utilised. The TDF comprises 12 theoretical domains that assess perceptions about intervention implementation and behavioural change among stakeholders.^58,59,61 These include: knowledge; skills; social/professional role and identity; beliefs about capabilities; beliefs about consequences; motivation and goals; memory, attention, and decision processes; environmental context and resources; social influences; emotion; behavioural regulation; and nature of the behaviours.⁶¹ Interview questions explored barriers and facilitators to dMH implementation related to TDF domains. Prior to data collection, the guide was piloted with three providers.

Of note, the guide was not originally designed to address the present research question regarding the SDH. Discussions about the SDH emerged organically in response to questions probing contextual factors that may influence the implementation of a digital platform in participants’ communities and service settings. Due to the prevalence and depth of the topic in focus groups and the coding process, we elected to conduct this analysis. Findings related to other barriers and facilitators to dMH are outlined in previous publications.^45,58,59

Focus groups

Twenty-three focus groups were conducted between November 2020 and June 2022^58,59 (see Table 1): 11 with schools and community-based service settings, 7 with specialised mental health services, and 5 with PCNs. Given participants’ locations across Alberta and restrictions due to the COVID-19 pandemic, focus groups were held remotely via Zoom. The duration of focus groups varied from 60 minutes to 2 hours. Within each community, focus groups were conducted separately with each service setting to ensure consistency in shared experiences and contextual relevance related to potential implementation challenges and opportunities. All professions (e.g., social workers, psychologists) attended the same focus group to diversify perspectives on dMH. Focus group size varied from 2 to 20 participants based on rural or urban location, team size, staff availability, and whether organisational leaders were able to provide coverage for staff to attend. Larger groups were made feasible by managerial support and operational capacity within the service setting.

Table 1.

Synthesis of 23 focus groups.

Service setting; total number of focus groups; total number of participants	Location (rural or urban)	Number of participants in focus group	Focus group duration
Schools and Community-based; 11 Focus Groups; 68 Participants	Rural	7	90 minutes
	Rural	10	2 hours
	Rural	10	2 hours
	Rural	9	2 hours
	Rural	5	90 minutes
	Rural	4	60 minutes
	Rural	3	60 minutes
	Rural	3	60 minutes
	Rural	11	2 hours
	Urban	4	60 minutes
	Urban	2	60 minutes
Specialised Mental Health Services; 7 Focus Groups; 54 Participants	Rural	5	90 minutes
	Rural	4	60 minutes
	Rural	12	2 hours
	Rural	3	60 minutes
	Urban	10	2 hours
	Rural	12	2 hours
	Rural	8	90 minutes
Primary Care Networks; 5 Focus Groups; 46 Participants	Rural	7	90 minutes
	Rural	8	90 minutes
	Rural	7	90 minutes
	Rural	4	60 minutes
	Urban	20	2 hours

Throughout data collection and analysis, information power was continuously assessed by revisiting earlier transcripts, considering newly emerging content, and ensuring that no significant new content was overlooked.⁵⁹ The point at which no new content or themes arose in discussions was identified as information power.⁶² This did not occur uniformly across service settings, as certain groups contributed nuanced perspectives from their distinct experiences and backgrounds. Information power was concluded at 23 focus groups and 168 participants based on the depth and richness of the data, the consistency of content and themes across focus groups, and the absence of novel insights in later stages of analysis. While the recommended sample size to reach saturation is four to eight focus groups,⁶³ our larger number of focus groups was necessary to learn from participants across Alberta in four unique service settings.

All focus groups were audio-recorded and transcribed verbatim and all identifying information was removed during the transcription process. As a form of member-checking, participants were sent a written preliminary synthesis of the focus group within 48 hours.⁵⁸ Participants were asked to review and provide feedback on the summary to confirm that their perspectives were captured.

Research team positionality

To ensure consistency in data collection, each focus group was conducted by the same facilitators. Researchers had no prior relationship with participants. In each focus group, the research team shared their career background and role within the project with participants.

Two senior clinician–researchers facilitated the focus groups: the project's co-principal investigator (GD) and a postdoctoral scholar (KB). GD holds a PhD in Social Work and has 25 + years of clinical experience working with youth with mental illness and their families, in tertiary and community-based settings. KB holds a PhD in Nursing and has 20 + years of clinical experience in mental health nursing. In addition, both lead facilitators have significant experience and expertise in qualitative research and leading group discussions. Both lead facilitators identify as women. Two research assistants (RAs) took notes during focus groups. Implementation leads attended focus groups in their respective communities.

In alignment with the project's youth engagement strategy and inclusion of the lived experience lens, the research team included individuals with lived experience of mental illness and working with youth with mental health concerns. This greatly enhanced our understanding of navigating mental health systems and the SDH. To establish reflexivity, we continuously memoed our thoughts about the data, emerging patterns, and potential biases, and discussed our reflections in weekly meetings.

Data analysis

This study employed a qualitative descriptive approach to data analysis.^64,65 Qualitative description aims to comprehensively describe participants’ perceptions and experiences, using easily understood language that remains close to participants’ own words. As such, this approach is aligned with the epistemological perspective of subjectivism, which considers knowledge and meaning-making as subjective and prioritises the worldview of participants.⁶⁶ Developing a rich description of participants’ perspectives is particularly helpful in clinical research that intends to improve aspects of their environment and practice.⁶⁵ In this study, we sought to describe participants’ perceptions and experiences regarding the impact of the SDH on youth's access to dMH.

Thematic analysis

Two senior clinician–researchers who facilitated the focus groups (GD and KB) along with a senior qualitative analyst (EB) supervised the data analysis process, conducted by six RAs – two of whom were present in focus groups as notetakers. We followed Braun and Clarke's⁶⁷ six phases of thematic analysis to explore and describe the data.

In the first phase, RAs and the larger research team familiarised themselves with the entire dataset^67,68 through their attendance in focus groups, creating preliminary syntheses for participant review and approval, and reading focus group transcripts. RAs memoed their reflections and questions about the data for discussion with senior researchers. In the second phase, a codebook was developed to reflect the domains in the TDF.⁶⁰ Deductive codes were determined based on the research team's expertise in implementation science and youth mental health. For example, in the ‘Environmental Context and Resources’ domain, codes included ‘lack of mental health resources’, ‘unstable Internet connection’, ‘collaborative sectors’, and other potential community barriers and facilitators. Transcripts were divided between RAs and coded deductively in Microsoft Word and Taguette coding software.⁶⁹ As new findings arose, RAs added inductive codes to the codebook to ensure that unexpected and unique factors were recognised. Researcher triangulation was attained through independent coding and subsequent review and discussion with the research team, to answer questions and resolve disagreements about coding (if any).

In the third phase, RAs reviewed the completed codebook and began clustering codes into larger patterns,^67,68 many of which emphasised the SDH. The research team developed a research question focused on the SDH to guide the remaining phases of thematic analysis: How might the SDH, including social, economic, environmental, and systemic factors, affect access to dMH for youth in Alberta, Canada? To develop preliminary themes, RAs carefully examined patterns of meaning and relationships between codes within the data using an iterative back-and-forth process between the codes and participant quotes. The research team reviewed the themes to confirm that ideas about the SDH were present across the dataset,⁶⁸ and not only in certain focus groups or individual perspectives. In the fourth phase, themes and related codes were reviewed and refined for coherence⁶⁷ and connection to the research question. Certain separate themes were collapsed into one theme (e.g., the impact of socio-economic circumstances), while others were divided to highlight specific patterns as subthemes (e.g., inequitable access to mental health resources in remote and rural communities).

In the fifth phase, themes were agreed upon, defined, and named in relation to the research question and ‘story’ within the data.^67,68 RAs selected exemplar quotes that captured the essence of each theme to include in theme titles. Finally, the sixth phase entailed producing the manuscript and presenting the themes in accordance with the qualitative descriptive approach. Exemplar quotes from participants across each service setting were included in the manuscript and are representative of sentiments shared by others.

Following the thematic analysis, the research team elected to revisit the data to observe any differences in perspectives and prevalence of discussions about the SDH between location (rural or urban), service settings, and professions, and note whether there was consensus about the SDH in focus groups. These observations are integrated in the Results and thematic analysis.

Trustworthiness and authenticity

This manuscript adheres to the consolidated criteria for reporting qualitative research (COREQ).⁷⁰

Results

Demographics

One hundred and sixty-eight participants took part in the study: 68 from schools and community-based service settings (collapsed to protect participants’ identities), 54 from specialised mental health services, and 46 from PCNs, in communities across Alberta. Participant demographics are outlined in Table 2 as frequencies and percentages.

Table 2.

Participant demographics (n = 168).

Variable	Values, n (%)
Gender
Woman	126 (75)
Man	24 (14)
Missing	18 (11)
Age
20–29 years	16 (10)
30–39 years	54 (32)
40–49 years	53 (31)
50 and over	29 (17)
Missing	16 (10)
Profession
Mental health professional (e.g., social worker, counsellor, therapist)	81 (48)
Administrator (e.g., leadership, case coordinator)	11 (7)
Community connector or teacher/educator	10 (6)
Psychologist	20 (12)
Nurse or physician	22 (13)
Missing	24 (14)
Length of time practicing
5 years or less	34 (20)
6 to 10 years	28 (17)
11 years or greater	91 (54)
Missing	15 (9)
Length of time at organisation
5 years or less	78 (46)
6–10 years	30 (18)
11 years or greater	46 (27)
Missing	14 (83)
Level of education
Some university, college, or trades school	6 (4)
Completed college or trades school	20 (12)
Bachelor's degree	49 (29)
Graduate school	76 (45)
Missing	17 (10)
Ethnicity
Indigenous to North America	7 (5)
Other North American origins	31 (18)
European origins	94 (56)
Asian origins	10 (6)
*Other	9 (5)
Do not know/prefer not to answer	17 (10)

Adapted from Dimitropoulos et al.⁵⁹ Some variables were collapsed to protect participants’ identities due to low numbers. Ethnicity percentages are not included as participants could select more than one option. *Other ethnicities include: Caribbean origins, Latin, Central, and South American origins, and participant-specified/non-specified other origins.

Discourse about the SDH across locations, service settings, and professions

Although a majority of focus groups were conducted in rural areas (19 rural and 4 urban) with common perceptions about the SDH, discourse about the SDH arose in all focus groups irrespective of location. Participants in all service settings discussed the SDH in proportion to the number of focus groups held with each service setting. The highest frequency of discussions about the SDH occurred in school service settings, which had the highest number of focus groups – followed by specialised mental health services and PCNs. Fewer discussions about the SDH occurred in community-based service settings simply due to their lower number of focus groups. Overall, mental health professionals (e.g., social workers, counsellors, therapists) prioritised the SDH above participants in other professions, followed by administrators (e.g., school leadership, clinical supervisors, case coordinators), psychologists, and nurses or physicians. There were no instances of discord among participants about the SDH. Rather, participants frequently reiterated or built upon the statements of their colleagues by sharing their own experiences.

Thematic analysis

Three overarching themes were identified that describe participants’ perspectives about the SDH and their potential impact on access to dMH for youth: (1) facing ‘ignorance and uncertainty’: the impact of social influences, (2) ‘hand-in-hand with mental illness’: the impact of socio-economic circumstances, and (3) ‘quite low-income and quite isolated’: the impact of community contextual and systemic factors. Given the need to access a service setting offering dMH, the themes are also reflective of factors affecting access to mental healthcare in general.

Theme 1: Facing ‘ignorance and uncertainty’: The impact of social influences

Participants recognised social influences as barriers to mental healthcare, and consequently, to dMH. Two distinct subthemes recurred across the data: (1) pervasive stigmatisation and marginalisation in the community, and (2) unsafe family and home environments.

Subtheme 1.1: Pervasive stigmatisation and marginalisation in the community

In schools, specialised mental health services, and PCNs, providers stressed the adverse impact of widespread ‘stigma of mental health or addictions’ (FG19) on youth's access to mental healthcare and dMH. Social stigmatisation and marginalisation around mental illness was frequently noted by mental health professionals working in small, rural communities where ‘people know who's who’ and ‘there's an image to upkeep in those areas’ (FG17). Due to the threat of being stigmatised and marginalised by the community, participants described that many youth are hesitant to seek professional mental health support – even in less conspicuous sites such as schools or PCNs. One participant stated, ‘They don’t want to be associated […]. So, they’re not reaching out at all’ (FG17), and another said, ‘…people do not like to be singled out […]. If you’re in an office or a school environment and someone walks by, all of a sudden the rumour mill starts…’ (FG22). Participants anticipated that feelings of shame and actual or prospective stigmatisation and marginalisation may affect youth's motivation to inquire about dMH in service settings, and use dMH itself. One participant contemplated, ‘…one of the unique challenges for our small community is around anonymity. I’m not so sure if the online platform, and given how people would identify themselves on an online platform like this, would cause any problems… But I would say, that's one of the things’ (FG23).

In both rural and urban areas, providers discussed compounded social influences and access-related barriers for youth who are Two-Spirit, lesbian, gay, bisexual, transgender, queer, intersex, asexual, or other gender identities and sexual orientations (2SLGBTQIA+). Participants shared that 2SLGBTQIA+ youth face ‘ignorance and uncertainty’ in the community and ‘struggle really, really hard’ (FG13). One participant elaborated on barriers to mental healthcare for youth who identify as 2SLGBTQIA+, or who are exploring and questioning their gender identity and/or sexual orientation: ‘We do have a few families at our school […] who are reluctant to have their kids access mental health support because their kids are gender-questioning and they’re not supportive. […] That could be a very, very, very specific barrier in terms of accessing mental health support’ (FG10). Others echoed that ‘conservative ideals’ (FG16) and ‘homophobic beliefs’ (FG17) held by the community and families contribute to dual stigmatisation and marginalisation around mental health and being 2SLGBTQIA+, and deter youth's help-seeking. Knowing that minors required parental/guardian consent to access dMH, participants felt that some 2SLGBTQIA+ youth may be excluded from using dMH with a provider.

Subtheme 1.2: Unsafe family and home environments

Providers in rural and urban areas in schools, specialised mental health services, and PCNs considered barriers to mental healthcare and dMH for youth experiencing child maltreatment and other unsafe living conditions. Among participants, mental health professionals with direct and daily contact with youth were most concerned about youth's safety due to witnessing struggles for youth accessing their services without parent/caregiver knowledge or support. The need for youth to find a safe and private space to use dMH and the potential for youth's devices to be monitored were perceived as barriers to some youth engaging fully with digital care. One participant explained, ‘Youth would be calling in seeking our services, oftentimes with the help of school and without parental consent, without parents who are supportive. […] We do have youth under 18 who could be involved in therapy where there might be some safety issues around using this material [dMH] at home, because their privacy might not be safeguarded’ (FG16). Considering that the online and accessible nature of dMH may facilitate disclosures of abuse, participants were wary that some parents/caregivers may not provide consent for minors to use dMH. One participant articulated providers’ apprehension: ‘…if there are issues in the home, drug use, domestic violence […], parents would be very reluctant for kids to be online. They’re probably reluctant to have them in therapy too. I do think that could play a factor in whether or not people would embrace the idea of getting involved [with dMH]’ (FG4). Others understood dMH as entirely unsuitable for youth experiencing child maltreatment due to safety concerns, and its inability to resolve ‘the treatment concerns […] such as family violence’ (FG6). Despite clear obstacles, some participants saw the potential for dMH to identify youth in precarious situations and enable urgent intervention by providers. One participant asked, ‘What if there is violence, or there's child protection concerns in the home? I think that's another entire area, and I’m not sure if any of those domains in the [dMH] assessment talks about – I can’t remember if it explored violence in the home, because that's going to be a concern as well’ (FG11).

Theme 2: ‘Hand-in-hand with mental illness’: The impact of socio-economic circumstances

Across rural and urban locations and all service settings, providers described socio-economic disparities as a predominant barrier to mental healthcare that may hinder youth's access to dMH. Socio-economic factors were intensely discussed by mental health professionals – particularly those in outreach roles in contact with youth's families and with exposure to youth's broader circumstances. Administrators in leadership positions also prioritised socio-economic factors, grounded in their comprehensive perspective of the community and service setting overall. A common concern among participants was the ability for ‘multi-stressed’ (FG12) youth with mental illness aggravated by competing stressors to engage in treatment of any kind when attending to their basic needs is their priority. One participant succinctly captured the interaction between the SDH, mental health, and access to mental healthcare:

‘…it's our [behavioural therapists] that have our highest no-shows. […] I think it goes hand-in-hand with mental illness and the complexity of their struggles and the social determinants of health that they’re lacking in. […] It's hard to be focused about making it to your appointment or remember that, when you’re hungry and you have other financial insecurities and lack of transportation and stuff’. (FG18)

In view of barriers to engagement, providers deliberated the feasibility of dMH for youth experiencing significant and ongoing socio-economic distress. Participants predicted that some youth may not pursue dMH, ‘…‘cause they’re worried about basic needs first’ (FG5). Others voiced similar trepidations for youth who are unhoused: ‘I do have a significant chunk of kids I don’t know that this will necessarily work for because they’re off and on homeless […], and don’t necessarily have access to regular Internet… Or maybe they go on and answer a couple questions, but they would never log in there again’ (FG19). Youth experiencing housing insecurity were seen as a key population who may benefit from dMH, yet paradoxically, face intensified access-related impediments. One participant reflected:

‘…the housing is pretty unstable for some of our youth. I’m interested to see what demographic of youth this platform finds, and who is going to respond best to it… I think a lot of our youth have so much uncertainty and instability […], and trying to then implement a platform in this holistic look at their lives… […] I think those are good demographics that might need it [dMH] the most. But yet, how do we get them there?’ (FG18)

Beyond youth who lack essential needs, providers expected financial barriers to the Internet, data, and devices among youth on their caseload who are ‘financially disadvantaged’ (FG23) and ‘just scraping by’ (FG10). Participants in school service settings were acutely aware of socio-economic factors impacting youth's access to dMH prerequisites due to the transition to online learning during the COVID-19 pandemic. However, participants in all service settings had worked with ‘…people who don’t have access to technology, or the funding for technology or Wi-Fi’ (FG16). One participant questioned, ‘I wonder about the cost and with [the] web… A lot of the youth who require ongoing mental health services do struggle with the social determinants of health, and economic realities are going to be a factor for them’ (FG23). Although the apps, e-tools, and community-specific resources recommended via Innowell are free, participants also raised concerns about hidden or unforeseen costs. One participant warned, ‘…you do need to have a credit card linked to the Apple account to download something, even though it's free’ (FG23). Others expressed concern regarding the cost of transportation to access resources suggested via dMH located outside remote and rural communities, where access is limited.

Theme 3: ‘Quite low-income and quite isolated’: The impact of community contextual and systemic factors

Participants noted that community contextual and systemic factors profoundly impact youth's access to mental healthcare, and may affect access to dMH. Focus group discussions centred around four core concerns: (1) inequitable access to mental health resources in remote and rural communities, (2) disparities in community access to the Internet, (3) lack of linguistically adapted dMH resources to support diverse community contexts, and (4) systemic marginalisation in mental healthcare.

Subtheme 3.1: Inequitable access to mental health resources in remote and rural communities

Mental health professionals in specialised mental health services and PCNs located in rural and rural-serving urban areas emphasised high rates of acute mental health concerns among youth. In juxtaposition, providers in all locations, service settings, and professions specified that youth's access to much-needed mental healthcare and tools such as dMH is limited by the scarcity of mental health resources in remote and rural communities. Inequitable resource allocation impacted service settings in differing yet equally detrimental ways. In specialised mental health services and PCNs, participants depicted the challenge of being the ‘one-stop-shop’ with ‘not a lot of layers in between’ (FG16). One participant shared, ‘…like literally there's no resources for these kids and we just do our very best’ (FG13). Participants were especially conscious of the interrelatedness of community contextual and systemic barriers for youth and families in under-resourced, remote areas. One participant explicated, ‘people who come from [community name withheld] are quite low-income and quite isolated, so the schools are the primary resource for families there’ (FG16). In school service settings, participants reiterated that ‘…after us [schools], there's few places to go’ (FG8) to access mental healthcare. Participants in community-based organisations working with youth with complex needs had ‘no psychologists to refer them [youth] to’ (FG25).

Given the lack of resources, providers considered how this ‘systemic barrier to child and youth mental health services’ (FG23) might impact youth's access to dMH. Fewer service settings overall and waitlists of up to 2 years were perceived as problematic due to the need to utilise dMH alongside a provider. One participant said, ‘…we have a massive waitlist for primary care physicians. Depending on how they would be involved with the individual's care may – whether or not they have one is going to greatly influence their service’ (FG23). Additionally, the capacity of communities and service settings to offer crisis support to youth who score high for suicidal thoughts and behaviours was a principal concern in all focus groups. Participants described the typical pattern of ‘children going in and out of emergency’ (FG13) with minimal post-discharge follow-up or support systems to manage reoccurring crises. One participant feared, ‘…are we going to be able to adequately support that [dMH], and do we have the resources in [community name withheld] to – if we’re flagging more kids, are we going to be able to support that?’ (FG17).

Subtheme 3.2: Disparities in community access to the Internet

In all rural service settings, providers frequently pointed to geographic disparities in access to the Internet as a factor uniquely affecting access to dMH versus in-person services. Mental health professionals, administrators, and psychologists described ‘sketchy’ (FG10) and ‘intermittent’ (FG24) Internet access in remote, rural, and remotely situated Indigenous communities based on personal experiences of living in the community and providing virtual treatment. Just as the COVID-19 pandemic illuminated socio-economic factors, it also accentuated the infrastructural digital divide outside urban centres. One participant conveyed the experience of many providers: ‘…it [COVID-19] brought to light how many students – because we are in a rural, northern, remote area, where Wi-Fi access and device access, cell phone access, all that stuff can be really spotty if not almost impossible for some of our families’ (FG22). Along with concerns regarding youth's ability to use dMH at home, some participants foresaw issues using dMH on-site due to unstable Internet in their organisations. One participant explained, ‘…we don’t have Wi-Fi here. Most of the other mental health clinics […] they have Wi-Fi so you could do them [dMH measures] with the client on their phone. We don’t have that in our own building’ (FG19).

Subtheme 3.3: Lack of linguistically adapted dMH resources to support diverse community contexts

Providers in schools, PCNs, and community-based service settings in rural and urban areas perceived the current availability of the dMH platform in English only as a barrier for their client population. Among professions, the need for linguistic adaptation in dMH was prioritised by mental health professionals working with immigrants, newcomers, international students, youth from military families, and others who do not speak English or are English Language Learners (ELL). One participant shared, ‘There is a big population that are needing mental health supports in ELL’ (FG21), and another hesitated, ‘I’m concerned about some of the students […]. Many of them come from military families, were transferred from Quebec. […] So, they speak French mainly, when they come here’ (FG8). Participants anticipated that completing dMH measures may pose difficulties for youth: ‘…some students just may not be able to do the psychometrics depending what their English level is at’ (FG10). As a result, participants felt that dMH may necessitate the involvement of providers or translators to support youth's use – and to navigate language differences when proposing dMH to parents/caregivers to obtain parental/guardian consent.

Subtheme 3.4: Systemic marginalisation in mental healthcare

In rural and urban schools and specialised mental health services, providers highlighted the impact of systemic marginalisation on youth's ability and willingness to access dMH embedded in current systems. Mental health professionals and administrators expressed that several population groups in their communities are historically and presently underserved and excluded by systems and institutions; for instance, youth who are racialized, minoritized, immigrants, undocumented immigrants, and migrants. Participants observed that systemic marginalisation in any system or institution may exacerbate youth's mistrust of mental healthcare, and therefore, ‘…minorities and marginalised communities don’t present [at] youth healthcare services of any kind unless things are persistent to severe’ (FG16). Regarding dMH itself, mistrust remained a concern among providers. Participants felt that ‘…a barrier with marginalised individuals might be trust issues’ (FG16) and ‘…there could be some hesitancy because there might not be that feeling of trust in the platform’ (FG9). One participant elucidated specific concerns that youth may encounter when deciding whether to engage with dMH: ‘…where is this information being taken to? Am I going to be further stigmatised or retraumatized by this exercise?’ (FG1). In addition to youth's experiences, participants considered the impact of parents’/caregivers’ experiences on their inclination to provide consent for minors. One participant stated, ‘I think it [dMH engagement] would depend on the backgrounds of the parents and the students. So, what their personal experience has been with our systems […] …especially if we’re looking at some parents who have not had positive experiences with our education system, and with institutions in general’ (FG5).

Discussion

This study explored providers’ perspectives of how the SDH may affect youth's access to dMH. Three themes were identified that describe the impact of social, socio-economic, and community contextual and systemic factors. Collectively, the three themes illustrate that the SDH do not occur in isolation and may combine to produce multiple forms of disadvantage. Our study brings to light areas for discussion along with practical implications and directions for future research.

Discourse about the SDH across locations, service settings, and professions

Providers in all locations (rural or urban) demonstrated their knowledge of the SDH affecting youth. While the higher number of focus groups in rural settings inevitably shifted the focus of discussions to rural-specific challenges, it is worth noting that rural regions face elevated adversity and exposure to the SDH^32,71 in comparison to urban centres. Factors such as economic stressors, higher unemployment,³² and barriers to needed resources may contribute to poorer mental health outcomes among rural youth.^50,72 Interestingly, the notion that perceived community belonging is associated with wellbeing in rural areas⁷³ underscores the negative impact of community stigmatisation and marginalisation noted by our participants.

Providers in schools, specialised mental health services, PCNs, and community-based service settings considered the SDH relatively equally and held common concerns. The fact that disparate access to mental health resources in rural areas was discussed in all service settings validates that access to health systems is a powerful SDH,^3,29 with cyclical influence on mental health and access to dMH. More quotes about the SDH were collected from school participants due to their larger number of focus groups. However, the nature of schools as a youth-serving institution mean that youth spend much of their time in schools²⁹ – increasing school providers’ exposure to youth's academic, social, and mental health difficulties.^74,75 School providers may be particularly aware of the SDH impacting youth's academic journeys, personal lives, and access to mental healthcare. Considering our participants’ description of the association between mental health and the SDH, it is logical that the SDH were heavily discussed in specialised mental health services which serve youth with moderate to high acuity mental illness. Youth who seek care in PCNs may also exhibit ‘social complexity’⁽⁷⁶^{, p. 223)} factors that shape their mental health, and the care that they receive. In community-based service settings, providers may hold valuable knowledge about the SDH given the recognition of social-ecological barriers and facilitators to mental health in community interventions.⁷⁴

The higher number of mental health professionals (e.g., social workers) who participated in our study (81 of 168) aligns with their frequency of discussions about the link between the SDH and dMH. Historically and presently, the social work field has advocated for acknowledgment of contextual factors affecting wellbeing.^77,78 The counselling profession similarly emphasises systems thinking,²⁰ mental health inequities,²⁹ and the potential for counsellors to utilise their positionality to address the SDH.^20,29 Although few administrators participated in the study (11 of 168), much dialogue about the SDH was initiated by providers in leadership roles (e.g., clinical supervisors). It is possible that some service setting leaders identified their original profession (e.g., nurse) in their demographic data and thus skewed the lower number of administrators. Regardless, their awareness of the SDH that mediate youth's access to dMH is encouraging – and appears less discussed in existing literature. Our team is exploring the role of leadership in dMH implementation as part of our larger project.⁷⁹ Fewer quotes about the SDH were tied to psychologists, nurses, and physicians, which may reflect the lower number of participants in these roles versus, for example, social workers. Prior work suggests a need for greater integration of training about the SDH in psychology,⁸⁰ nursing,⁸¹ and medical academic and residency programmes.^82,83 If medical providers have a thorough understanding of the SDH, they may still feel uncertain of how to address external factors in their scope of practice.⁸⁴ Our study amplifies the importance of providers in all roles in recognising the SDH and strategizing to improve youth's digital access.

Focus group consensus

In all focus groups, discussions about the SDH provoked agreement between providers through amenable interaction on the topic or simple expressions of consensus (e.g., ‘I agree’, ‘same here’, nodding). Some providers simply did not respond to the subject. If probed to share their opinion, the conversation moved to a related or new direction. Overall consensus about the SDH may be due in part to focus groups being held with providers from the same community and service setting, and genuine similarity in perceptions and experiences. Further, focus group dynamics may naturally create acceptance of others’ perspectives⁸⁵ and the tendency for certain voices to dominate the discussion.⁵⁹ The presence of service setting leadership may have affected interactions⁸⁶ by deterring some participants from sharing openly.⁵⁹ Lastly, the time pressure of the focus groups⁸⁶ and need for providers to return to their regular working day may have limited some participants’ desire to disagree or interact in general.

Thematic analysis

Theme 1: Facing ‘ignorance and uncertainty’: The impact of social influences

In the first theme, findings show that rural community stigmatisation, marginalisation, and concerns about anonymity are barriers to youth accessing mental healthcare and dMH. The relationship between rurality and barriers to mental health help-seeking is previously documented.^50,87,88 To preserve anonymity and reduce perceived stigma around mental health, dMH and virtual care are cited as solutions that expand rural access to mental health resources.⁸⁹ However, Borghouts et al.⁴⁶ found that ‘setting matters’ (p. 14); maintaining privacy may be more difficult in small communities due to the potential of sharing self-identifying information through dMH, being seen using dMH,⁴⁶ or being seen accessing a service setting that offers dMH. dMH alone also cannot adequately address the stigma underlying youth's desire for privacy around their mental health and access to services. Researchers caution that strategies to improve help-seeking targeting attitudinal barriers (e.g., anti-stigma campaigns) may be ineffective in promoting behavioural change.^87,89–91 Rather, studies recommend community interventions that adapt to local contexts and engage with local residents, organisations, and informal support networks to understand community inequities and strengths.^50,89 Our findings call for increased efforts to address community-level stigma in rural regions to facilitate youth's access to mental healthcare and dMH.

Results also indicate that stigmatisation and marginalisation especially limits help-seeking among 2SLGBTQIA+ youth. Consistent with our findings, prior work suggests that stigma around gender identity and sexual orientation may deter access to mental healthcare by way of concerns about experiencing further discrimination in health systems⁹² – particularly in rural communities.⁹³ Our study's requirement for parental/guardian consent to access dMH may be a barrier for youth with families/caregivers that are not affirming of their gender identity, sexual orientation, or journey of self-exploration and questioning. Conversely, other studies show that 2SLGBTQIA+ youth are actively engaged online^94–96 and are willing to seek mental health support through online mediums.⁴⁴ dMH tools are developed that connect youth with inclusive service settings and other safe, 2SLGBTQIA+ -friendly spaces in the community.⁹² Given that youth's preference for online support may be tied to minority stress in various forms,⁹⁶ we advocate for community work to address the stigmatisation and marginalisation of 2SLGBTQIA+ individuals so that youth are comfortable seeking dMH in local organisations.

Our study reveals that youth experiencing child maltreatment and other unsafe family and home environments face heightened barriers to dMH. In congruence with participants’ concerns, literature cautions that devices may be monitored,^47,97 and that dMH may lack sufficient privacy measures to protect the safety of the user.⁴⁸ Youth may be challenged to find a safe and private space within their home to engage with dMH,⁹⁷ without placing themselves at risk. Notably, some evidence alludes that the anonymity, flexibility, and accessibility of dMH may enable access among youth in unsafe circumstances.⁹⁸ This study adds that dMH may present the opportunity to disclose child maltreatment or other trauma to a provider, and facilitate intervention. We encourage greater attention to underserved populations who are at higher risk of experiencing family violence and concurrently face barriers to dMH due to intersecting social, socio-economic, geographic, and other inequities.⁴⁸

Theme 2: ‘Hand-in-hand with mental illness’: The impact of socio-economic circumstances

The second theme establishes that socio-economic factors significantly impact youth's access to mental healthcare of any kind, including dMH. Our participants felt that youth who lack access to basic needs and/or are unhoused may engage only briefly with dMH – if at all. In prior research, studies found that youth experiencing housing instability do use and benefit from dMH, but prefer brief interventions requiring minimal interaction⁹⁹ or brief but frequent engagement (e.g., multiple times per day).¹⁰⁰ Although existing work supports the feasibility of dMH for youth in socio-economic distress, Lal et al.¹⁰¹ note that dMH may be most effective in improving mental health when used alongside providers who are prepared to address youth's multifactorial needs. This along with our findings exemplifies a need for intersectoral collaboration in dMH implementation so that all influences on youth mental health and access to digital resources are addressed.

Also in the second theme, our study affirms that financial barriers limit youth's access to the technology required to use dMH. Concerns about the cost of the Internet, data, devices, or in-app purchases are documented in scoping³³ and systematic reviews,⁴⁶ and a qualitative study of rural youth perspectives.¹⁰² In the Canadian context, Yu et al.⁴⁹ found that dMH users report higher incomes, private insurance, and access to a primary care physician in comparison to non-users. These findings imply that dMH may reach financially advantaged youth with existing access to health systems and providers. Accordingly, we restate the urgency to ensure that youth who are economically marginalised by current systems are not also limited in their ability to access dMH.

Theme 3: ‘Quite low-income and quite isolated’: The impact of community contextual and systemic factors

The third theme calls attention to the prevalence of unmet mental health needs among youth in rural communities. Our study is consistent with Canadian data, which finds that rural youth experience a high burden of mental health crises including suicide attempts and non-suicidal self-injuries.¹⁶ Mental health stigma, economic pressures,⁷² limited service availability,^50,72 and other previously noted factors affect youth mental health and risk of suicide in isolated areas.^50,72 Many Indigenous communities are rurally situated and thus disproportionately impacted by geographic inequities in access to services.¹² Although dMH is recommended to expand access to mental healthcare,^33,40,41 dMH offered via current systems cannot improve access if service availability is limited by geography. We reiterate our participants’ assertion that rural communities require increased access to resources to address mental health disparities.

In rural contexts, our results also stress the digital divide as a prominent environmental barrier to dMH.^33,103 This reflects the finding that a higher proportion of dMH users reside in urban centres,⁴⁹ where Internet stability is more likely. Moreover, our study aligns with the argument that dMH may ‘disproportionately benefit the more digitally advantaged segments of the population, even though such initiatives would do the most good among the digitally disadvantaged who also bear the greatest burdens in terms of poor health’.^104(p576) Reglitz and Rudnick¹⁰⁵ assert that access to the Internet is a human right – necessary to realise the human right to mental healthcare in under-resourced communities. We advocate for improved infrastructure so that youth in any geographic location may exercise their right to mental healthcare, and dMH.

Our study suggests that offering dMH in English only does not equitably serve communities in Alberta. Systemic barriers for individuals who do not speak English or are learning English are well-documented,^106–110 and greatly impact information-seeking^106,107 and engagement in therapy¹⁰⁷ with English-speaking providers. Qualitative studies emphasise wait times for available interpreters,¹⁰⁹ reliance on family members for communication, and issues with confidentiality.¹¹⁰ In Canada, youth who are racialized are adversely affected by the provision of mental healthcare in English only (or French in some areas).¹⁵ This study highlights that the predominance of the English language in health systems and dMH may interact with and exacerbate other barriers to accessing mental healthcare. Using community co-design, the translation of dMH products into multiple languages may increase the accessibility¹¹¹ and cultural relevance of dMH.

Finally, a key finding is that systemic marginalisation may affect youth's ability and willingness to access dMH embedded in current mental healthcare pathways. There is heterogeneity between and within the populations noted by our participants; individual experiences may also vary irrespective of affiliation with a particular group, and are impacted by intersectionality. In line with our findings, Kamali et al.¹¹² found that youth who are racialized, ethnic minorities, immigrants, or refugees were less likely to seek and/or access mental healthcare. A Canadian survey found that People of Colour sought mental health services more frequently – yet experienced greater access-related barriers than White participants.¹⁵ Mistrust of systems, service settings, and providers is a barrier for some youth who are racialized, immigrants,²² migrants, or refugees.¹⁰⁸ Youth may be alienated from mental health systems by experiences of discrimination and racism, cultural misunderstandings leading to improper diagnoses and treatment,²² challenges in obtaining legal documents to access services,¹⁰⁸ or other factors. Together with our study, these data denote the need to attend to systemic barriers to improve access to the mental health system and dMH for youth experiencing marginalisation.

Relevance for clinical practice

Participants identified recommendations for addressing the SDH affecting youth's access to dMH (Table 3). For example, participants advised the inclusion of specific assessment domains, providing access to Internet and technology in service settings, and training to build trust with marginalised populations. Participants also considered ways that dMH might improve access to mental healthcare by providing access in under-resourced areas or to youth on waitlists.

Table 3.

Provider recommendations for increasing access to dMH for youth.

Factors affecting access to dMH	Intended user	Recommendations from providers
Facing ‘Ignorance and Uncertainty’: The Impact of Social Influences	dMH implementation teams	Include dMH assessment domains related to family circumstances to aid providers to identify youth in unsafe situations
‘Hand-in-hand with Mental Illness’: The Impact of Socioe-conomic Circumstances	Providers	Establish a directory of local locations where youth may access Wi-Fi and devices (e.g., youth centres, public libraries, local businesses)
	Providers	Provide youth with Wi-Fi and device access at the service setting
	dMH implementation teams	Ensure apps and e-tools embedded in dMH are free and do not require a credit card for access
	dMH implementation teams	Ensure that community-specific resources suggested via dMH are free and accessible. In remote/rural communities, ensure resources do not require extensive travel and cost of transportation
‘Quite Low-income and Quite Isolated’: The Impact of Community Contextual and Systemic Factors	Providers	Use dMH as an auxiliary resource for youth in remote/rural areas with limited access to mental health services
	Providers	Use dMH with youth in remote/rural areas who lack access to transportation to regularly attend in-person services
	Providers	Use dMH with youth who are on waitlists to receive mental health services to ensure they are supported and monitored while waiting
	Providers	Provide language support to youth whose first language is not English to complete dMH assessments in-session
	dMH implementation teams	Provide dMH, including apps and e-tools, in various languages
	Providers, dMH implementation teams	Provide training and resources for providers to build trust among marginalised populations interested in using mental healthcare and dMH

dMH: digital mental health.

Our findings offer other implications for service settings, providers, and decision-makers. In relation to the first theme, providers perceived that some minors may face barriers in obtaining consent to access mental healthcare and dMH. We suggest that providers apply the same informed consent and mature minor practices to dMH as are applied in mental healthcare in general (e.g., limits to confidentiality in disclosures of child maltreatment). Service settings should consider developing protocols to address disclosures in the context of dMH, and providers should work with youth to develop a safety plan for using dMH. dMH itself should incorporate a safe-exit feature.

The second theme indicates that youth experiencing socio-economic instability should be met ‘where they are at’ by addressing their current needs. Service settings and providers might consider using dMH to support flexible hours for accessing care and incorporating dMH into mobile services. dMH can also enable continuity of care⁴⁰ for youth who are unhoused/mobile by allowing providers to access youth's data no matter where youth present for services.

There are also opportunities to simultaneously address multiple SDH. First, we propose the implementation of dMH in integrated youth services (IYS). IYS provide youth-centred care including physical health, mental health, and social services in one location.¹¹³ Recent data show that IYS attract youth who are historically and presently underserved and excluded,^113,114 including youth who are racialized, unhoused, or unemployed.¹¹³ Implementing dMH in IYS would provide accessible, flexible access to mental healthcare alongside assistance in meeting youth's other needs (e.g., food, housing, employment).

Second, we recommend that dMH incorporate screening for various social, economic, environmental, and systemic factors. A holistic approach to mental health assessment may provide valuable information about external factors exacerbating mental health concerns and engagement with mental healthcare, and enable providers to intervene in meaningful ways. Providers should work with youth to understand their own experiences with the SDH and collaboratively identify relevant and realistic areas for intervention.

Future directions

This study reveals a pressing need for system-level change. We suggest that researchers utilise co-design methodologies involving youth, systems, service settings, providers, decision-makers, and other partners to determine how mental health systems might improve their overall accessibility and access to dMH for youth who are underserved and excluded. The involvement of youth partners in initial project phases through data collection and analysis is imperative to ensure that research conducted about youth is pertinent to youth themselves. Youth partners may provide insight regarding how to reach and engage other youth who are not currently accessing mental healthcare or dMH due to barriers. This work should identify strategies and best practices for providers, outlining ways that providers can address the SDH with youth.

Within this programme of research and larger project, we are exploring the perspectives of youth,¹¹⁵ providers,^45,58,59 and leadership⁷⁹ to understand how systems might improve access to dMH. Manuscripts presenting the post-implementation perspectives of providers and leadership regarding barriers and facilitators to dMH access and implementation are forthcoming.

Strengths and limitations

To our knowledge, this study is the first to describe the relationship between the SDH and access to dMH from providers’ perceptions and practical experiences. A strength of this study is the inclusion of providers from diverse disciplines and communities across Alberta, Canada. This allowed for a breadth of perspectives on the ways in which the SDH may affect youth's access to dMH. Another strength is the involvement of research team members with lived experience of mental illness, along with members with clinical and research experience. This provided a balance of insights during data analysis. A limitation is that our interview guide focused on general barriers and facilitators to dMH implementation, rather than questions about the SDH. Inquiring explicitly about the SDH may have resulted in more specific barriers and recommendations. Relatedly, our findings may not capture the nuances of barriers to dMH for specific population groups, or individual and intersectional experiences. It is also important to note that our study presents the perspectives of providers about youth, and not youth themselves. Our participants included more female than male participants; this reflects the gender distribution of providers in the mental health field. Lastly, our findings centre the experiences of providers in Alberta, Canada, and may not be representative of other contexts.

Conclusions

This study sought to explore the perspectives of providers regarding how the SDH may affect access to dMH for youth in Alberta, Canada. Our findings show that social influences, socio-economic circumstances, and the community context and systems are instrumental and intersecting SDH affecting youth's pathways to accessing dMH. The identified themes provide practical insight to service settings and providers working with youth experiencing mental illness, and navigating external factors along their journey.

Providers’ experiences in working with youth from various social locations emphasise that access to dMH is a matter of mental health equity. Understanding and addressing the barriers to dMH is crucial to ensure that dMH reaches and benefits youth who are underserved and excluded by current systems – alongside youth who already access mental healthcare. Through additional research and efforts, we may better understand how dMH might create new and transformative pathways to mental healthcare and improve mental health outcomes for all youth.

Footnotes

Acknowledgements

The authors extend their gratitude to the study's implementation team who facilitated the implementation of dMH in Alberta communities, trained providers in using dMH, and shared providers’ feedback with the research team throughout the project. Additionally, the authors acknowledge the time and efforts of providers responsible for implementing dMH, organisation leaders, and other partners involved in this work. We thank you for sharing your perspectives with us to inform accessible mental health services for young people. To the individuals with lived experience whom we have met through research, advocacy, and in health systems: thank you for continuously inspiring us to think and work reflexively, ask questions, and prioritise youth. Your stories and expertise guide our work, and our passion for youth mental health.

Author Note

Jason Gondziola, Leanne Stamp, Melanie Fersovitch, Karen Moskovic, and Jessica Bradley are now affiliated with the Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada.

ORCID iDs

Lia Norman

Katherine Bright

Emilie M. Bassi

Marianne Barker

Julia Hews-Girard

Karina Pintson

Lauren Volcko

Simron Sidhu

Katelyn Greer

Jason Gondziola

Melanie Fersovitch

Haley M. LaMonica

Ian Hickie

Frank Iorfino

Gina Dimitropouloss

Ethical approval

This study was approved by the Conjoint Health Research Ethics Board at the University of Calgary (‘eMH Qualitative Study – Pre-Implementation and Implementation’ – REB20-1137).

Contributorship

LN, GD, KB, EB, SS, HL, IH and FI were involved in conceptualisation; LN, GD, KB, EB, MB, JHG, KP, SD, LV, SS and KG in data curation and formal analysis; GD in funding acquisition and methodology; GD, KB, EB, LN, KP, JG, LS, JB, MF and KM in investigation; GD, KB and EB in project administration; GD, KB, EB, MB and JHG in supervision; LN, GD, KB and EB in writing – original draft; and LN, GD, KB, EB, MB, JHG, JG, LS, JB, MF, KM, HL, IH and FI in writing – review and editing.

Funding

The authors disclose receipt of the following financial support for the research, authorship, and publication of this article: this work was supported by the Partnership for Research and Innovation in the Health System (PRIHS) Program, Alberta Health Services, the Alberta Children's Hospital Foundation, and the Canadian Institutes of Health Research (CIHR) [Operating Grant: SPOR iCT Rewarding Success].

Declaration of conflicting interest

The authors declare no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Data availability

Research data is not shared in compliance with ethics measures in place to protect participant confidentiality and privacy.

Guarantor

GD.

Informed Consent

All participants provided written informed consent via an online consent form prior to participating.

Peer Review

XXX

References

McGorry

Mei

Chanen

, et al. Designing and scaling up integrated youth mental health care. World Psychiatry [Internet]. 2022; 21: 61–76.

Solmi

Radua

Olivola

, et al. Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies. Mol Psychiatry 2022; 27: 281–295.

Kirkbride

Anglin

Colman

, et al. The social determinants of mental health and disorder: evidence, prevention and recommendations. World Psychiatry. 2024; 23: 58–90.

Wiens

Bhattarai

Pedram

, et al. A growing need for youth mental health services in Canada: examining trends in youth mental health from 2011 to 2018. Epidemiol Psychiatr Sci. 2020; 29: e115.

Kourgiantakis

Markoulakis

Hussain

, et al. Navigating inequities in the delivery of youth mental health care during the COVID-19 pandemic: perspectives of youth, families, and service providers. Can J Public Health. 2022; 113: 806–816.

Malla

Shah

Iyer

, et al. Youth mental health should be a top priority for health care in Canada. Can J Psychiatry. 2018; 63: 216–222.

Sadath

Troya

Nicholson

, et al. Physical and mental illness comorbidity among individuals with frequent self-harm episodes: a mixed-methods study. Front Psychiatry. 2023; 14: 1121313.

Gili

Castellví

Vives

, et al. Mental disorders as risk factors for suicidal behavior in young people: a meta-analysis and systematic review of longitudinal studies. J Affect Disord. 2019; 245: 152–162.

McHugh

Iorfino

Zmicerevska

, et al. Premature mortality in young people accessing early intervention youth mental healthcare: data-linkage cohort study. BJPsych Open. 2023; 9: e76.

10.

MacDonald

Ferrari

Fainman-Adelman

, et al. Experiences of pathways to mental health services for young people and their carers: a qualitative meta-synthesis review. Soc Psychiatry Psychiatr Epidemiol. 2021; 56: 339.

11.

MacDonald

Fainman-Adelman

Anderson

, et al. Pathways to mental health services for young people: a systematic review. Soc Psychiatry Psychiatr Epidemiol. 2018; 53: 1005–1038.

12.

Murray

Knudson

. Mental health treatment and access for emerging adults in Canada: a systematic review. Front Public Health. 2023; 11: 1088999.

13.

Radez

Reardon

Creswell

, et al. Why do children and adolescents (not) seek and access professional help for their mental health problems? A systematic review of quantitative and qualitative studies. Eur Child Adolesc Psychiatry. 2021; 30: 183–211.

14.

Stunden

Zasada

VanHeerwaarden

, et al. Help-seeking behaviors of transition-aged youth for mental health concerns: qualitative study. JMIR. 2020; 22: e18514.

15.

Faber

Osman

Williams

. Access to mental health care in Canada. Int J Ment Health. 2023; 52: 312–334.

16.

Mahinpey

Pollock

Liu

, et al. Self-harm and rurality in Canada: an analysis of hospitalization data from 2015 to 2019. Soc Psychiatry Psychiatr Epidemiol. 2023; 58: 1161–1170.

17.

Holley

Tavassoli

Stromwall

. Mental illness discrimination in mental health treatment programs: intersections of race, ethnicity, and sexual orientation. Community Mental Health J. 2016; 52: 311–322.

18.

Shim

. Dismantling structural racism in psychiatry: a path to mental health equity. Am J Psychiatry. 2021; 178: 592–598.

19.

O’Brien

. Social determinants of health: the how, who, and where screenings are occurring; a systematic review. Soc Work Health Care. 2019; 58, 719–745.

20.

Sheperis

Cuff

Sheperis

. Educating professional counselors about the social determinants of mental health. J Couns Dev. 2023; 101: 429–439.

21.

Chaiton

Musani

Pullman

, et al. Access to mental health and substance use resources for 2SLGBTQ+ youth during the COVID-19 pandemic. Int J Environ Res Public Health. 2021; 18: 11315.

22.

Fante-Coleman

Jackson-Best

. Barriers and facilitators to accessing mental healthcare in Canada for Black youth: a scoping review. Adolesc Res Rev. 2020; 5: 115–136.

23.

Gajaria

Guzder

Rasasingham

. What’s race got to do with it? A proposed framework to address racism’s impacts on child and adolescent mental health in Canada. J Can Acad Child Adolesc Psychiatry. 2021; 30: 131–137.

24.

World Health Organization. A conceptual framework for action on the social determinants of health. Report, 2010. Available from: https://iris.who.int/bitstream/handle/10665/44489/9789241500852_eng.pdf?sequence=1

25.

Braveman

Egerter

Williams

. The social determinants of health: coming of age. Annu Rev Public Health. 2011; 32: 381–398.

26.

Viner

Ozer

Denny

, et al. Adolescence and the social determinants of health. Lancet. 2012; 379: 1641–1652.

27.

World Health Organization. Closing the gap in a generation: health equity through action on the social determinants of health. Report, 2008.

28.

Allen

Balfour

Bell

, et al. Social determinants of mental health. Int Rev Psychiatry. 2014; 26: 392–407.

29.

Johnson

Cunningham

Tirado

, et al. Social determinants of mental health considerations for counseling children and adolescents. J Child Adolesc Couns. 2023; 9: 21–33.

30.

Marmot

Bell

. Social inequalities in health: a proper concern of epidemiology. Ann Epidemiol. 2016; 26: 238–240.

31.

Settipani

Hawke

Virdo

, et al. Social determinants of health among youth seeking substance use and mental health treatment. J Can Acad Child Adolesc Psychiatry. 2018; 27: 213–221.

32.

Flavel

Kedzior

SGE

Isaac

, et al. Regional health inequalities in Australia and social determinants of health: analysis of trends and distribution by remoteness. Rural Remote Health. 2024; 24: 1–11.

33.

Wies

Landers

Ienca

. Digital mental health for young people: a scoping review of ethical promises and challenges. Front Digit Health. 2021; 3: 697072–697072.

34.

Liverpool

Mota

Sales

CMD

, et al. Engaging children and young people in digital mental health interventions: systematic review of modes of delivery, facilitators, and barriers. JMIR. 2020; 22: e16317–e16317.

35.

Kruzan

Biernesser

Hoffmann

, et al. Digital interventions for adolescents and young adults experiencing self-injurious thoughts and behaviors. Curr Treat Options Psychiatry. 2024; 11: 76–89.

36.

Racine

Hartwick

Collin-Vézina

, et al. Telemental health for child trauma treatment during and post-COVID-19: limitations and considerations. Child Abuse Negl. 2020; 110(Pt 2): 104698–104698.

37.

Kleiman

Glenn

Liu

. Real-time monitoring of suicide risk among adolescents: potential barriers, possible solutions, and future directions. J Clin Child Adolesc Psychol. 2019; 48: 934–946.

38.

Gilmore

Ward-Ciesielski

. Perceived risks and use of psychotherapy via telemedicine for patients at risk for suicide. J Telemed Telecare. 2019; 25: 59–63.

39.

Rheinberger

Baffsky

McGillivray

, et al. Examining the feasibility of implementing digital mental health innovations into hospitals to support youth in suicide crisis: interview study with young people and health professionals. JMIR Form Res. 2023; 7: e51398–e51398.

40.

Lal

. E-mental health: promising advancements in policy, research, and practice. Healthc Manage Forum. 2019; 32: 56–62.

41.

Lal

Adair

. E-mental health: a rapid review of the literature. Psychiatr Serv. 2014; 65: 24–32.

42.

Bakhti

Daler

Ogunro

, et al. Exploring engagement with and effectiveness of digital mental health interventions in young people of different ethnicities: systematic review. JMIR. 2025; 27: e68544.

43.

Hicks

Toombs

Lund

, et al. Expanding our understanding of digital mental health interventions for Indigenous youth: an updated systematic review. J Telemed Telecare. 2024;1357633X241239715.

44.

Lucassen

Samra

Iacovides

, et al. How LGBT+ young people use the internet in relation to their mental health and envisage the use of e-therapy: exploratory study. JMIR Serious Games. 2018; 6: e11249–e11249.

45.

Barker

Hews-Girard

Pinston

, et al. Organizational factors impacting the implementation of a digital mental health tool in Alberta’s mental health care of youth and young adults. Digit Health. 2025; 11: 20552076241310341.

46.

Borghouts

Eikey

Mark

, et al. Barriers to and facilitators of user engagement with digital mental health interventions: systematic review. JMIR. 2021; 23: e24387.

47.

Emezue

. Digital or digitally delivered responses to domestic and intimate partner violence during COVID-19. JMIR Public Health Surveill. 2020; 6: e19831.

48.

Ghidei

Montesanti

Tomkow

, et al. Examining the effectiveness, acceptability, and feasibility of virtually delivered trauma-focused domestic violence and sexual violence interventions: a rapid evidence assessment. Trauma Violence Abuse. 2023; 24: 1427–1442.

49.

Sequeira

. Determinants of e-mental health use during COVID-19: cross-sectional Canadian study. JMIR. 2022; 24: e39662.

50.

Paquet

Hibbard

Brett-MacLean

. The landscape of non-psychotic psychiatric illness in rural Canada: a narrative review. Rural Remote Health. 2024; 24: 1–11.

51.

Iorfino

Cross

Davenport

, et al. A digital platform designed for youth mental health services to deliver personalized and measurement-based care. Front Psychiatry. 2019; 10: 595.

52.

Davenport

LaMonica

Whittle

, et al. Validation of the Innowell platform: protocol for a clinical trial. JMIR Res Protoc. 2019; 8: e13955.

53.

LaMonica

Iorfino

Lee

, et al. Informing the future of integrated digital and clinical mental health care: synthesis of the outcomes from Project Synergy. JMIR Ment Health. 2022; 9: e33060.

54.

McKenna

Piper

Capon

, et al. The polarization of clinician and service staff perspectives after the use of health information technology in youth mental health services: implementation and evaluation study. JMIR Hum Factors. 2023; 10: e42993.

55.

Connors

Douglas

Jensen-Doss

, et al. What gets measured gets done: how mental health agencies can leverage measurement-based care for better patient care, clinician supports, and organizational goals. Adm Policy Ment Health. 2021; 48: 250–265.

56.

Lewis

Boyd

Puspitasari

, et al. Implementing measurement-based care in behavioral health: a review. JAMA Psychiatry. 2019; 76: 324–335.

57.

Scott

Lewis

. Using measurement-based care to enhance any treatment. Cogn Behav Pract. 2015; 22: 49–59.

58.

Bassi

Bright

Norman

, et al. Perceptions of mental health providers of the barriers and facilitators of using and engaging youth in digital mental-health-enabled measurement based care. Digit Health. 2024; 10: 20552076241253093.

59.

Dimitropoulos

Bassi

Bright

, et al. Implementation of an electronic mental health platform for youth and young adults in a school context across Alberta, Canada: thematic analysis of the perspectives of stakeholders. JMIR Ment Health. 2024; 11: e49099.

60.

Cane

O’Connor

Michie

. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012; 7: 37.

61.

French

Green

O’Connor

, et al. Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework. Implement Sci. 2012; 7: 38.

62.

Malterud

Siersma

Guassora

. Sample size in qualitative interview studies: guided by information power. Qual Health Res. 2016; 26: 1753–1760.

63.

Hennink

Kaiser

. Sample sizes for saturation in qualitative research: a systematic review of empirical tests. Soc Sci Med. 2022; 292: 1–10.

64.

Colorafi

Evans

. Qualitative descriptive methods in health science research. HERD. 2016; 9: 16–25.

65.

Doyle

McCabe

Keogh

, et al. An overview of the qualitative descriptive design within nursing research. J Res Nurs. 2020; 25: 443–455.

66.

Bradshaw

Atkinson

Doody

. Employing a qualitative description approach in health care research. Glob Qual Nurs Res. 2017; 4: 2333393617742282.

67.

Braun

Clarke

. Using thematic analysis in psychology. Qual Res Psychol. 2006; 3: 77–101.

68.

Terry

Hayfield

Clarke

, et al. Thematic analysis. In Willig

Rogers

(eds) The SAGE handbook of qualitative research in psychology. 2nd ed. Thousand Oaks, CA, USA: Sage Publications, Inc.; 2017. pp. 1–38.

69.

Taguette. About Taguette. Taguette; n.d. Available from: https://www.taguette.org/about.html

70.

Tong

Sainsbury

Craig

. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007; 19: 349–357.

71.

Myers

. Using telehealth to remediate rural mental health and healthcare disparities. Issues Ment Health Nurs 2019; 40: 233–239.

72.

Rauch

Ryan

Ramsey

, et al. Suicidality in rural communities: a scoping review of research in Canada. Can J Commun Ment Health 2023; 42: 41–57.

73.

Kelly

Lewin

Stain

, et al. Determinants of mental health and well-being within rural and remote communities. Soc Psychiatry Psychiatr Epidemiol 2011; 46: 1331–1342.

74.

Castillo

Ijadi-Maghsoodi

Shadravan

, et al. Community interventions to promote mental health and social equity. Curr Psychiatry Rep 2019; 21: 35.

75.

Koslouski

Chafouleas

Briesch

, et al. School-based screening of social determinants of health: a scoping review. School Ment Health. 2024; 16, 1–14.

76.

Katz

Chateau

Enns

, et al. Association of the social determinants of health with quality of primary care. Ann Fam Med. 2018; 16: 217–224.

77.

de Saxe Zerden

Cadet

Galambos

, et al. Social work’s commitment and leadership to address social determinants of health and integrate social care into health care. J Health Hum Serv Adm. 2020; 43: 309–323.

78.

Rine

. Social determinants of health: grand challenges in social work’s future. Health Soc Work. 2016; 41: 143–145.

79.

Henry

Hews-Girard

Bright

, et al. Balancing support with sustainability: bridging the gap between first-level leadership vision and practice in youth digital mental health. J Can Acad Child Adolesc Psychiatry. 2025: 1–30.

80.

Woods-Jaeger

Cho

Briggs

. Training psychologists to address social determinants of mental health. Train Educ Prof Psychol. 2024; 18: 31–41.

81.

Thornton

Persaud

. Preparing today’s nurses: social determinants of health and nursing education. Online J Issues Nurs. 2018; 23: 1–9.

82.

Gard

Peterson

Miller

, et al. Social determinants of health training in U.S. primary care residency programs: a scoping review. Acad Med. 2019; 94: 135–143.

83.

Hudon

Dumont-Samson

Breton

, et al. How to better integrate social determinants of health into primary healthcare: various stakeholders perspectives. Int J Environ Res Public Health. 2022; 19: 15495.

84.

Yelton

Rumthao

Sakhuja

, et al. Assessment and documentation of social determinants of health among health care providers: qualitative study. JMIR Form Res. 2023; 7: e47461.

85.

Tümen Akyildiz

Ahmed

. An overview of qualitative research and focus group discussion. Int J Acad Res Educ. 2021; 7: 1–15.

86.

Tausch

Menold

. Methodological aspects of focus groups in health research: results of qualitative interviews with focus group moderators. Glob Qual Nurs Res. 2016; 3: 2333393616630466.

87.

Cheesmond

Davies

Inder

. Exploring the role of rurality and rural identity in mental health help-seeking behavior: a systematic qualitative review. Rural Ment Health. 2019; 43: 45–59.

88.

Sullivan

Bartik

. What do rural young people want from their mental health service. Aust J Rural Health. 2023; 31: 1072–1082.

89.

Caxaj

. A review of mental health approaches for rural communities: complexities and opportunities in the Canadian context. Can J Commun Ment Health. 2016; 35: 29–45.

90.

Stuart

. Reducing the stigma of mental illness. Glob Ment Health. 2016; 3: e17.

91.

Waqas

Malik

Fida

, et al. Interventions to reduce stigma related to mental illnesses in educational institutes: a systematic review. Psychiatric Quart. 2020; 91: 887–903.

92.

Byron

Rasmussen

Wright Toussaint

, et al. ‘You learn from each other’: LGBTIQ young people’s mental health help-seeking and the RAD Australia online directory. Report, Young and Well Cooperative Research Centre, 2017.

93.

Robards

Kang

Tolley

, et al. Marginalised young people’s healthcare journeys: professionals’ perspectives. Health Educ J. 2018b; 77: 692–704.

94.

Fish

McInroy

Paceley

, et al. “I’m kinda stuck at home with unsupportive parents right now”: LGBTQ youths’ experiences with COVID-19 and the importance of online support. J Adolescent Health. 2020; 67: 450–452.

95.

McInroy

Craig

Leung

VWY

. Platforms and patterns for practice: LGBTQ+ youths’ use of information and communication technologies. Child Adolesc Social Work J. 2019; 36: 507–520.

96.

Steinke

Root-Bowman

Estabrook

, et al. Meeting the needs of sexual and gender minority youth: formative research on potential digital health interventions. J Adolesc Health. 2017; 60: 541–548.

97.

Kim

Royle

. Domestic violence in the context of the COVID-19 pandemic: a synthesis of systematic reviews. Trauma Violence Abuse. 2024; 25: 476–493.

98.

van Rosmalen-Nooijens

Wong

SLF

Prins

, et al. Young people, adult worries: randomized controlled trial and feasibility study of the internet-based self-support method feel the vibe for adolescents and young adults exposed to family violence. JMIR. 2017; 19: e204.

99.

Glover

Schueller

Winiarski

, et al. Automated mobile phone-based mental health resource for homeless youth: pilot study assessing feasibility and acceptability. JMIR Ment Health. 2019; 6: e15144.

100.

Adkins

Zalta

Boley

, et al. Exploring the potential of technology-based mental health services for homeless youth: a qualitative study. Psychol Serv. 2017; 14: 238–245.

101.

Lal

Elias

Sieu

, et al. The use of technology to provide mental health services to youth experiencing homelessness: scoping review. JMIR. 2023; 25: e41939.

102.

Orlowski

Lawn

Antezana

, et al. A rural youth consumer perspective of technology to enhance face-to-face mental health services. J Child Fam Stud. 2016; 25: 3066–3075.

103.

Robinson

Schulz

Dodel

, et al. Digital inclusion across the Americas and Caribbean. Soc Incl. 2020; 8: 244–259.

104.

Robinson

Cotten

Ono

, et al. Digital inequalities and why they matter. Inf Commun Soc. 2015; 18: 569–582.

105.

Reglitz

Rudnick

. Internet access as a right for realizing the human right to adequate mental (and other) health care. Int J Ment Health. 2020; 49: 97–103.

106.

Ohtani

Suzuki

Takeuchi

, et al. Language barriers and access to psychiatric care: a systematic review. Psychiatr Serv. 2015; 66: 798–805.

107.

Pandey

Kamrul

Michaels

, et al. Perceptions of mental health and utilization of mental health services among new immigrants in Canada: a qualitative study. Community Ment Health J. 2022; 58: 394–404.

108.

Robards

Kang

Usherwood

, et al. How marginalized young people access, engage with, and navigate health-care systems in the digital age: systematic review. J Adolesc Health. 2018a; 62: 365–381.

109.

Salami

Salma

Hegadoren

. Access and utilization of mental health services for immigrants and refugees: perspectives of immigrant service providers. Int J Ment Health Nurs. 2019; 28: 152–161.

110.

Tulli

Salami

Begashaw

, et al. Immigrant mothers’ perspectives of barriers and facilitators in accessing mental health care for their children. J Transcult Nurs. 2020; 31: 598–605.

111.

Poulsen

Hickie

Alam

, et al. Overcoming barriers to mHealth co-design in low- and middle-income countries: a research toolkit. Inf Technol Dev. 2024; 30: 1–20.

112.

Kamali

Edwards

Anderson

, et al. Social disparities in mental health service use among children and youth in Ontario: evidence from a general, population-based survey. Can J Psychiatry. 2023; 68: 596–604.

113.

Hetrick

Bailey

Smith

, et al. Integrated (one-stop shop) youth health care: best available evidence and future directions. Med J Aust. 2017; 207: S5.

114.

Fusar-Poli

. Integrated mental health services for the developmental period (0 to 25 years): a critical review of the evidence. Front Psychiatry. 2019; 10: 355.

115.

Daniel

Volcko

Bassi

, et al. Exploring youth perspectives on digital mental health platforms: a qualitative descriptive study. JMIR Hum Factors. 2025; 12: e69907.