Unlocking mobile health adoption: A qualitative exploration of user experiences,barriers,and facilitators within integrated youth services in British Columbia,Canada

Abstract

Background

Early onset of mental health disorders is common, but many cases remain undetected and untreated, highlighting the need for early intervention. In Canada, youth mental health services face challenges, including fragmentation and resource limitations. Integrated youth services (IYS) aim to address these gaps for individuals aged 12–24 years. Mobile health (mHealth) programs, like Foundry Virtual BC, offer potential solutions, yet their integration and sustainability within IYS require further exploration.

Objective

This study examined interest-holder perspectives on creating a sustainable, youth-centred mHealth system to improve mental health outcomes. The research focused on three questions: (a) How do users, service providers, and nonclinical staff perceive mHealth's effectiveness and impact? (b) What are the barriers and facilitators to mHealth integration within the Foundry IYS network? and (c) What strategies support the sustainability of mHealth services?

Methods

A qualitative study using semi-structured interviews was conducted with 23 interest-holders, including youth users, service providers, and nonclinical staff from the Foundry network. Participants were recruited via social media and snowball sampling. Thematic analysis identified key themes and subthemes.

Results

Three themes emerged regarding mHealth perceptions: (a) its own value, (b) its potential to address barriers to in-person care, and (c) its inherent limitations. Barriers and facilitators of mHealth integration were categorized into three domains: (a) design characteristics (e.g., app usability and content quality), (b) individual youth factors (e.g., privacy concern and inner struggle), and (c) external factors (e.g., safe space and support from peers). Sustainability was linked to service quality and external support.

Conclusion

This study highlights the complexity of mHealth integration within an IYS network. Interest-holders emphasized addressing user motivations, privacy, and accessibility while advocating for co-design approaches to ensure mHealth meets diverse youth needs. Future research should focus on underrepresented groups to promote equity and improve mental health outcomes through sustainable mHealth solutions.

Keywords

Youth mental health mobile health integrated care integrated youth services youth engagement

Introduction

Recent reports from the World Health Organization (WHO) and Lancet Psychiatry indicate that the peak onset for most mental health disorders occurs around 14.5 years of age.^1,2 This critical developmental period underscores the urgent need for early intervention, as it significantly influences educational achievements, functional capacity, and social roles throughout adulthood.³ Given the profound impact of mental health during this transition to adulthood, there is an immediate demand for a mental healthcare system that is not only affordable and effective, but that is also developmentally appropriate. In Canada, the mental health system has been critiqued for being fragmented, under-resourced, and inefficient to meet the needs of youth.^4–8 Recently, integrated youth services (IYS) have emerged as a novel solution by creating a single access point of different services including mental health and substance use (MHSU), physical and sexual health, peer support, and social services. Establishing IYS in a community requires a comprehensive strategy that emphasizes co-design with youth and families, coordinated service implementation, and youth-centred evaluation processes.⁹

In 2020, the COVID-19 pandemic marked an important period to reimagine how healthcare services can be delivered using mobile health (mHealth) modalities. This included IYS in British Columbia (BC), where mHealth services were quickly designed, developed, and implemented to provide virtual care, including app-based services, to youth across BC communities. Before COVID-19, evidence demonstrated that mHealth was a powerful modality for psychoeducation,^10,11 self-management,^12,13 and generally improving health outcomes.^14,15 Studies published during the pandemic have also shown the feasibility of transitioning in-person healthcare services to remote services with high effectiveness and positive feedback.^16–18 However, evidence demonstrated limited sustainability of mHealth interventions or services.^19,20 For youth specifically, there is a notable concern that youth mHealth technologies and interventions are highly unregulated, and vary significantly in terms of evidence level, measurement tools, delivery methods, and evaluation standards.¹⁴ Additionally, there is limited evidence on the user experience of youth mHealth services within youth MHSU settings, including IYS. More information is needed to understand how mHealth is integrated as a core part of an IYS system of care. In this context, youth adoption of mHealth reflects its integration. When youth use the platform meaningfully, it shows mHealth is embedded into their healthcare-seeking journey. This includes understanding the critical perspectives of those who use it to receive care (youth), those who provide care (service providers), and those who organize systems of care delivery (nonclinical staff).

mHealth adoption in an IYS: Foundry

For the past 10 years, a province-wide IYS initiative known as Foundry was developed, implemented, and scaled up to enhance care access for youth in BC. In April 2020, Foundry launched its provincial virtual service with a program called Foundry Virtual BC, which enables youth to access online health resources via web and Foundry BC app, to schedule appointments with service providers, and to communicate through chat, audio, or video calls (https://foundrybc.ca/virtual/).

Between 2018 and 2023, Foundry provided services to over 41,000 unique youth through both virtual and in-person options. In a recent descriptive study led by our team, we found that one-fourth of these youth reported they would not have sought help elsewhere if the services offered by Foundry were not available.²¹ Among those who did receive care, approximately 60% utilized in-person services only, 20% accessed only virtual care, and 20% accessed both types of service. Notably, youth who relied solely on mHealth services were more likely to seek help for stress, anxiety, and depression. Additionally, older youth and those with poorer mental health were more inclined to use mHealth services compared to those accessing in-person care. The study also found that the rate of repeated visits was significantly lower among youth who used only virtual services, compared to those who accessed in-person services or both service types.²¹

This mHealth service has become a core part of the Foundry service delivery model. However, its integration across the initiative and its long-term sustainability are still evolving and remain key areas of focus. The primary aim of this study is to explore how interest-holders perceived the integration, implementation, and sustainability of mHealth solutions. The study also seeks to understand how mHealth can be improved and embedded more effectively to support youth-centred, accessible, and sustainable mental healthcare.

We had three key questions that guided our exploration:

RQ1: What are the perceptions of mHealth among users, service providers, and nonclinical staff regarding its impact on youth mental health services?

RQ2: What are the perceived barriers and facilitators amongst IYS interest-holders to mHealth integration within the larger Foundry IYS network?

RQ3: What strategies do interest-holders identify as essential for the sustainability of mHealth services for youth in BC?

Methods

Study design

This study used a descriptive qualitative approach²² with semi-structured, in-depth interviews with three priority participant groups within the Foundry network. This included youth, service providers, and nonclinical staff. Ethical approval was received from the University of British Columbia Office of Research Ethics Behavioral Research Ethics Board (#H22-03454). Study findings are reported in alignment with the COREQ checklist (see Appendix 2) for qualitative studies.²³

Study sample

Youth users of Foundry Virtual BC

Youth participants were between 16 and 24 years old, able to communicate in English, and had used Foundry Virtual BC within the past year. Although Foundry serves youth as young as 12, those under 16 were excluded from this study due to the requirement for parental consent. This decision helped protect participants’ privacy, reduce the risk of response bias, and support youth autonomy when discussing sensitive health topics. However, future research is planned to explore the perspectives of youth aged 12‒15. Youth were recruited from recurring social media posts from January 2024 to May 2024. These posts included a brief introduction to the study and outlined what to expect during an estimated one-hour interview. To ensure a diverse range of experiences, we did not impose restrictions on the frequency or purpose of mHealth usage.

Clinical service providers

For this group, we recruited IYS service providers (e.g., counselors, social workers, and primary care providers) who have used mHealth to deliver care (e.g., virtual youth counseling, remote info sessions, and online peer support groups). Most service providers were purposively recruited from Foundry Virtual BC and Foundry Richmond, as Foundry Richmond was the first physical centre to fully integrate the virtual platform into its clinical service workflows. We also used snowball sampling²⁴ to recruit service providers across the two recruitment pools.

Nonclinical staff

For this group, we recruited technology and implementation experts affiliated with Foundry Virtual and Foundry central office who were involved in the design, development, and implementation stages of the Foundry BC Platform. Upon receiving ethical approval, we reached out to the Foundry communications team to share information about the study opportunity to qualified mHealth nonclinical staff who met the inclusion criteria. This process was used to ensure confidentiality of staff so they could make an unbiased decision to participate in the interviews.

Data collection

We constructed open-ended questions based on a previous literature review and descriptive analyses of Foundry's virtual service utilization patterns.²¹ We used the Technology Acceptance Model (TAM) to guide our question design. This model suggests that users decide to adopt a technology based on its perceived usefulness and ease of use.^25–27 Authors (XD, SB) who were professionally trained in health research conducted the interviews with recruited participants. The semi-structured interview format allowed participants to elaborate on topics of interest beyond the interview guide (Appendix 1), focusing on three major areas: perceptions of the mHealth concept, user experiences with the Foundry BC app, and sustainability in mHealth services. We recorded and transcribed all interviews using Zoom, taking notes during the sessions to aid in later data cleaning processes. All participants were given an alias throughout the study, from recruitment to research result interpretation, to protect privacy. Additionally, we provided two participants with a summary of the preliminary findings and invited their feedback, ensuring their perspectives were accurately represented and enhancing the credibility of our research. We conducted interviews until data saturation was reached.

Data analysis

Following Clarke and Braun's six-step guide,²⁸ we conducted a thematic analysis to analyze the qualitative data from interviews with three interest-holder groups. We used an inductive approach to identify and summarize common categories to address all three research questions.²⁹ The lead (XD) and senior author (SB) transcribed and read all interviews to familiarize themselves with the data while taking note of preliminary ideas and codes. We organized the codes into potential themes, collating all relevant data under broader thematic categories. Researchers XD and SB reviewed the themes using an iterative approach to ensure they reflected the coded data and the overall content of the data set. After identifying themes for each research question, our team discussed and selected the most representative examples from the transcripts for each theme, presenting in-depth quotes alongside the group name and a pseudonym for each participant. Our judgment of saturation was based on repeated patterns in the data, consistent codes, and team consensus that additional interviews were unlikely to generate brand new insights. To better reflect the experiences of youth and providers, we displayed all information in tables, labeling each key theme according to its frequency of mention by three participant groups: youth (FY), clinical service providers (FC), and nonclinical staff (FNC). We classified frequency as follows: +++ for the most frequently mentioned themes, ++ for frequently mentioned themes, + for themes mentioned occasionally, and “‒” for themes not mentioned by that group. Finally, we carefully examined the identified themes to detect similarities, differences, and relationships horizontally across the three mHealth interest-holder groups and vertically across three research questions.

Results

Participants

We conducted a total of 23 participant interviews.

For youth

Sociodemographic characteristics (age, gender, and ethnicity) along with basic mHealth utilization characteristics (frequency and the main purpose of using mHealth) were collected during the interview in an open-ended way without any predetermined choices nor categories. A total of 12 youth were interviewed and their descriptions are presented in Table 1. Youth users (n = 12) were of a median age of 20 (range: 18–24). Most youth reported using mHealth mainly to access online articles and peer recovery stories (n = 7), and some (n = 4) used mHealth to book appointments for both in-person and virtual sessions at Foundry.

Table 1.

Description of youth demographics (n = 12).

Characteristics
Age
Mean, median, range	20.4, 20, 18–24
Self-reported gender (N, %)^a
Female	10 (83.3)
Male	2 (16.7)
Self-reported ethnicity^b (N)
South Indian; Indian; South Asian; “Immigrant”; Chinese and Indonesian; Indian/South Asian; Asian; Middle East/Iran; White; East Asian; Chinese; half Filipino, half Vietnamese	1 of each response
Frequency of mHealth use (N, %)
Once a week	3 (25.0)
Once every two weeks	1 (8.3)
Once every few months	1 (8.3)
Whenever needed	5 (41.7)
Not sure/not reported	2 (16.7)
Main purpose of mHealth use^c (N)
Make appointments with service providers	4
Attend online sessions	3
Reading articles and stories	7

Participants were asked an open-ended question about gender; all responses were “male” or “female.”

We kept the original answer from youth without categorizing them.

Each youth could report more than one main purpose.

For clinical service providers and nonclinical staff

We interviewed a total of six clinical service providers and five nonclinical mHealth staff who supported the design, development, and implementation of Foundry BC platform, whose profiles are detailed in Tables 2 and 3. The service providers (n = 6) had a median age of 33.5 years, with ages ranging from 23 to 45. On average, they had 4.2 years of experience in the health field, with a range of 1.5‒7.0 years. The nonclinical staff (n = 5) had a group a median age of 34, with ages spanning from 29 to 46. Their average experience in the health sector was 14.1 years, ranging from 8 to 23.5 years.

Table 2.

Description of clinical service providers (n = 6) and nonclinical staff (n = 5).

Characteristics	Clinical service providers	Nonclinical staff
Age
Mean, median, range	32.8, 33.5, 23–45	35.6, 34, 29–46
Self-reported gender (N, %)
Female	4 (66.7)	3 (60)
Male	1 (16.7)	1 (20)
Nonbinary	1 (16.7)	1 (20)
Place of work (N, %)
Foundry Richmond	5 (83.3)	–
Foundry Central Office	–	4 (80)
Foundry Virtual	1 (16.7)	1 (20)
Years of experience
Mean (SD), median (range)	4.2 (2.2), 4.3 (1.5–7.0)	14.1 (5.8), 12 (8–23.5)
Years with foundry
Mean (SD), median (range)	2.5 (1.0), 2.3 (1.5–4.0)	3.4 (1.1), 3 (2–5)

Table 3.

Interest-holders’ perception of mHealth (RQ1).

Themes	Subthemes	FY	FC	FNC
Theme 1. “Good on its own”	Easy to access	+++	+++	+++
	Easy scheduling	+	++	+
	Power of youth being in control	+	+	+++
	One stop for all resources	+	+	+
Theme 2. Solution to existing barriers	Physical limitation	+++	+++	+
	Time limitation	++	++	+
	Fear of attending in-person sessions	+++	+++	+++
Theme 3. Limitations of mHealth	Lack of personal connection	+++	++	+
	Limited capacity	++	++	++
	Technology anxiety	++	+	+++

+++: very frequently mentioned by most participants; ++: frequently mentioned by around half of participants; +: occasionally mentioned by one or two participants.

Themes for RQ #1: What are the perceptions of mHealth among users, service providers, and nonclinical staff regarding its impact on youth mental health services?

In total, three main themes were identified to answer this research question. A complete list of themes, with the frequency of mentions from the three groups, is presented in Table 3.

Theme 1: “good on its own”

Participants identified that the most important aspects of mHealth are: (a) ease of access, (b) ease of scheduling, (c) youth being in control of healthcare choices, and (d) a one-stop-shop for all health resources; these were classified as four subthemes. All three participant groups agreed the greatest strengths of mHealth services within the IYS network are the enhanced accessibility of health and wellness services and the platform's flexibility in scheduling and connecting to various resources, including service providers and educational materials. Participants highlighted the empowering effect of mHealth on youth, noting that control over modalities fosters effective two-way communication and boosts their confidence in seeking services. This sentiment underscores the importance of mHealth in addressing the anxieties of youth and facilitating their engagement in care.

Youth who are going through lived experience need the power, and they need that choice because most of the time they don't feel like in control of their lives. (Allison, nonclinical staff)

Participants also discussed how the mHealth platform grants youth the power of being in control. It empowers youth choices about the preferences of the providers, the type of information they want to access, and the hours they want to access services or information. For service providers, participants reported that they feel more in control of their work performance due to the flexibility brought by the mobile technology.

You could feel better about the job and feel better about your work and actually be there for your clients because you're just in a better head space yourself. Your work-life balance is better. Being able to work from home feels more sustainable to me. (Jacob, clinical service provider)

Lastly, participants emphasized that mHealth's ability to centralize available resources into a single access point is crucial. Youth participants noted that they especially value this feature, as it eliminates the need to visit multiple locations for different services and prevents them from having to repeatedly share their personal stories with various service providers. While all participant groups mentioned this aspect, the youth participants provided the most detailed insights into its significance, highlighting how it streamlines their access to care and enhances their overall experience.

I think the idea is just being able to have an access point for those who are unhealthy for whatever fits their needs. Just being able to actually access it, and then just be like a one stop shop to have those resources for those who can’t go to all the places they need to be. (Rachel, youth)

Theme 2: Solution to existing barriers

The second theme relates to participants’ perceptions related to how mHealth can be used to overcome the barriers encountered when accessing in-person services. Within this theme, three subthemes were identified: (a) physical limitation, (b) time limitation, and (c) fear of attending in-person session.

Most participants mentioned the challenge of the physical location of centres as causing an inability to access health. Participants highlighted transportation issues, with youth like Emily stating, “There is no centre nearby, so I had to find a bus or beg someone to drive me.” Another crucial aspect proposed by all three groups articulated that mHealth serves as a vital solution for young individuals who are unable to leave their homes due to factors such as exhaustion, chronic illnesses, and physical disabilities. Service providers underscored the significance of this subtheme, highlighting the necessity of recognizing all barriers to accessing health and wellness services. Participants indicated that mHealth effectively mitigates both invisible barriers, such as fatigue, and tangible physical barriers that impede mobility, thus enhancing access to care for youth facing structural or situational challenges.

They are not allowed to leave the house because strict parents or have chronic illness chronic pain make it really difficult for them to get out. (Olivia, clinical service provider)

For the second subtheme, participants also reported that mHealth can help both youth and service providers to solve time-related challenges such as unfit centre hours, no time to travel, and long wait times. Participants in this subtheme emphasized the importance of flexibility that mHealth offers to access services in a way that is fit for purpose for their needs.

There's a lot of issues for drop in, especially with the wait times. People often find themselves waiting for a drop in at a Foundry site, for in person and it takes up a really big part of their visit time. (Olivia, clinical service provider)

The third subtheme, fear of attending in-person sessions, was strongly emphasized by all three participant groups. Many participants reported that youth often experience social anxiety or stigma associated with accessing in-person appointments. As one nonclinical staff, Sarah, noted, “It is a distressed place. Everything feels so overwhelming, and they're just looking for a simple, easy pathway.” Participants identified mHealth as a valuable tool for alleviating the pressure of interacting with service providers and facilitating communication while maintaining a degree of anonymity. Additionally, a unique perspective raised exclusively by youth was the concern regarding the physical location of centres, which they sometimes described as being situated in “sketchy” neighborhoods. Consequently, even when transportation is not a significant barrier, some youth expressed a reluctance to visit in person, opting for mHealth as a safer and more comfortable alternative.

I think what's happening is, and we have a lot of service providers think this as well, is that these young people are getting scared and they're going, ‘Wait! I don't want to see anybody! I don't want to talk to anybody!’ (Allison, nonclinical staff)

Theme 3: Limitations of mHealth

The third theme identified by participants relates to the awareness of the inherent limitations of mHealth overall. Although participants reported many benefits of mHealth, participants reported that this is not a complete replacement for high-quality evidence-based in-person services. Participants reported mHealth to be an adjunct to in-person services, and also unique in its potential and limitations (“I think that it can't fully replace it. But it can add on to it. It could be a 50-50.” Emily, youth). In addition to the overall impressions provided, three subthemes were established from the data: (a) lack of personal connection, (b) limited capacity, and (c) technology anxiety.

In the first subtheme, participants noted that the personal connections developed over mHealth are different that in person. Youth participants strongly emphasized that they are often trying to seek a personal connection when accessing services, and that this was often very difficult in a virtual environment. Youth noted the experience online is different that the supportive experience that a youth may receive in a physical centre:

Talk to a peer support worker at the front desk. They can just strike up a conversation, or there might be candy on the table, and oh, that's so nice. (Kate, youth)

The second subtheme relates to the participants’ perception that mHealth is limited in its capacity to provide a full-service experience, including care for the full range of needs that youth ask for such as physical and sexual health. Participants reported that centres have a natural flow to service access and referrals. Service providers particularly reported that there are often more distractions such as someone walks in to a session or cat scratching the door when offering services using mHealth. Some participants discussed their worries regarding how the organic nature of in-person relationship building can get lost.

Sometimes I would take the youth for a walk, or sometimes we would use the land, or sometimes I would have like fidget toys in my office. So just not being able to use the like physical stuff virtually. (Grace, nonclinical staff)

Youth and service providers reported significant challenges when utilizing art-based modalities or silence during online treatment sessions. Some providers expressed that the virtual format often contributed to a sense of personal isolation and loneliness, especially with excessive screen time. They conveyed feelings of missing out on essential collegial support from others, opportunities for collaborative learning, and the ability to leverage the physical environment as a therapeutic space to enhance care. This absence of shared experiences limited their capacity to create a more engaging and supportive therapeutic atmosphere.

Especially for people who might not communicate best verbally. So they want to use sign language and to describe with their body. Clinicians cannot detect surroundings to help with the session. (Kate, youth)

The third subtheme, technology anxiety, was discussed mostly by nonclinical staff. This group collectively worried about technology-related challenges like confidentiality, bugs, or simply that “technology is not for everyone” (Allison, nonclinical staff). Youth who reported being engaged extensively with contemporary innovative technologies also expressed concern about current technological advancements, and the ability of mHealth to keep up. Interestingly, few service providers discussed this as an issue, but most did recognize the importance of expertise and investments to keep the systems operating so that they could provide the best care possible.

Our society have this trend of turning everything to technology online, there is a precaution of like how much is true and what is your actual situation behind screen? (Rachel, youth)

Themes for RQ#2: what are the perceived barriers and facilitators amongst IYS interest-holders to mHealth integration within the larger Foundry IYS network?

To answer research question #2, we asked participants to reflect on the barriers and facilitators to mHealth integration across the Foundry network. Of note, the nonclinical staff, who mainly worked with development and implementation strategies, reported that they have limited user experience with the Foundry BC app itself. In response, they were asked about their experiences with the youth and clinicians that they worked with. Full lists of main themes and subthemes for barriers and facilitators are presented in Tables 4 and 5. (A)

Perceived Barriers

Table 4.

Barriers for mHealth adoption from user experience (RQ2).

Domains	Subthemes	FY	FC	FNC
Theme 1: Mobile health design characteristics	Scheduling	++	+++	+
	Navigation	+++	+	+
	Reliability and usability	+	+++	+++
Theme 2: Individual youth factors	Inner struggle	+++	+++	+
	Privacy concern	++	+	+++
	Lack of human interaction	+	+	–
Theme 3: External factors	Lack of safe space	+++	+++	+++
	Technology literacy	+++	++	++
	Language	++	–	–

+++: very frequently mentioned by most participants; ++: frequently mentioned by around half of participants; +: occasionally mentioned by one or two participants; –: not specifically mentioned.

Table 5.

Facilitators for mHealth adoption from user experience (RQ2).

Domains	Subthemes	FY	FC	FNC
Theme 1. Mobile health design characteristics	“My Story” feature	+++	+	+
	Connection tool	+++	++	+
	Content	+++	++	-
Theme 2. Individual youth factors	Escape in-person burden	++	++	-
	Self-driven motivation	+	+	+
	Privacy concern	+++	+	+
Theme 3. External factors	Support from peers	++	+	-
Theme 3. External factors	Provide safe space	++	+++	+

Perceived barriers theme 1: mHealth design characteristics

The first theme focuses on the design characteristics of mHealth, specifically addressing how the product was developed and its functionality. This theme is further delineated into three concise subthemes: (a) scheduling, (b) navigation, and (c) reliability and usability.

The first subtheme pertains to scheduling. Youth participants expressed frustration with the limited availability of appointments on the app and the challenges of coordinating sessions with their preferred service providers. Participants noted that having to repeatedly share their personal stories with different individuals can erode trust, diminishing their motivation and confidence to seek help in the future. Service providers echoed these concerns, reporting that the introduction of a new booking channel often resulted in additional scheduling difficulties, creating a sense of frustration.

They can only see 2 weeks ahead. If they were looking for a specific counselor. That was maybe booked out. And it is hard to bypass anything on the platform, compared to you directly talk to the counselor and add sessions to their calendar. (Kelly, service provider)

The second subtheme is navigation. Participants felt that the redundant registration and login processes posed a threat to the adoption and integration of mHealth services. It was brought up repeatedly by youth users who expressed concern that younger youth, without their own phone number or email, would not even be able to complete mHealth service registration. Participants indicated that the time required to complete demographic questionnaires, along with the inconvenience of logging in without a saved password option, significantly hindered their willingness to proceed with the mHealth platform. This added burden created unnecessary barriers, deterring users from fully engaging with the services offered.

You have to log in and deal with all the questions. And I don't know if everyone has a phone number, many other personal information that youth may not know. (Rice, youth)

The third subtheme is design-related reliability and usability. Participants stated that the Foundry BC app sometimes crashes and this can be extremely frustrating. Nonclinical participants emphasized that this area of ongoing development and product refinement requires 24/7 attention, viewing it as a crucial long-term investment to fully optimize and integrate the service. Other usability concerns were discussed as a significant barrier to mHealth adoption, particularly from the service providers’ perspectives. While mHealth users prefer the chat option over traditional phone calls for reaching clients, service providers reported difficulties in contacting youth through online tools. Some youth also reported that design characteristics like the Foundry BC app's appearance and navigation can also influence service usability.

It is hard to get in touch with clients on the app. You check your ins your texts every day but apparently youth don’t check their Foundry app all the time. You need to find a way to sync the notification system and the calendars. (Ying, clinical service provider)

Perceived barriers theme 2: Individual youth factors

This theme highlights how personal attributes can serve as barriers to the adoption and integration of mHealth solutions, focusing on internal concerns rather than the characteristics of the mHealth product itself. This theme encompasses three subthemes: (a) inner struggle, (b) privacy concern, and (c) lack of human interaction.

The first subtheme emerges from individuals’ internal conflicts, particularly the challenges they face in motivating themselves to seek care through mHealth. This struggle is predominantly fueled by the fear and anxiety experienced by youth who are uncertain about what to expect from their upcoming mHealth sessions, as reported by both youth participants and service providers.

If they've never accessed the health service, they have the perception like they're gonna ask me really deep questions off the bat. And feel really triggered. They do not know what to expect. (Lulu, clinical service provider)

The second subtheme pertains to privacy, a significant concern for youth who share their devices and accounts with family members. As one clinical service provider, Kelly, noted, youth often use share platforms such as “iCloud accounts, family teenager accounts, and household phones or desktop computers.” Although parents and caregivers may not actively interfere with their access to services, youth reported that they frequently refrain from seeking care to avoid potential privacy violations.

For someone who has such lived experiences. It's scary to think that your story is out there. Where is the database? I think that kind of scares me. (Rachel, youth)

The final subtheme highlights the absence of human interaction that is inherent in mHealth services. Many youth participants, particularly those who value personal connections, reported that they may decline to use mHealth, even it is the only available option. As Emily, a youth participant noted, “I'm very much a people-oriented person, and I need that personal interaction with people because it can be very beneficial.” Additionally, nonclinical staff also expressed concerns about the increased isolation that can accompany the adoption of mHealth solutions.

Perceived barriers theme 3: External factors

The third main theme describes the external factors contributing to the barriers of mHealth adoption and integration within the IYS initiative. There are three subthemes included: (a) lack of safe space, (b) technology literacy, and (c) language.

The first and the most prominent external factor identified by all three groups is the lack of a safe space when accessing mHealth services. This concern is multifaceted and encompasses conflicting perspectives, as individuals define a safe environment differently. Some youth have expressed concerns that their homes are not safe places to access mHealth services due to parental involvement and cultural stigmatization of seeking mental health support. Conversely, others have stated that their homes are the only safe places for them to have virtual calls without disturbances or bullying at school.

I'm from a Brown family, and we saw mental health being present in our family like ‘Oh, mental health! You're fine. Just go take a nap!’ It will be a big, big thing if you go to someone… and get ‘help.’ There's a lot of stigmas around it for a lot of people. (Sisi, youth)

The second subtheme is technology literacy, defined as the ability to use, manage, understand, and assess technology,³⁰ which was also a frequently mentioned barrier by all three groups of interest-holders. Something as seemingly simple as owning a phone, downloading from an app store, or having internet access can become significant obstacles, particularly in rural and remote communities. Learning to seek help through mobile devices and trusting sensitive health information to technology represents a significant psychological shift for some youth and their caregivers, particularly those from more conservative household environments.

You first need to own a smartphone; some places don’t even have cell service. Youth need to go to public library. Someone older gen caregivers just call in like the old way, it's impossible to all of a sudden just [say] hey you need to use an app for these. (Flora, clinical service provider)

The final subtheme addresses language barriers. Some youth participants reported difficulties accessing mHealth services in their native language due to the limited availability of such options online. While many youth are capable of communicating in English or French (Canada's official languages), they often reported feeling more at ease in sessions conducted in their native language, as this fosters a greater sense of support, connection, and intimacy with the service provider. As one youth participant, July, articulated, “I speak English, but English is not my first language, and when it comes to expressing myself to the therapist, it gets harder.” (B)

Perceived Facilitators

Perceived facilitators theme 1: mHealth design characteristics

Similar to the barriers to mHealth integration, the first main theme highlighting facilitators for mHealth use is the design characteristics of mHealth platforms. This theme encompasses three subthemes that motivate youth engagement with mHealth services: (a) “My Story” feature, (b) connection tool, and (c) content.

Firstly, a majority of young users identified the “My Story” feature as the most valuable aspect of the Foundry BC app. The opportunity to read the recovery narratives of their peers served as a significant motivator for youth to continue utilizing mHealth services. Furthermore, participants reported that this feature allows service providers to familiarize themselves with the background stories of youth prior to their sessions, thereby enhancing the overall user experience and promoting a more informed and supportive interaction.

You can just read My Story, and kind of know in advance what you've been through. So that's kind of like my favorite part that I don't have to tell every single person my story over and over again. (John, youth)

The second subtheme is using mHealth as a connection tool. All participants expressed how mHealth can facilitate connections to resources is valuable. It provides information for youth currently seeking services on how to initiate them, connects those who have not yet seen a service provider and connect them to accessible services, and offers those already receiving in-person services access to more mHealth resources.

But most people who use the chat function will end up doing a video session, and quite often then will engage in where it's appropriate and will engage in in-person services because they've been acclimatized. (Jojo, nonclinical staff)

The final subtheme pertains to the content itself, which has been identified as a critical factor in attracting youth to the mHealth services. Many participants emphasized that the quality of the resources and articles is paramount (“The articles and tips on the app are so helpful”- Chealsea, youth), with a strong focus on youth-centred content that is often authored by peers. Participants reported that this content is presented in an accessible and engaging manner, tailored to meet the needs of a diverse audience. Participants across all three groups noted that such thoughtful curation not only enhances the platform's appeal but also fosters a sense of relevance and connection among youth users.

Perceived facilitators theme 2: Individual youth factors

Three subthemes have been identified as facilitators for mHealth adoption within this main theme: (a) escape in-person burden, (b) self-driven motivation, and (c) privacy concern.

The first subtheme highlights that youth utilize mHealth as an escape from the challenges associated with in-person services. When faced with the frustrations of attending in-person appointments, the solutions offered by mHealth motivate youth to engage with these services. In this context, they perceive potential risks associated with seeking traditional services and find a sense of security through mHealth alternatives. As one youth participant, Chelsea, noted, the reason for many of their peers to access mHealth was “They feel judged by therapists and they don't want to access in person.”

It is much easier to deal with social anxiety during online chat and you don’t have to show your face. (Sunny, youth)

The second subtheme emphasizes the role of self-motivation among youth. Concerns and worries about their own individual health serve as a significant motivator for youth to seek out mHealth services, driving their engagement and willingness to adopt these digital solutions.

I think there's a whole spectrum, and I think on one end they come out of desperation, they feel like their life is crumbling and they've tried to do it on their own and it's collapsing. And they’re at breaking point. On the other end of the spectrum, it speaks to the reduction in mental health, stigma, and counseling in general, maybe going to a counselor could help me have a better life. I think those are the 2 ends of the spectrum. (Jacob, clinical service provider)

Lastly, while privacy concerns are an identified barrier for mHealth adoption, using mHealth to address these concerns is also reported by most youth users. It is also valuable to note that one participant reported the privacy concern as both the barrier and the facilitator for mHealth adoption. While there are concerns that using mHealth may breach data security and confidentiality, all interest-holders acknowledged the capability for youth to protect themselves behind screens.

It is easier to stay low key on the app, you can just delete the app and everything is gone. (Sisi, youth)

Perceived facilitators theme 3: external factors

There are two subthemes identified as facilitators in this theme group: (a) support from peers and (b) provide safe space.

When exploring the motivation that drove youth to use mHealth service, a word that was mentioned commonly was “friend.” The outside support from someone's friends or peers in general cannot be neglected.

I had a few friends who also did it, so I guess they were generally my motivation cause we would talk about these things, and I would hear that. Oh, like they don't think they don't have any stigma present. (Sisi, youth)

The second subtheme in external factors is the use of mHealth to establish a secure environment. Some youth expressed feeling unsafe when attending in-person appointments, especially in smaller communities where encountering therapists who are family friends can jeopardize their privacy and sense of security.

They'd be more willing to sign up and come in as long as they don't have a helicopter parent who's like, ‘What are you doing? What are you doing? What are you doing?’ (Kelly, clinical service provider)

In such instances, participants indicated that the adoption of mHealth is essential for establishing a safe environment for youth. Consequently, while the lack of a safe space is viewed as a barrier to mHealth adoption by certain interest-holders, it is perceived as a facilitator by individuals from diverse personal and cultural backgrounds. This divergence underscores the complex interplay between perceived safety and the motivation to engage with mHealth services, highlighting the need for nuanced understanding among interest-holders.

Themes for rQ#3: What strategies do interest-holders identify as essential for the sustainability of mHealth services for youth in BC?

Two themes were identified with respect to the sustainability of mHealth service. The full table of themes and subthemes is presented in Table 6.

Table 6.

Factors influencing mHealth sustainability (RQ3).

Theme	Subthemes	FY	FC	FNC
Theme 1 Quality of mHealth itself	Long-term quality improvement	+	+++	+++
	Service quality	+	++	+
	Cost-effectiveness	+	++	+
Theme 2 External support	Promotional campaign	++	++	-
	Outreach and engagement	+++	++	++
	Connection to “real-life” service	++	+	+
	Policy	+	+	+

Theme 1: Quality of mHealth technology

The first theme essential for the sustainability of mHealth is the quality of the mHealth product itself. Three subthemes were identified to uphold this standard: (a) long-term quality improvement, (b) service quality, and (c) cost-effectiveness.

Firstly, the necessity for long-term quality improvement emerged as a significant concern, particularly among service providers and nonclinical staff. Participants highlighted that the absence of follow-up resources to support this quality improvement process represents a substantial threat to the sustainability of mHealth services. Without these resources, mHealth initiatives risk failing to meet the evolving needs of both youth and service providers, ultimately jeopardizing their effectiveness and relevance.

We got a certain amount of funding and resources to build the app, develop the app but not necessarily to make modifications unless it's getting in the way of like the apps usability. (Lulu, clinical service provider)

The second subtheme is related to the quality of health and wellness services provided. Participants reported that sustainable service delivery must provide resources that are more comprehensive than what you can get from physical centres. (“Going through all these different steps and you see ‘currently not available’ is kind of annoying.” Sunny, youth.) Participants proposed that the content should be “not boring,” “fun,” and “interesting,” The nonclinical staff in particular wanted to ensure that mHealth does not turn into an “mHealth version of a hospital room.” In addition, with the rising attention given to artificial intelligence (AI), it is essential to ensure that the high-quality content, resources, and the unique value from mHealth services are not easily replaceable by AI tools, such as generative AI chatbots. Participants reported that ensuring the quality of service is fundamentally dependent on comprehensive staff training, which is recognized as a critical component of mHealth user retention. Participants emphasized that properly trained staff not only enhance the overall user experience but also foster trust and satisfaction among users, thereby contributing to sustained engagement with mHealth services within an IYS.

After 20 min the counselor was like ‘I'm sorry, my dog's here, I would have to leave this session to take him out on a walk!’ It was really unprofessional. (John, youth)

The final subtheme pertains to cost-effectiveness. Many youth expressed that the origin of support ‒ whether from the private sector or governmental organizations ‒ is largely inconsequential. Their continued engagement with mHealth solutions was reported to be contingent upon the services remaining “FREE!” of charge.

Theme 2: External support

The second theme explores the external factors influencing the sustainability of mHealth services. This theme is further delineated into four subthemes: (a) promotional campaign, (b) outreach and engagement, (c) connection to “real-life” service, and (d) policy.

The first subtheme is promotional campaigns, characterized by the imperative to advertise. Participants frequently emphasized the importance of diverse advertising methods, including utilizing social media, bus stops, subways, and flyers. The overarching objective of these efforts is to enhance public awareness and inform individuals in the community of the existence and availability of mHealth IYS services.

Constantly have ads on Facebook or social media, or some buses. Just be like, hey, you need help? Here's an app. We can help you. (John, youth)

The second subtheme is the need for an outreach and engagement framework within the healthcare system. All interest-holder groups emphasized the importance of the mHealth team consistently communicating with partners in schools, local clinics, community centres, and health organizations. Participants underscored that this engagement is crucial for identifying the desired features of an effective mHealth service. By incorporating these insights, participants felt that interest-holders can more effectively align the services with the specific needs of youth.

If you're building a service that is supposed to be useful for them. Then you need to co-design it with them. Co-design led to the success and adoption of over 10,500 users of the platform. The only reason we could make this work is we co-designed everything with youth. (Allison, nonclinical staff)

The third subtheme concerning external support highlights the necessity of integrating mHealth services with physical centres that offer in-person services, to keep the modality options open. While there are ongoing debates regarding the extent to which mHealth can entirely replace traditional face-to-face services ‒ illustrated by comments such as “no parents involved at all” and “it worked well in extreme situations like COVID” ‒ most participants advocated for a “hybrid model” as the optimal configuration for mHealth services. As articulated by nonclinical staff participant Alex, “I think it's integration; it shouldn't be parallel systems or anyone replacing anything.”

The last subtheme is the policy and operational support for sustainability of mHealth within an IYS network. Participants noted that there is a need for a comprehensive regulatory framework that considers the diverse needs of all interest-holders and understands how they can work together to achieve the best outcomes over time.

Service providers not having people on their teams who know how to implement good mHealth solutions, it is also hard to find experienced clinicians on the app. We need someone who can speak both languages so they can understand the workflows of clinicians, and how they operate on a day-to-day basis, and understand what people are looking for in their services, to see if the technology is going to meet that need or create additional barriers. (Allison, nonclinical staff)

Discussion

The findings of this study provide critical insights into the perceptions of youth, clinical service providers, and nonclinical staff regarding mHealth services within the IYS network, including perspectives on the development of a sustainable, youth-centred mHealth system to improve mental health outcomes. Through this detailed analysis of qualitative data from youth, service providers, and nonclinical staff, we identified themes to understand interest-holder perception of mHealth integration and sustainability (Table 3). We also identified barriers and facilitators of mHealth adoption and integration (Tables 4 and 5) and sustainability of mHealth services (Table 6).

Previous studies have predominantly focused on researching mHealth adoption through the TAM, emphasizing perceived usefulness (PU) and ease of use (PE) as core predictors of user acceptance and intention to use the technology.^31–34 More comprehensive reviews have also identified other contributing factors, such as design and technical concerns, cost, time, privacy and security, social influence, self-efficacy, trust, technology anxiety, performance and effort expectancy, and resistance to change.^35,36 While inner drivers like self-efficacy were identified to be associated with PU and PE,^37,38 our study suggests that we should look beyond app usability. Our results emphasize the importance of sustainable implementation planning, meaningful engagement of multiple interest-holders, and resourcing mHealth solutions over time. Furthermore, our results suggest that it is imperative to devote attention to the systematic analysis of the factors influencing mHealth utilization among younger populations, who are often perceived as primary proponents of technological innovations.³⁹ This study reveals that, beyond the inherent characteristics of mHealth platforms, concerns regarding safe spaces and privacy emerge as distinct subthemes that function both as barriers and facilitators to engagement. Our results also suggest that it is essential for service providers and developers to acknowledge that the concept of a “safe environment” is subjectively defined by each individual youth. This underscores the necessity for a nuanced approach in developing and recommending safe usage scenarios for mHealth services, as there is no singular correct answer that universally applies to all youth, with each living in distinctive environments⁴⁰ and following unique developmental paths.⁴¹

In our study, we also found that it was important to not only conduct a horizontal comparison across the three groups, but also a vertical comparison across the three research objectives. This integrated approach enabled us to elucidate the interconnectedness of various themes. For example, youth residing in rural communities, who often encounter transportation barriers, may perceive mHealth as an instrumental resource for overcoming these challenges, thereby placing a high value on facilitators that help bridge this gap. Youth who reported belonging to cultures that stigmatize mental health may regard mHealth as a refuge, where they can engage with services safely and discreetly. For these individuals, features that enhance privacy and security are paramount for facilitating the adoption of mHealth. By examining these relationships further, we can attain a more nuanced understanding of the multifaceted challenges faced by youth, which in turn will inform the development of more effective mHealth solutions targeted for diverse youth.

Current research on mHealth adoption reveals a notable gap in understanding the sustainability of mHealth services, especially within youth populations.^42,43 Much of the existing literature predominantly focuses on the factors that influence the ongoing implementation and use of these applications.^31,37,44,45 This study aimed to extend the discourse beyond mere app usage duration—a commonly employed metric—to highlight the importance of quality engagement and outcomes, including service integration. The results suggest that effective outreach, meaningful engagement, and participatory co-design are critical components for the sustainability of mHealth services.^19,46 However, there is still a lack of evidence that clearly defines these concepts or offers a comprehensive framework for understanding the engagement processes and key characteristics of successful engagement experiences.^47,48 Future youth-centred and embedded research opportunities hold significant potential to explore these factors in greater depth, thereby enhancing our understanding and informing regulatory frameworks that support effective mHealth interventions for youth.

Overall, this study provides valuable insights into the integration of mHealth within an IYS network by examining diverse perspectives of various interest-holder groups. Youth participants articulated their motivations for engaging with mHealth services, highlighting specific design characteristics that resonate with their needs. In contrast, service providers emphasized the challenges they encounter regarding scheduling and communication, noting that mHealth solutions can inadvertently diminish the effectiveness of direct interactions, particularly when youth prefer app-based communication. Meanwhile, developers (nonclinical staff) focused on broader conceptual goals, such as designing services that empower youth and foster a sense of control. Our findings underscore that, while existing literature primarily emphasizes user experience, user interface design, and the intervention's overall effectiveness, these factors alone do not comprehensively capture the dynamics influencing the sustained use of mHealth services among youth and service providers. This calls for a paradigm shift towards more holistic approaches that consider contextual, relational, and experiential dimensions of mHealth within an IYS setting, consistently centring the needs of youth and clinicians.

In addition to insights from youth, service providers, and nonclinical staff, this study offers more implications for system-level leaders and policy makers aiming to embed mHealth within youth mental health services. Youth adoption can serve as an indicator of effective integration. Addressing privacy concerns, technology access, and safe use environments may require system-level strategies beyond technological design to support adoption. Sustained implementation also relies on workforce capacity, aligned service workflows, and stable organizational infrastructure – factors beyond the control of service providers but within the responsibility of leaders and policymakers. Policy support should enable adaptable, youth-responsive, and hybrid models that advance equity and long-term sustainability. By broadening the focus of future research to encompass these multifaceted elements, we can enhance the effectiveness and sustainability of mHealth interventions, ultimately better serving the health and well-being of youth populations.

Limitations

Although our study is an in-depth analysis of qualitative data, it is important to acknowledge certain limitations. First, we relied exclusively on semi-structured interviews for data collection with youth 16–24-year-olds, which may constrain the generalizability of our findings to younger youth accessing IYS. It is important to note that the majority of youth in our sample were proficient in English, potentially limiting the inclusivity of our findings. This is especially relevant since language was identified as a barrier to mHealth use. Future research should prioritize the recruitment of a more diverse cohort, including youth for whom English is not the first language, to ensure a broader range of experiences and perspectives are captured. Additionally, our recruitment strategy relied on social media outreach, which likely recruited participants who are proactive and comfortable engaging online. To obtain a more representative view, future studies must develop strategies to amplify the voices of less active youth who may be reluctant to initiate contact or share their experiences independently. Addressing these limitations will enhance the robustness and applicability of future research in this critical area.

Conclusion

This study offers a critical exploration of the complexities and opportunities surrounding the adoption and integration of mHealth within an IYS network, drawing on qualitative insights from diverse interest-holder perspectives. By uncovering key themes, we reveal the nuanced perspectives of mHealth youth users, service providers, and developers (nonclinical staff), while identifying the complex barriers and facilitators that impact mHealth adoption and long-term sustainability. Our findings highlight the imperative for holistic approaches that transcend conventional usability metrics, emphasizing the importance of addressing youths’ intrinsic motivations, privacy and safety concerns, and external barriers to accessibility. In doing so, we advocate for a more inclusive understanding of the factors that drive engagement with mHealth services, particularly focusing on how to reach less-vocal youth whose voices are often overlooked. Looking ahead, it is crucial for future research to further incorporate principles of engagement and co-design in the development and implementation of mHealth solutions. Such efforts will not only enhance the relevance and effectiveness of these services, but also ensure that they are truly reflective of and responsive to the diverse needs of young users and those providing the services. By prioritizing these areas, we can contribute to a more equitable and impactful landscape for youth mental health support through mHealth innovations.

Supplemental Material

sj-pdf-1-dhj-10.1177_20552076251365073 - Supplemental material for Unlocking mobile health adoption: A qualitative exploration of user experiences, barriers, and facilitators within integrated youth services in British Columbia, Canada

Supplemental material, sj-pdf-1-dhj-10.1177_20552076251365073 for Unlocking mobile health adoption: A qualitative exploration of user experiences, barriers, and facilitators within integrated youth services in British Columbia, Canada by Xiaoxu Ding, Kirsten Marchand, Liisa Holsti, Julia Schmidt, Natalie Parde, Brodie Sakakibara and Skye Barbic in DIGITAL HEALTH

Footnotes

ORCID iDs

Xiaoxu Ding

Liisa Holsti

Natalie Parde

Skye Barbic

Ethical approval

Ethical approval was received from the University of British Columbia Office of Research Ethics Behavioural Research Ethics Board (#H22-03454).

Author contributorship

XD contributed to conceptualization, methodology, data collection, analysis, and writing–original draft. KM contributed to methodology and analysis. LH contributed to methodology and writing–review and editing. JS contributed to methodology and writing–review and editing. NP contributed to writing–review and editing. BS contributed to writing–review and editing. SB contributed to conceptualization, methodology, writing–review and editing, and supervision.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

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

Supplemental material

Supplemental material for this article is available online.

Appendix 1. Sample questions to guide the semi-structured interview.

Part 1. Perception of mHealth concept
Selected example interview questions	Example prompt and elaboration
1. Are you familiar with the concept mHealth? Can you describe what exactly is mHealth and its goal?	What are some in-person service barriers can be addressed by mHealth?
2. Describe the top three best things and your three worst concerns about mHealth.
3. Do you think or to what extent mHealth can replace traditional in-person mental health support?	Can you explain your answer based on your own experience?
Part 2. User experience of Foundry App
1. (Perceived Usefulness) In what ways do you believe the Foundry App is helpful to youth health status and in their work/life?	If possible, can you describe a real-life situation?
2. (Perceived Ease of Use) How easy do you think it is for youth to learn and use the mHealth technology?	What is some potential difficulties youth could have while using?
3. (Attitudes) How do you feel about the Foundry app when you are using?	What are your general impressions of the app?
4. (Subjective norm) Do you feel youth would receive pressure from others when they use mHealth services?	Will it be different compared to in-person services? How did you start to use this service?
5. (Intention to use) What is your biggest concern before they schedule your first appointment using Foundry app?	What do you think is biggest barrier that stopped youth to access service?
6. (Actual system use) What was the motivation that eventually made you to use the service?	What do you think is the motivation that made youth to access service?
Part 3. Sustainability in mHealth
1. Have you used similar products or services in the past?	How did they compare to the Foundry App?
2. What do you think are some key challenges to keep a service operating, to keep the sustainable?	To makes sure the app was not released and disappear after a year.
3. If you were asked to design your own sustainable mHealth product for your community or your company. List your top three tasks that you put on the priority list.

Appendix 2. COREQ Checklist.

See supplementary file uploaded separately.

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Supplementary Material

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