Engaging young people within a collaborative knowledge mobilization network: Development and evaluation

Abstract Background It is critical that mental health systems place a focus on prevention and early intervention focused on young people while integrating youth voice to guide priority directions. Objective This study was designed to better understand how youth advisories can be utilized to influence strategic directions within integrated knowledge mobilization networks operating within the youth mental health system. Design To support this objective, we reviewed the detailed stages of development in establishing a youth advisory within a national network designed to support the integration of youth services. We also engaged the advisory in a participatory evaluation process that examined the extent to which the network had created processes to include youth voice in decision‐making. Results Results from the surveys identified moderate to high levels of individual engagement as well as strong development of processes and procedures that support the inclusion of youth voice across the network. Discussion Major successes and challenges are presented and discussed with respect to the development of the advisory. The findings are useful for youth advocates and adult allies working to support youth engagement (YE) in knowledge mobilization to enhance the mental health services system. This study also contributes to research and evaluation efforts examining YE and represents an exemplar methodology for evaluating YE efforts at the system level. Patient or Public Contribution Young people as mental health service users and youth mental health advocates were involved in the design, data collection, analysis and interpretation of the data as well as the preparation of this manuscript.


| INTRODUCTION
Approximately one in five children and young people experience mental health issues, [1][2][3] and the majority of lifetime mental illnesses begin before an individual reaches adulthood. 4 Effective intervention in the early stages of mental illnesses has been associated with better short-and long-term outcomes. [5][6][7] Recognizing these issues, it is imperative that mental health systems place a focus on prevention and early intervention targeted at youth. 5 Despite the advantages of reinforcing services for young people, the youth mental health system has been characterized as fragmented and difficult to navigate. 8 In addition, youth who are entering adulthood typically must transition to adult services, which often results in disengagement and diminished mental health outcomes. 9,10 Leaders in the field of mental health, including youth advocates, academics and policy-makers, have identified that services must be transformed to place a focus on individual needs and strengths. [11][12][13][14] They recommend that this be achieved through collaborative efforts that can provide seamless support throughout the lifespan that incorporate considerations related to a range of developmental influences and contexts. Youth engagement (YE) is one strategy that has been successfully applied to improve outcomes for young people with mental health issues. [15][16][17] YE is a process whereby young people partner with adults and share their perspective to enhance youthfocused programmes and policies. 18,19 Within mental health, YE has been applied to support client empowerment, the design of services, the strengthening of relationships between young people and staff and as a strategy within peer support services. 20 Models of YE that have been applied within the mental health system include youth advisories 21,22 as well as involving young people in decision-making roles on boards. 17 This study was part of a larger study designed to better understand how YE can be utilized to influence strategic directions within integrated knowledge mobilization created to support the integration of youth services. This paper describes the establishment of a youth advisory and a participatory evaluation process that was designed to examine the processes that helped facilitate the involvement of youth perspective within strategic planning and implementation of an international network. This paper also applies the bioecological model (BEM) to better understand the interactions between the youth advisory and the network and to explain how they might function to influence youth mental health promotion across Canada and the world.

| Youth engagement in mental health
YE is a process that integrates the perspective of young people to enhance programmes and policies that are focused on them. 18,19 This study involves the development of partnerships between adults and young people with the intention of contributing to social change. 23 YE strategies evolved from an increased focus on the rights of young people as a result of the United Nations Convention on the Rights of the Child. 24 The convention was created in 1989 and has since become the most highly ratified treaty in history. 25,26 YE in child and youth mental health has been defined as 'empowering all young people as valuable partners in addressing and making decisions that affect them personally or that they believe to be important' 27 (p. 5). Within mental health, YE has been applied to support client empowerment, enhance service design, strengthen relationships among staff and young people and as a strategy within peer support services. 20 In a review of YE within mental health and substance use services, 15 researchers identified a range of approaches that can be applied to enhance youth-focused interventions, including the involvement of young people in programme development.
It is important to note that despite the potential benefits that can be offered through YE, there continues to be many initiatives that fall into tokenistic practices. 28 27,32 Integrated youth service (IYS) models combine mental health and substance use services with community supports, including primary care, housing, vocational and other services. 11,20,[33][34][35] These models are designed to provide seamless holistic supports that can be tailored to client needs and goals. YE is widely practised within IYS models. 36 In a recent review of youth-friendly mental health and substance use services, 37 researchers identified that service integration was a major factor that enhanced the youth-friendliness of services. In addition, they found that involvement of youth voice was of key importance to inform overall policy and operations, environmental characteristics, staff qualities and service features. This included the formation of youth advisories to guide planning and implementation.

| Youth advisories within system-level initiatives in mental health
There are several examples of youth advisories within Canadian practice. The ACCESS Open Minds IYS research network youth advisory supported site efforts to engage youth within implementation teams as well as to include young people and families on hiring committees. 34 These efforts resulted in the incorporation of Facebook and text communication, mobile services, providing services in flexible locations and the integration of mental health services alongside other types of services. 38 Knowledge mobilization networks have adopted youth advisories to inform their strategic direction. For example, Wisdom2Action is a network designed to promote mental health and well-being for children and young people across Canada. 22 Wisdom2Action conducted a participatory evaluation that involved interviews and document review to explore the process and impact of YE within the network. They identified that mentorship, clear communication, opportunities for skill-building and financial and reputational resources were necessary to facilitate effective YE processes. They also identified other themes including the benefits of mentorship, difficulties with retention and the need for flexibility, career development opportunities, investment of resources and to reflect diversity across organizational levels.

| The BEM
It is useful to apply the BEM to better understand the functioning of a youth advisory focused on mental health at the system level as it places a focus on the individual's agency over his or her surroundings while also highlighting the reciprocal influence of context on individual development. 39 The model is based on four major components: (1) process, (2) person, (3) context and (4) time. [39][40][41] Process, or proximal process, symbolizes the increasingly complex reciprocal influence between an individual and his or her developmental context.
The person component represents both agency and outcomes related to the developing individual. The concept of time captures the dynamic nature of continuous development as well as the historical environment that surrounds development. Finally, context represents the multiple systems that influence development. 39,42 Recognizing that the network is functioning at a complex system level, wherein there are multiple levels of influence and dynamic contextual interactions, the BEM provides a conceptual framework through which to operationalize multiple mechanisms and processes, such as examining how advisory members and the network more broadly can influence system-level outcomes.

| Purpose
There is a need for more research that examines youth advisories 43 and, in particular, how young people can influence organisations functioning at the system level. [44][45][46] There are several other areas of YE research that are lacking, including studies examining how YE relates to implementation, 44,47 youth diversity 48,49 and the development of youth social capital. 48,50 This study was designed to address the following research questions: (1) how can a youth advisory body be developed to inform organisations working at the system level? (2) How can youth perspective be integrated within strategic directions to inform knowledge mobilization in mental health? We present a detailed description of how a youth advisory was formed within an international knowledge mobilization network. Through a participatory evaluation, we also describe the processes that were developed to integrate youth perspective within strategic planning and implementation of the network to measure the quality of YE. This study applies the BEM 39 to support the interpretation of the findings to better understand how YE functions to influence youth mental health promotion.

| CONTEXT
Meeting minutes, communications and other operational documents  (2) ethnicity, (3) age, (4) gender, (5) LGBTQ identities, (6) socioeconomic status and (7) Indigenous identity. Recruits were contacted through their respective organisations, and a summary of the overall network strategy and the general purpose of the advisory was shared to determine interest. The Youth Advisory Leads conducted brief phone interviews with interested candidates to provide more context and confirm interest. Through this recruitment process HALSALL ET AL. | 619 and a later targeted call, the advisory was formed by 13 members with representation from seven provinces and territories from across the country, coast to coast to coast. Member diversity was also reflected across genders, sexual orientation and cultural groups, including Inuit, First Nations, Métis and newcomers.  Table 1.

| Bringing youth voice to the system level
One of the first tasks that youth advisory members engaged with at the outset was the development of the ToR. The draft ToR was developed based on two existing prototypes and then shared with all advisory members, and it was discussed during the first meeting to collect feedback with respect to important details. The advisory members agreed that lived experience should be a qualifying characteristic held by all members. Lived experience did not have to include the experience of receiving services. Advisory members also felt that it was important to build in an option for a leave of absence to accommodate members who might be struggling with their mental health.

| Development of the honorarium process
In partnership with the family advisory, an honorarium process was also developed to establish a standard procedure for equitable reimbursement of advisory member contributions (available in Supporting Information Materials). The honorarium process was revised over several months and finally included a tiered format whereby compensation was related to the amount and skill level of work being conducted. Processes were also created to facilitate participation in events through pre-payment of travel and accommodation costs. Many organisations reimburse travel costs after travel is complete and costs have been incurred. However, these costs can be prohibitive and limit access for many young people who do not have the available funds or a credit card to purchase flights or make a hotel booking.
Similar to the ToR, a prototype YE policy was used to draft the initial policy. The policy was designed to inform the roles and responsibilities of network staff and the Leadership Team with respect to supporting meaningful YE. It elaborated on a range of youth roles, procedures for engaging youth, training, budget requirements, compensation and the creation of positive, safe and accessible spaces.
In the first year of advisory formation, the Youth Advisory Leads conducted strategic planning interviews with individual members to identify their personal objectives for working within the advisory, their ideas for project development and their career aspirations and alignment with advisory work. During these interviews, members also reviewed their current skill sets and examined which skills they were hoping to develop. These included general professional skills such as project management and organisation, written and oral communication, meeting facilitation, negotiation and conflict management.
Initially, it was proposed that one youth member be drawn from the youth advisory to participate on the board, while the other youth board member would be independent. At the outset, this was the case; however, after deliberation, concerns emerged that this strategy might result in misalignment among the youth board members and as a result, the independent youth board member joined the youth advisory. Both youth board members received a brief orientation facilitated by Halsall before their first board meeting and participated in a debrief call after the meeting to discuss their experience and collect their feedback on the process. In addition, before the youth board members' initial meeting, adult board members received a brief presentation about the rationale and importance of YE as well as an orientation to the critical role of youth-led projects within the network. In addition, an exception was made in the By-Laws to allow youth and family board members to receive honoraria as acknowledgement for their time contribution.
In its first 2 years, the advisory was involved in a range of projects and activities. Table 2 provides an overview of advisory projects and activities as well as how advisory members were involved.

| Challenges
One of the major challenges encountered during the early stages of the youth advisory development was ensuring equitable focus on

T A B L E 5 Open-ended responses to the YVAL survey
Responses to the question: What is going best in supporting meaningful youth/young adult (Y/YA) participation in the network?
Responses to the question: What is most challenging in supporting meaningful Y/YA participation in the network?
Leadership commitment to listening and being responsive to youth perspectives and expertize at all levels It's a big project with lots of moving parts, and sometimes it's hard to keep track of them all-makes it hard to feel confident in our participation sometimes The advisory network is well established and representative.
The discussions are open and transparent Our precise roles or responsibilities are unclear. We are considered, at the broadest level, to strategically advise. However, our meetings seem to consist of having established initiatives that might be approved or disapproved by youth, rather than empowering youth members to contribute their own perspectives. was not a process that was in place. In effect, the process was in place; however, not all members were aware of it.
Despite the existence of some processes and structures that were not broadly recognized, advancements can continue to be made within the network with respect to staff and partner training.

| Theoretical implications
The BEM also serves to highlight the significance and potential in- It should also be noted that the Youth Advisory Leads were functionally different from other advisory members as they played facilitation roles during meetings and teleconferences, they took on more responsibility and had more intimate understanding of the functioning and impacts of the network as well as the related YE processes. Since Youth Advisory Leads are more closely involved in processes, meetings and higher-level decision-making, their level of engagement is more frequent and extended than other advisory members. Recognizing the potential benefits of frequency, duration and increasing complexity, the benefits accrued through proximal processes would be more significant for advisory members acting as Youth Advisory Leads and to a lesser extent, board members.
The influence of social determinants on mental health and potential interventions that focus on multiple domains, including neighbourhood, environmental and social/cultural, have been recommended. 58,59 Policy and practice must increase their focus on developmental contexts that can have a significant positive influence on youth development outside of the health system. In particular, creating healthy microsystems where children and young people spend considerable portions of their time should be a key focus in addition to formalized services. This might include, but is not limited to, school-based initiatives, extracurricular activities, parental supports, initiatives to build community networks, vocational opportunities, urban planning that supports healthy communities and, as represented in this particular case, youth advisories.

| Strengths and limitations
Although this study demonstrates several strengths with respect to a methodological approach and contributions to the field of YE, there are also limitations that should be identified. First, there were difficulties interpreting some of the items as the YVAL and the SSE tools are designed to be used within agencies that serve young people.
Since the network did not provide direct services, it was difficult for respondents to answer items that were connected to direct service provision. Relatedly, some survey respondents suggested that it would have been beneficial to have a Does not apply/I do not know option. In addition, we would like to note that it was difficult to identify how the paper should be delimited with respect to the period of time that is described. We describe activities from the very outset of the network and advisory formation; however, the network and advisory continued to evolve after the writing of this paper. This meant that new developments and challenges emerged that were not captured within this article. It will be important for the network and advisory to continue to share lessons learned as they explore new territory with respect to YE within system-level knowledge mobilization initiatives.