Improving the quality of child and youth mental health care through an implementation science lens

TL;DR

This paper discusses how implementation science can improve child and youth mental health care by better applying quality standards in real-world settings.

Contribution

The paper introduces a structured implementation science approach to apply WHO quality standards in child and youth mental health services.

Findings

Implementation science can help bridge the gap between policy and practice in youth mental health care.

Stakeholder engagement and context-specific adaptations are crucial for successful implementation.

The WHO quality standards offer a framework that can be enhanced through implementation science methods.

Abstract

Mental disorders in children and youth are on the rise worldwide, affecting approximately one in five young people in Europe. The negative educational, social and economic consequences of mental health problems underline the urgent need for accessible, high-quality mental health services. In response, the WHO Regional Office for Europe has developed Quality Standards for Child and Youth Mental Health Services to provide a framework for evidence-based, youth-centred care. Previous efforts have shown that translating quality standards and guidelines into practice remains a major challenge. While implementation science offers valuable approaches to improving the uptake of evidence-based quality standards and has been successfully applied in various healthcare fields, it remains underutilised in child and youth mental health care. This article explores how implementation science can be leveraged to improve the quality of child and youth mental health care. Using the implementation of the WHO European Quality Standards for Child and Youth Mental Health Services as a practical case example, we highlight the importance of a structured approach to implementation, guidance by theories, models and frameworks, timely stakeholder engagement, and context-specific adaptation. Harnessing implementation science in youth mental health policy and practice has the potential to bridge the gap between policy formulation and real-world service delivery, ensuring that all young people receive the high-quality mental health care they deserve.

Full text

Introduction

The mental health of children and youth in the World Health Organization (WHO) European Region is deteriorating (1). In this region, approximately one in five young people aged 15–19 years lives with a mental disorder (2, 3). Mental health support is most effective when it is received timely and is of high quality. Limited access to quality mental health care can have lifelong negative impacts on young people, their families, and communities. Across the WHO European Region, mental health conditions are the leading cause of disability among young people, emphasising the need to improve access and quality of care (4).

However, despite increasing recognition of child and youth mental health as a public health priority, significant disparities exist in access, quality, and outcomes of mental health services across the WHO European Region. More than one-third of countries in the WHO European Region lack mental health policies or plans for children and adolescents (5), and just over half have mechanisms in place to assess the quality of child and adolescent mental health services (6). Standardizing and improving service quality is crucial to reducing existing inequalities and ensuring all children and youth receive the mental health care they need.

WHO Europe’s approach to improving quality in mental health care for children and youth

To address these gaps, the WHO Regional Office for Europe developed Quality Standards for Child and Youth Mental Health Services (the ‘Standards’), providing a comprehensive framework for delivering evidence-based, accessible, and youth-centred care (7). The development of the Standards followed a collaborative, evidence-guided process which actively engaged a wide range of collaborators, including children and youth, their carers, and service providers. The development process was informed through a comprehensive review of national and international quality standards and peer-reviewed literature, as well as input and contributions from service users and providers. This included surveys, focus group discussions, and consultations to identify what constitutes good quality mental health care from the perspective of young people and those who support them (7).

The resulting Standards outline essential components for high-quality mental health care: (1) Youth participation and empowerment, (2) Rights and safety, (3) Family and community engagement, (4) Smooth transitions, (5) Timely support, (6) Developmentally appropriate and evidence-based support, (7) Workforce competency, and (8) Quality improvement and data collection. The Standards are intended to serve as a benchmark for governments, policymakers, and service providers to assess and improve mental health systems. Their overarching goal is to ensure that all children and young people, regardless of their background or location, receive high-quality mental health care that is safe, effective, and equitable.

Implementation science: a crucial but under-recognised field in mental health care

While the development of quality standards is a critical step, their existence does not guarantee better service delivery or improved outcomes. Research shows that guidelines and standards are not always effectively implemented and often they remain underutilised or inconsistently applied (8). It is estimated that only 60% of healthcare is provided according to evidence-based guidelines, while 30% is unnecessary or of low value, and 10% causes harm (9). In child and youth mental health care, adherence to guidelines is similarly low (10). This may be due to several barriers, including a lack of appropriate implementation strategies and stakeholder involvement, which compromises the incorporation of context-specific knowledge and expertise (10). Poor guideline implementation may help explain why WHO World Mental Health Survey data show that at least two-thirds of patients with major depressive or anxiety disorders in high-income countries receive inadequate treatment (11, 12).

The persistent gap between what is known, the provision of adequate care and what is done in practice (i.e., the ‘knowledge-implementation gap’) emphasises the need for systematic approaches to support the implementation of evidence-based practice. Bridging this gap requires more than producing guidelines and standards; it demands a focused effort to understand the implementation process and to develop strategies to sustainably embed quality standards into everyday care (13).

Implementation science provides systematic methods and strategies to facilitate the integration of evidence-based practices into routine care. It focuses on translating research into practice, identifying barriers to implementation, and ensuring sustainable change through evaluation. A wide range of models, frameworks, and theories provide guidance in optimizing implementation success (14).

Implementation science has been previously applied to improve quality of care, enhance patient safety, implement clinical guidelines, and facilitate many different health innovations (15–18). However, its role in enhancing quality improvement efforts in mental health care, particularly in child and youth mental health care, remains largely under-investigated (19–21), with only a few examples of evaluations of quality improvement in child and adolescent mental health service found (22, 23). The implementation of quality standards in particular in this field has received little attention, as highlighted by a 2023 systematic review on the implementation of health and social care standards, which found no studies addressing quality standards for youth mental health (20).

Without a thorough examination and planning of the implementation process, adopting and sustaining quality standards is unlikely. Successful implementation of quality standards requires a comprehensive understanding of key factors, including who is responsible for implementation, the cultural and systemic contexts in which it takes places, and perceptions and attitudes toward implementation (20). Moreover, for successful implementation efforts, engaging a broad range of partners in sustained, long-term collaborations is essential (24). This involves guideline and standards developers working closely with implementers, such as policymakers, service providers and users, as well as implementation researchers, to ensure that the implementation process is contextually relevant and addresses the actual needs and challenges faced in practice (8). Systematic consideration of these factors is crucial for developing targeted strategies to strengthen implementation and ultimately improve the quality and safety of mental health care. While implementation science provides useful tools, there is limited experience of its application in the context of child and youth mental health policy. Therefore, capturing and systematically documenting how implementation science approaches are used to facilitate the uptake of new guidelines and standards is critical to informing future implementation efforts and identifying effective strategies to improve their uptake.

Here we describe how implementation science has been utilised to enhance the implementation and uptake of the WHO Quality Standards for Child and Youth Mental Health Services.

Harnessing implementation science: a case example of the WHO regional office for Europe quality standards for child and youth mental health services

Timely development of implementation support and resources

From the outset, the ‘Standards’ development and implementation process aimed to capitalise on early motivation and opportunity. This involved the use of the Capability, Opportunity, and Motivation Model of Behaviour (COM-B Model), a behaviour change framework that provides insights into an organisation's readiness for implementation (25). The COM-B Model proposes that readiness to implement a change depends on capability, opportunity and motivation. For the Standards, it was therefore essential to target these factors among decision makers and implementers. When a product is launched, the initial excitement and interest can create a window of opportunity and motivation for its implementation. In case implementation support is not available, this excitement can quickly dissipate, and motivation and opportunity lost. We aimed to overcome this barrier by simultaneously developing and launching the Standards alongside tools to support its implementation. A rapid review of implementation tools for standards and guidelines was conducted as soon as the idea for the Standards had been conceptualised. Initial versions of the implementation tools were developed at the same time as the Standards, allowing for a parallel consultation and update process. Upon development of initial versions of the Standards and its implementation tools were available, interviews with key stakeholders were conducted to understand key implementation barriers and facilitators and provide further support where necessary. This enabled lessons already learnt on implementation processes to be available for those interested in implementing the Standards at the time of their launch.

To strengthen the perceived capability of policymakers and service providers, case studies illustrating the practical implementation of the Standards were developed. These case studies demonstrated how different stakeholders could adapt and integrate the Standards into their existing practice. By highlighting real-world applications, they provided tangible examples that implementation was achievable. The case studies were shared widely among networks and will be made available online.

Interdisciplinary collaboration

A key aspect in harnessing the potential of implementation science was the collaboration between a diverse array of experts in implementation science, child and youth mental health, and quality of care. Through regular meetings, joint workshops, and iterative discussions, the team created spaces to exchange perspectives and challenge assumptions about implementation approaches. Implementation scientists helped to ensure that approaches are grounded in evidence-based frameworks, theories and models, while mental health professionals contributed contextual knowledge of service delivery and settings across the WHO European Region, and quality of care experts contributed experience of having implemented quality improvement in health systems. This interdisciplinary approach facilitated the integration of evidence-informed implementation methods while ensuring relevance to children and youth mental health care settings.

Engaging service users, providers, and decision-makers

Given the significant heterogeneity among the 53 Member States in the WHO European Region, ensuring relevant implementation support across various health system contexts was a major challenge. Efforts to overcome this barrier included actively involving a wide diversity of partners and member states from across the WHO European Region. The implementation process of the Standards engaged international organizations, policymakers, program managers, health care professionals, as well as service users and their carers throughout all stages. The implementation of the Standards was discussed and refined through feedback gathered at key events and conferences, including the 3rd WHO Mental Health Week (2–7 November 2024), with over 200 participants, and the 1st WHO Autumn School on Quality of Child and Adolescent Mental Health (2–6 November 2024), which brought together 36 participants from 15 different countries. There were continuous efforts to build multi-sectoral and cross-country partnerships. We used embedded research approaches to integrate decision makers and implementers and establish a direct link to the use of findings. For instance, the developed implementation tools were shared widely across the whole WHO European Region for feedback decision makers and implementers and updated accordingly. Moreover, in-depth interviews were held across 4 countries (Latvia, Greece, North Macedonia, and Kazakhstan), purposefully selected as ‘early adopters’ due to their heterogeneous nature, to inform context-specific adaptations and increase the potential for successful implementation across the Region.

Consideration of implementation needs across a multi-sectoral system

Implementation theories identify the importance of engaging different levels of the health system for successful implementation. Applied to a mental health system, this can mean engaging those responsible for governance and leadership, as well as those responsible for quality audits and improvement at the service level. In recognition of its holistic nature, a multi-sectoral approach is recommended for child and youth mental health care with smooth transitions and working between different sectors (7, 26). To gain a comprehensive perspective on the implementation of the Standards, a diverse group of collaborators, including policymakers, service managers, and service providers from each country were interviewed to assess knowledge, awareness, perception, and implementation factors (such as adoption, capacity, adaptation, facilitators, and barriers) of the Standards across all layers of the multi-sectoral system. This was guided by the Consolidated Framework for Implementation Research (CFIR), which offers a comprehensive structure to assess factors influencing implementation outcomes (27).

Interviews across countries revealed common barriers to implementation, including workforce capacity constraints and resource limitations. Facilitators included strong multi-sectoral collaboration, sustainability through long-term policy commitment and financial investment, and involvement of the perspectives of young people and their families. Most collaborators agreed that adopting the Standards would be difficult without context-specific adaptations such as translation of resources, considering sociocultural factors, and aligning outputs with available resources. Key findings from the interviews were shared at a technical meeting for further discussion. Participants felt that their perspective had been well taken into account and found the findings useful as a basis for deriving context-specific implementation actions, designing implementation plans, and planning capacity-building activities.

Moving forward to improve child and youth mental health

The learnings from the implementation process of the Standards illustrate the potential of implementation science in advancing child and youth mental health care. In line with evidence from other health sectors, applying structured and systematic methods can help anticipate and overcome potential barriers, thereby ensuring more efficient and sustainable implementation of quality standards, guidelines, and service innovations (15, 16, 18). Individuals and organizations involved in policy, research, and practice can benefit from more systematically applying implementation science to improve child and youth mental health care.

A key factor for successful implementation is the meaningful engagement of all individuals and groups affected by the process or its intended outcomes. When policymakers, researchers, service providers, and service users are actively involved, mental health services become more relevant, effective, and of higher quality (7). Our experience highlights the importance of engaging service users, community members, implementers, and decision-makers early on and sustaining their involvement throughout the implementation process. In the context of child and youth mental health care, this is particularly important as young people are often excluded from decision-making processes that directly affect them (28).

Moreover, to effectively implement quality standards, broader societal barriers must be addressed, as decision makers and implementers also highlighted in the implementation of the Standards. This may include tackling mental health stigma, raising public awareness through innovative and youth-engaging communication strategies, and shifting from top-down approaches to community-driven solutions. Social participation is vital for building resilient and sustainable health systems in the European Region (29), making it crucial to provide space, listen to, and act upon the voices of children, youth, and their families. We strongly call for more meaningful and inclusive participation of young people in implementation and quality improvement efforts in mental health care to ensure that services truly reflect their needs and lived realities (30).

Successful implementation efforts require more than technical guidance; long-term quality improvement depends on strong political commitment and sustained investment. Given the worsening state of youth mental health in the WHO European Region (1, 3), it is essential that policymakers champion efforts to address persistent challenges such as geographical disparities in service availability, inadequate funding and/or resource allocation, and a shortage of trained professionals in child and youth mental health. Research, particularly implementation science, plays a key role in providing the necessary evidence to inform and guide these efforts (19). Without targeted action on system-level barriers, quality standards risk remaining aspirational rather than transformational.

Looking ahead, greater emphasis on sharing methods, good practices, challenges, and lessons learned across countries will be essential for advancing child and youth mental health care. This can be facilitated through communities of practice, strategic communication efforts, and other collaborative platforms. Such approaches could generate valuable insights and send strong signals to support policymakers and service leaders in driving quality improvements.

Conclusion

While the Standards provide an innovative evidence-based framework for improving child and youth mental health services, their impact on mental health and wellbeing of young people depends on effective implementation. Through the systematic use of implementation science, WHO aims to bridge the gap between governance and practice to ensure that all young people receive the high-quality mental health care they need and deserve. The lessons learned from this case study echo learnings from previous initiatives, such as the importance of adopting an implementation science lens at all stages, the use of structured methodologies, strong and sustained stakeholder collaboration, and the continuous adaptation of implementation to different contexts. In addition, the learnings highlight the importance of taking a multi-sectoral approach that engages children, young people and their caregivers in the process in order to develop strategies that are grounded in the context of child and youth mental health care to be developed. Drawing on these lessons can help optimise future implementation initiatives in health care for greater sustainability and impact. Fostering collaborative communities of practice and meaningfully engaging young people can advance evidence-based improvements in child and youth mental health care in the WHO European Region and beyond.