How can we strengthen mental health services in Swedish youth clinics? A health policy and systems study protocol

Introduction Strengthening first-line mental healthcare services for youth remains a priority for the Swedish government. The government is currently investigating how different sectors involved can be strengthened, but evidence is scarce. Youth clinics play a key role in these discussions, being one of the most trusted services for youth. However, analysis of organisational functions and coordination with other services is important to strengthen youth clinics’ role in first-line mental healthcare. This study investigates these challenges and aims to analyse the integration of mental healthcare within youth clinics to identify strategies to strengthen first-line mental healthcare for youth in Sweden. Methods and analysis This study adopts a health policy and systems approach. In the first phase, a formative realist evaluation is conducted to ascertain what works in terms of integrating mental healthcare services within youth clinics, for what type of youth subpopulations and under what circumstances. National-level stakeholders will be interviewed to elicit the programme theory that explains how the intervention is supposed to work. The programme theory will then be tested in three–five cases. The cases will be comprised of youth clinics and their stakeholders. Quantitative and qualitative information will be gathered, including via visual methodologies and questionnaires. The second phase includes a concept mapping study, engaging stakeholders and young people to build consensus on strategies to strengthen the integration of mental healthcare into youth clinics. Ethics and dissemination The Swedish Ethical Review Authority has approved the study (2019-02910 and 2020-04720). The results will be published in open-access peer-reviewed journals and presented at scientific conferences.

The article is very well written, and I have no major comments regarding the study design or methodology. The figures help clarify the design and concepts. However, a third figure depicting the various stakeholders in the FLMHS for youth -the integration of primary care with mental health care -would be helpful. Through the provision of special youth clinics, the Swedish health system is more complex than some other health systems. By providing this additional figure it would make it easier to compare health systems, and to see how the YCs fit in within the larger system in relation to FLMHS. It would also be useful to provide a sentence about the usual care provided by youth clinics. (Line 95-) The title could be improved by cutting one superfluous 'youth': How can we strengthen mental health services in Swedish youth clinics? A health policy and systems study protocol Alternatively: How can we strengthen mental health services for young people in Swedish youth clinics? A health policy and systems study protocol The introduction could be improved by providing a more generic introduction to integrated care options before setting the scene in the Swedish context. This would also limit repetition, currently at the beginning of third and fourth paragraphs.
The paragraph about YC's could be added to the previous paragraph, and the first sentence changed: More than 250 youth clinics have been in operation in Sweden since the 1970-1980s, providing youth-centered health services for young people.
Sentence starting on line 99 is too lengthy or complex. Suggest : In this paper, we present the protocol for a health policy and system study with an aim to analyse Swedish policy efforts to strengthen FLMHS for youth. We focus on YCs and adopt Atun's et al conceptual framework for investigating the integration of health interventions into health systems [21].
Line 103: The first research question is ambiguous. Suggest: What is the role and function of YCs in the First Line Mental Health Services for youth in the Swedish health system? Discussion: Additional information on any amendments made to methodology or data collection methods due to Covid-19 would be beneficial.

Minor comments & edits
Line 27: youth-clinics' Line 35: casesplease add information about what you mean with cases Line 36: including via visual methodologies … Line 48: the barriers to youth accessing high quality mental health services Line 61: as they have = unlike and suicide rates have not decreased in younger age groups unlike in the overall population Line 62: challenges for Swedish health policies, but is not Line 73-75: Sentence is too complex: the Swedish health system embarked in 2009 to develop and gradually integrate youth mental health services within primary care services, the so-called First-Line Mental Health Services Line 79: have found it Line 99: system study with an aim to analyse Swedish policy efforts to strengthen Line 111: centred on the service user Line 121: influenced by, and influences, both policies and research. Figure 1: Youth clinics (plural) Line 139: advantage, and are less complex and risky Line 145: different interests at stake Line 147: young service users Line 178: have been informed Line 179: previous studies exploring youth views on YC. Furthermore, Line 185: second phase. Stakeholders Line 212: once an intervention has ended or come to a conclusion Line 235: how the intervention is supposed to work Line 265: Specialist mental health professionals will include those working in child mental health services and adult mental health services Line 269-70: (…) we will engage young people in an auto-driven photo-elicitation interview to gather their perspectives Line 275: aged 16-25 (compare line 269) Line 286: This analysis will inform the intervention implementation Lines 294-7: Sentence too complex. (…) participatory process; professionals and young people will be invited to take part in workshops followed by a concept mapping Line 307: YCs involved in the case studies will be asked to invite Really enjoyed the explanation of complexity theory-may be familiar to readers as wicked problems. This is a hugely complex piece of work, as brought home by How analysis will be completed is not really outlined in detail; likely as this is a description certainly in phase one of several studies contributing to the whole. However I think this would strengthen the paper e.g. perhaps a table in line with Table one, with approaches you plan to take in terms of each component. This is a hugely ambitious project with broad scope. The writing throughout is excellent and engaging.

REVIEWER 1
The figures help clarify the design and concepts. However, a third figure depicting the various stakeholders in the FLMHS for youth -the integration of primary care with mental health care -would be helpful.
Through the provision of special youth clinics, the Swedish health system is more complex than some other health systems. By providing this additional figure it would make it easier to compare health systems, and to see how the YCs fit in within the larger system in relation to FLMHS.
Thank you for this good suggestion. We have added a figure that illustrate the stakeholders in FLMHS for youth.
Two clarifying sentences are added and inserted (line 125-128).
A new figure 1 is inserted (Line 130) It would also be useful to provide a sentence about the usual care provided by youth clinics. (Line 95-) Yes we agree, more information on the usual care provided by YC will clarify. This is now added (Line 119-125).
The title could be improved by cutting one superfluous 'youth': How can we strengthen mental health services in Swedish youth clinics? A health policy and systems study protocol Alternatively: How can we strengthen mental health services for young people in Swedish youth clinics? A health policy and systems study protocol We welcome this suggestion and have adopted the first alternative! Title changed accordingly (Line 1-2).
The introduction could be improved by providing a more generic introduction to integrated care options before Thank you for bringing this to our attention. We agree that a more generic start will improve the introduction.
We have included a broader paragraph in the beginning of the introduction (Line 65-68) setting the scene in the Swedish context. This would also limit repetition, currently at the beginning of third and fourth paragraphs.
We have also moved other more universal parts of the introduction to this initial paragraph (Line 68-75) After this, the Swedish setting is introduced and overlapping parts have been removed. (Line 77-95 and following) The paragraph about YC's could be added to the previous paragraph, and the first sentence changed: More than 250 youth clinics have been in operation in Sweden since the 1970-1980s, providing youth-centered health services for young people.
We agree! Thank you for the suggestion.
The changes suggested are carried through.  Sentence starting on line 99 is too lengthy or complex. Suggest : In this paper, we present the protocol for a health policy and system study with an aim to analyse Swedish policy efforts to strengthen FLMHS for youth. We focus on YCs and adopt Atun's et al conceptual framework for investigating the integration of health interventions into health systems [21].
Again, a good suggestion that we welcome.
The sentence is changed in line with the reviewers suggestion (Line 132-135) Line 103: The first research question is ambiguous. Suggest: What is the role and function of YCs in the First Line Mental Health Services for youth in the Swedish health system?
We agree that this research question is ambiguous. We have still decided to keep the current formulation of the first question. The current formulation "How and under what circumstances..." is grounded in the realist evaluation approach which is the methodological base of the first part of the research project. We consider that by keeping the research question as it is now there is more coherence between the research questions and the methodological design. -How analysis will be completed is not really outlined in detail; likely as this is a description certainly in phase one of several studies contributing to the whole.
However I think this would strengthen the paper e.g. perhaps a table in line with  Table one, with approaches you plan to take in terms of each component.
Thank you for this comment! We agree that the analysis could be more clear and have addressed this.

GENERAL COMMENTS
This is a huge project, with many aspects, which you have well recognised, and you attempt to bring the many voices and stakeholders together in a very laudable way. It has the potential to greatly impact service design and delivery both in Sweden and in approaches taken elsewhere. In this draft, I really appreciated the outline of the methodology and description of this for the reader not necessarily working in this arena often. My only comments are very minor, not really regarding the work itself or the content; but rather minor grammatical/ clarifying points to help improve an already excellent draft.
-Unclear meaning for sentence at line 72 p 6 of the proof, "In Sweden, the prevalence of mental health problems among young people has increased dramatically with about 70% during the period"-This could perhaps be " by about 70%" ?
-Line 95 p 7 -"Currently, the sectors that are most frequently involved in FLMHS are primary health care centers, school health services and youth clinics"-It would be helpful to know what services are available in the youth clinics specifically. These clinics are not seen necessarily elsewhere (my own country does not have these)-and likey will differ in terms of how constituted. The paper refers to mental health but I am not clear what the provision is e.g. .Are they GP led? Is this primary care or secondary care in some instances, is there psychiatry? Psychology? Is couonselling available? Educational psychology? Social work etc? Or do they refer on to mental health services? It seems there are 250 of these, which is very robust as a network, and you are absolutely right in highlighting the potential for primary care, but no doubt may also mean there are very many different configurations! May be worth acknowledging this. Of course, perhaps they are very uniform and this may help.
P20 line 399-" Due to the Covid-19 pandemic some adjustments to the planned methodology has been, and will be necessary. During the year 2020 and 2021 meetings and travels has…"-In English, travels and adjustments are plural -so suggest "Due to the Covid-19 pandemic some adjustments to the planned methodology have been, and will be, necessary. During year 2020 and 2021 meetings and travels have been", again" the restrictions" are plural and "have" been in line 400 and following line. Sorry if this seems pedantic but better to have it correct! Thank you for this comment. We realized that international readers might need more information about the services provided in the Swedish Youth Clinics.
We have added some more information about the Youth clinics in lines 99-108. We have also added two new references, number 25 and 26.
The reference numbers were changed consequently throughout the manuscript and in the reference list (line 501-508).
P20 line 399-" Due to the Covid-19 pandemic some adjustments to the planned methodology has been, and will be necessary.
During the year 2020 and 2021 meetings and travels has…"-In English, travels and adjustments are plural -so suggest "Due to the Covid-19 pandemic some adjustments to the planned methodology have been, and will be, necessary.