Mental health issues have overtaken cardiovascular disease and cancer as the leading cause of health loss in New Zealand (NZ) [1,2]. The majority of people affected by mental health concerns (eg, depression and anxiety) also exhibit more than 1 risk behavior (eg, smoking, problem drinking, substance abuse, and physical inactivity) [2]. These mental health and risk behaviors (MHBs) are the major contributing factors to NZ’s health loss [2]. The Ministry of Health recognizes that to improve the health of NZ, reduction of these MHBs is needed [2].

Most mental health disorders begin in adolescence [3-5], and risk behaviors established at this time can continue into adulthood [6-9], significantly impacting on long-term mental, physical, and social well-being [10-12]. Mental health issues affect 1 in 4 of NZ youth [4,13], and the number of NZ secondary school students reporting mood disorders, self-harm, and peer problems has increased [14]. NZ has the highest rate of youth suicide in the Organisation for Economic Cooperation and Development countries [15]. Māori (the indigenous people of NZ) youth living in deprived, rural areas have significantly higher rates of MHBs and suicide than their non-Māori peers. Further, educational, employment, and health outcomes are worse for adolescent Māori, and their life expectancy is much lower [16-21].

Rather than disclose their MHB concerns at primary care, adolescents often present primarily with vague, physical symptoms [8,9,16,22-25]. Opportunistic discussions about MHB do not occur in primary health care unless the problems are severe [9,26-34]. Yet, if the conversation is initiated by the clinician, young people are willing to discuss MHB [28,34-41]. Screening for youth MHB concerns occurs in less than 50% of primary health care provider (PHP) consultations, with the result that over half of adolescent MHB concerns are not detected [34,35,42]. Clinicians in primary care describe being underresourced in terms of time, appropriate screening tools, and experience in youth health [28,34,36]. Screening can reveal issues that may otherwise be overlooked and facilitate discussions between PHPs and young people [31]. This process can be therapeutic for youth, increasing their satisfaction with care and the likelihood that they will ask for help in the future [28,31,34].

There are a number of MHB screening tools available [41], but it can be time-consuming to administer these and interpret the results [43], and not all screening tools are suitable for use in all clinical contexts [43,44]. Where MHB screening for youth does occur, rates of follow-up and service use remain low [42,44,45]. The referral of every positive screen to secondary services creates an overwhelming need for appointments, delaying timely access to care [17,28,41,42,46]. In a stepped care approach, the primary health care team forms the hub of care for mild-to-moderate mental health issues. Increasing levels of care are added stepwise relative to the severity of more complex or worsening issues, providing effective management in primary care and more efficient use of specialist services [47].

The NZ-developed electronic Case-finding and Help Assessment Tool is a multi-item, electronic screening tool for use in primary health care to screen adults for substance misuse (smoking, alcohol, and drugs), problem gambling, depression, anxiety, exposure to abuse, difficulty controlling anger, and physical inactivity [48]. A youth version, YouthCHAT, has been developed using a co-design approach with input from clinicians and young people[49], and it contains 4 additional youth-specific modules: sexual health, youth stress, conduct disorder, and eating issues [10,48,50-55]. For positive screens in the smoking, substance abuse, depression, and anxiety modules, branching logic links users to validated assessment tools (eg, the Substances and Choices Scale [56], the Patient Health Questionnaire-Depression Adolescent version [57], and general anxiety disorder assessment, GAD-7 [58]). Some modules provide a nonclinical score that indicates the number of positive responses to questions (eg, the behavior or conduct module), and others simply indicate the presence of risky behavior (eg, gambling). The help question allows young people to prioritize concerns and indicate the areas where they are ready to accept help [51,59,60]. A stepped care-based resource pack guides clinicians to effective evidence-based interventions. Youth health providers in Northland have also undertaken mental health credentialing through the Primary health organisation (PHO) in order to provide brief interventions to clients for low to moderate mental health issues at the time of the screening.

Youth can complete YouthCHAT on an electronic device (eg, a tablet) before their consultation; completion takes approximately 5-15 minutes. A video briefly introduces the screen and explains confidentiality before giving the option to “start” or “exit” the screen. Upon completion of the screen, a clinical summary report is available to the clinician seeing them, indicating which domains screened positive, the severity of the condition (from validated assessments), and where help is sought. This report facilitates a conversation between the clinician and the young person, supporting shared decision making and youth input into their plan of care.

YouthCHAT has been successfully used in 1 rural NZ youth clinic and found to be acceptable to clinic staff (CS) and young people [54]. A randomized trial in an urban high school indicates that YouthCHAT compares favorably to the HEEADSSS (Home, Education, Eating, Activities, Drugs and Alcohol, Sexuality, Suicide and Depression, Safety) interview-based assessment, currently used to screen all Year 9 students in NZ low-decile secondary schools for psychosocial issues [49].

This study will evaluate the implementation of the YouthCHAT program into primary health clinics in Te Tai Tokerau (Northland, NZ). Using a co-design approach, YouthCHAT, the processes around its use, and the stepped care resources offered will be tailored to meet the needs of local communities, with the aim of improving screening rates and brief intervention delivery for MHB concerns as well as developing a framework for scaling up the implementation of YouthCHAT more widely across Northland.

Specific objectives are to assess YouthCHAT with respect to the following:

Considered the founding document of NZ, the Treaty of Waitangi was signed by Māori Chiefs and representatives of the British Crown in 1840. The agreement ratified the unification of Pākehā (Western settlers) and Māori as a nation while affording Māori values, traditions, and practices [61]. Inherent in the Treaty of Waitangi is the Māori principles of kāwanatanga (giving governance to the Crown) and tino rangatiratanga (respecting Māori self-determination). The Treaty of Waitangi Act in 1975 [62] outlined the principles of partnership, participation, and protection as representing the true intent of the Treaty [63-65]. The principles continue to be the foundation of the relationship between Māori and the New Zealand Government today [66]. Research involving Māori in NZ must be carried out in accordance with the principles of the Treaty of Waitangi and ensure that Māori culture, values, and beliefs are respected and protected [67-71].

A randomized controlled trial, considered the epitome of clinical trials, would provide evidence about how an intervention is used in a controlled context with a specific population. However, these findings may not apply to the use of the intervention with real populations in actual clinical settings [71-73], particularly in areas of wide cultural diversity, such as NZ [71].

Kaupapa Māori (research for the benefit of Māori by Māori) is influenced by Māori culture, history, indigenous knowledge (Mātauranga), language (te reo), values, and worldview [67,68,70,71,74-76]. The proverb “kaua e takahia te mana o te tangata” (do not trample on “mana” or dignity and status) highlights the guiding principle of Kaupapa Māori, to respect the mana not only of individuals but also of the Māori culture, values, and beliefs [67,68,77]. The self-determination of Māori to identify challenges, solve problems, and form new knowledge (tino rangatiratanga) affords control over research processes and the protection of Mātauranga [67-71]. This study was not conceived as a Kaupapa Māori project; however, as the majority of participants are envisaged to be Māori, their culture, values, and beliefs must be validated, respected, and protected. Provided Māori retain control of the research, non-Māori researchers can undertake research involving Māori. To do so, they must first reflect on their own culture, worldview, values, and beliefs and, having done so, acknowledge, give credence to, and respect those of Māori [67-71,77]. Non-Māori researchers can then work in partnership with Māori, as long the methodology affiliates with the principles and values of Kaupapa Māori and is undertaken in collaboration with those who will benefit from the research [78].

In a co-design approach, research is undertaken with, rather than on, people [67,79]. The research processes evolve in conjunction with and from the perspectives of the participants [79-82], allowing researchers to gain an understanding of context-specific requirements and challenges [79-84]. Participants become actively involved in the research process as partners, designers, and developers alongside the research team. The knowledge, experiences, ideas, and skills of the participants are used to help find acceptable and workable ways of identifying and overcoming problems [80,85,86]. Co-design research, therefore, aligns with Kaupapa Māori, and in this study, researchers from both cultures will work alongside each other sharing research principles, processes, and skills in bicultural research [87].

Māori have been involved in the development of YouthCHAT. The tool has been translated into te reo Māori (Māori language) and tested to ensure acceptability among Māori youth and clinicians in Te Tai Tokerau [54]. The same clinical educator (CE) who was part of the proof of concept trial noted above is a qualified nurse educator and registered nurse. As a coinvestigator and the Kaitautoko (support person or advocate) for this project, she will implement YouthCHAT in her clinical practice first and then train and work with other clinical staff as YouthCHAT is iteratively implemented in other clinics. Further, this research will be developed through engagement with young people, local iwi (confederation of Māori tribes), the local PHO and District Health Board, CS, and community providers for their input and participation. The cultural relevance of YouthCHAT and its implementation has been valued in its development. Equitable approaches will be taken with all participants in all locations, and the findings of this study may contribute to a long-term reduction in disparities between Māori and non-Māori young people. Engaging and partnering with stakeholders and users throughout the research process will respect Māori tikanga (customs and etiquette), and validation of Māori culture, values, and beliefs will be integral to the success of the study [75,82]. With the assistance of local project investigators, the bicultural, co-design approach will ensure that the YouthCHAT model initially employed, further scaled up, and then rolled out is culturally appropriate and meets the needs of the local community.

This study has received approval from the New Zealand Health and Disability Ethics Committee (reference 18/CEN/31) on May 05, 2018. A pragmatic rollout of YouthCHAT will take place over 3 years using an iterative process of implementation, modification, and evaluation to assess the processes for using YouthCHAT across different clinical settings in Te Tai Tokerau.

The YouthCHAT program is being implemented into the youth screening policies and procedures across all the clinics taking part in this study. Youth between 12-24 years of age visiting the clinic will be asked to complete YouthCHAT as per the clinic’s screening procedures. Feedback about YouthCHAT will be sought in the form of surveys, interviews, and focus groups from 3 participant groups: (1) the CE, (2) CS, and (3) young people aged 16-24 years who have used YouthCHAT.

All CS, including the CE, will be informed about the study and invited to participate by members of the research team before the implementation of YouthCHAT into their practice. All youth meeting the participation criteria will be informed about and invited to take part in the study after their consultation with the clinician. This will be done by either the clinician or by administration staff, depending on each clinic’s systems. Young people who are interested in taking part will leave their contact details and will be contacted by the research team to arrange a suitable time for the focus groups. All participation is voluntary. Written, informed consent will be obtained prior to their participation. Youth taking part in the focus groups will receive a NZ $20 voucher, and kai (food) will be provided.

All information will be kept confidential, and analyzed data will be presented in a deidentified manner. HealthLink will provide secure storage of all YouthCHAT screening data and transmit encrypted, secure data to the clinics’ practice management system software by the same private network used for their electronic referrals. Participant data will be deidentified before being stored by the research team. Clinical data obtained through YouthCHAT will be available to relevant health providers. All surveys are Web-based and anonymous and will be completed using Qualtrics. Recordings of semistructured interviews and focus groups will be transcribed (without anything that could identify participants), and the recordings will be deleted. The transcriber will be asked to sign a confidentiality agreement. Data will be retained for 10 years as per the University of Auckland protocol.

Early detection intervention for mental health disorders and risky behaviors in youth can prevent long-term health and psychosocial issues [9,30,41,92]. For this to happen, it is imperative that a means of detecting existing and developing MHBs in adolescence is found and timely management initiated [22]. Interventions need to respect the ability of youth to change risk behaviors and provide them with the resources, skills, and support to do so [6,17,18,22,31,36,60,93,94]. YouthCHAT promotes wellness planning and supports youth to self-manage. The systematic approach of screening and provision of guides for stepped care intervention aims to lead to the early and more comprehensive intervention of youth mental health, substance misuse, and other lifestyle issues, which will have substantial impacts on future physical, mental, and social health as well as well-being. It is anticipated that a successful rollout of YouthCHAT will be associated with improved health and social outcomes through early identification of and intervention for mental health concerns, leading to an improvement in youth help-seeking behavior.

Complex interventions, such as YouthCHAT, with the potential to improve health outcomes, can only do so if they can be successfully implemented and then integrated or normalized into routine clinical practice [88-91]. However, this will not happen unless those who will be using the tool find it acceptable and unless its delivery is feasible. The implementation of YouthCHAT requires the necessary internet capability and availability of mobile devices, such as tablets, for the completion of the screen. The feasibility of implementing YouthCHAT relies on more than technological infrastructure, it is dependent on the impact YouthCHAT has on the people who will be using it [88-90]. For example, if clinical staff see the benefit of using YouthCHAT in their daily practice, enhancing engagement with young people and improving health outcomes while reducing their workload, then it is feasible that the tool can become normalized in their daily practice [88,89]. Feasibility is also reliant on factors that encourage or inhibit the uptake of the screen by young people, for example, the length of the screen, ease of completion, and the electronic interface. A co-design approach will assist the research team to identify and overcome barriers to the use of YouthCHAT.

With the assistance of local project investigators, the co-design, bicultural approach will ensure that the YouthCHAT model initially employed, further scaled up, and then rolled out, is culturally appropriate, meets the needs of the local community, and is easily integrated into practice. This study, underpinned by NPT, seeks to develop YouthCHAT as a sustainable, culturally acceptable, cost-effective, and time-saving screening tool for clinicians in primary care to identify mental health concerns and ultimately improve equity for Māori youth. This is particularly important in rural NZ where provider recruitment and retention remain difficult.

If YouthCHAT can be implemented across a variety of primary health care settings in NZ, it has potential to be a user-friendly, time efficient, and culturally safe screening tool for early detection of psychosocial issues in NZ youth. The resource pack assists clinicians to provide appropriate intervention for emerging and developed youth mental health and lifestyle issues. The bicultural approach involving input from community providers, users, and stakeholders will ensure that modifiable elements of YouthCHAT can be tailored to meet the specific health needs of each context and could have a positive influence on future mental, physical, and social outcomes for NZ youth.