Collaborative Involvement of Indigenous Youth in the Design and Evaluation of Digital Mental Health Interventions: A Scoping Review Protocol

Josie Povey (  josie.povey@menzies.edu.au ) Menzies School of Health Research, Charles Darwin University, Casuarina campus, Ellengowan Drive, Casuarina, NT, Australia https://orcid.org/0000-0001-6961-4674 Buaphrao Raphiphatthana Menzies School of Health Research: Charles Darwin University Michelle Torok University of New South Wales Tricia Nagel Menzies School of Health Research: Charles Darwin University Fiona Shand University of New South Wales Michelle Sweet Menzies School of Health Research: Charles Darwin University Anne Lowell Charles Darwin University Kylie Dingwall Menzies School of Health Research: Charles Darwin University

and grey literature in English that meet eligibility criteria are included. Data, including; study methods, methodologies, digital mental health program details, participant information and engagement and reporting processes are extracted and included for analysis. Data extraction variables are guided by the Consolidated Criteria for Strengthening Reporting of Health Research (CONSIDER statement). This statement provides a best practice checklist for reporting research involving Indigenous peoples. This scoping review protocol has been registered with Open Science Framework (available via osf.io/2nkc6).
Discussion: To date, there are no reviews which critically analyse engagement of Indigenous youth in the development and evaluation of youth-speci c digital mental health interventions. This review will aim to ll that gap and appraise alignment of current practice with best practice guidelines to inform future research. It will highlight appropriate strategies for the engagement of youth in collaborative processes, providing guidance for health practitioners, policy makers, and researchers working in the eld of Indigenous youth and digital mental health.

Background
The majority of Indigenous youth worldwide are resilient, proud of their culture and possess social capital beyond any other recent generation (1)(2)(3). Despite this, they remain at heightened risk of developing mental illness in adolescence compared to their non-Indigenous counterparts (4). We use the collective word 'Indigenous' to describe people who originate from a particular region, however, acknowledge the rich diversity and knowledge represented by this term. Despite the need, Indigenous youth worldwide are less likely to access mental health treatment than non-marginalised young people (5,6). Barriers to accessing mental health treatment include stigma, fear, shame, intergenerational trauma, distrust of services and being unable to identify signs and symptoms of illness (5,6). Furthermore, the location of populations in need are often decentralised, meaning long distances, increased costs and challenges in the delivery of services (5,7). Treatment services are often non-existent, underfunded or occur in a localised or prescribed manner within Indigenous communities, limiting their ability to affect meaningful sustained change. Considerations of language, diversity and worldview differences are sometimes overlooked, resulting in programs that are less meaningful or acceptable to the young people they are intended to serve (8,9). Despite the need for culturally safe, effective, early intervention treatments, there remains relatively few approaches which are evidence based (10). Recent increased availability of technology and connectivity has been identi ed as an opportunity to increase access to health services within underserved communities and marginalised youth populations (6).
Digital mental health is identi ed as "mental health, suicide prevention and alcohol and other drugs services delivered via a digital platform" (11). There remains limited cultural diversity in the digital mental health eld, despite recognition of their potential to increase access to treatment for Indigenous populations (12)(13)(14). To date, ve systematic or scoping reviews have been conducted in the area of health technologies for Indigenous populations (15)(16)(17)(18)(19), however only one has focused on youth and mental health interventions (19). One other related article contains a literature review and a case study (20). There is a consensus among the authors of these reviews that meaningful engagement of end users in design, development or evaluation is a necessary component of digital health solutions (15,(17)(18)(19).
However, none examine in-depth the strategies undertaken to engage Indigenous youth in the design or evaluation process.
Despite the importance of end user involvement in the design and evaluation of digital mental health interventions being widely identi ed (11,21,22), there remains a lack of clear reporting on the methods and processes undertaken (23,24). A popular methodology outlined in the literature is Participatory Design (PD), which is the involvement of end users in the co-creation and evaluation of digital health resources, as partners (25). This process allows an iterative approach whereby digital resource design is continually reviewed and updated (22), a necessary process which is identi ed in National Guidelines for safety of digital mental health solutions (11).
Furthermore, ethical guidelines on the conduct of research with Indigenous communities emphasise the importance of cultural considerations when engaging Indigenous youth in research practices (26)(27)(28)(29). Engagement of Indigenous youth potentially protects young people and communities from being detrimentally affected and disempowered and allows better opportunity for self-determination (26,30,31). A review of ethical standards in Indigenous research, has led to speci c guidelines for reporting, such as the Consolidated Criteria for Strengthening Reporting of Health Research involving Indigenous peoples (CONSIDER statement), which aims to improve the quality of research practices involving Indigenous peoples (32). Within this statement, researchers are provided a comprehensive checklist of recommendations which include considerations on the governance, prioritisation, relationships, methodologies, participation, capacity building, analysis and interpretation and dissemination, of research involving Indigenous peoples. Critically reviewing research practices ensures they uphold ethical guidelines, and safeguards and informs best practice into the future (30).
International research has identi ed signi cant strengths unique to Indigenous young people which help build and maintain resilience (33,34). One such strength is a particular a nity for creative technological innovation and design (15,35,36), and willingness to embrace empowerment and self-determination (1).
The involvement of Indigenous young people in solutions to address their health needs is therefore as an essential component of health service design and delivery (37). For these reasons it is essential to focus effort on engagement of Indigenous youth in the design and evaluation of digital mental health solutions, to receive the most bene t. This review aims to map evidence regarding the collaborative involvement Indigenous youth in the design and evaluation of digital mental health interventions. Findings will provide recommendations for future projects aiming to collaboratively develop or evaluate digital mental health interventions with Indigenous youth.

Study Design
Scoping reviews are particularly useful in providing an overview of research on a given topic where evidence is emerging (38) and to review research processes on a given topic (39). For these reasons a scoping review was considered the most appropriate methodology. This scoping review is based on the guidelines proposed by Arksey and O'Malley (40) and the subsequent modi cations proposed by Levac et al. (38) and Peters et al. (41). It involves a six-stage process which includes: 1) identifying research question; 2) identifying relevant studies; 3) developing a study selection and data extraction method, which is re ned using an iterative process (38); 4) charting the data; 5) collating, summarising and reporting results. Additionally, Step 6) consultation, engages a male and female senior Indigenous researcher throughout scoping review processes, a minimum of three times, ensuring analysis and ndings are informed by Indigenous worldviews. Given the iterative nature of a scoping review, changes to the protocol can be expected (41), and any changes are detailed and justi ed in the nal reporting.

Protocol
The protocol was drafted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement (see supplementary le 1). This scoping review protocol has been registered with Open Science Framework (available via osf.io/2nkc6), as scoping review protocols are not currently accepted on PROSPERO.

Research question
The objective of this review is to map evidence regarding the collaborative involvement of Indigenous youth in the design and/or evaluation of digital mental health interventions. More speci cally it aims to determine: Which strategies, processes and methods are used to include Indigenous youth in the design or evaluation of digital mental health interventions? Did strategies, processes or methods used to engage Indigenous youth in design or evaluation of digital mental health interventions align with best practice guidelines?

Eligibility Criteria
Type of studies All study designs are included. Reviews and opinion pieces are used for reference searching only and not included in analysis. If full text articles are not available, corresponding authors are contacted. The emergence of the internet in the mid 1990's provided opportunities for health professionals to explore alternatives to face to face care (42), and literature on tele-psychiatry appeared not long after (43).

Intervention
Digital mental health interventions 'provide treatment and support to people with mental health disorders through telephone, mobile phone, computer and online applications, and can range from the provision of information, peer support services, virtual applications and games, through to real time interaction with trained clinicians' p.7 (45). Studies focused on developing or evaluating all digital mental health interventions are eligible. Electronic health or medical records, decision support tools for clinicians, analytic services, services that primarily provide support and education to health professionals, clinical practice management software, and clinical work ow and communication software are excluded (11).

Outcomes
There are two broad categories of outcomes that are of interest, 1) study methodology and methods and 2) processes which increase engagement, governance, prioritisation, relationships, participation, capacity, analysis and interpretation and dissemination, as per the CONSIDER statement described earlier (32).
A full list of inclusion and exclusion criteria is included in Table 2.

Study selection
The search is performed by two reviewers (JP, BR), who independently review article titles and abstracts and apply inclusion and exclusion criteria outlined in Table 2. If a study's eligibility is unclear, reviewers review full text and apply inclusion and exclusion criteria. Reviewers meet to discuss abstract screening and selection of articles. A good inter-rating agreement kappa is established at the title/abstract review stage, with two reviewers reviewing a minimum random sample of 25 studies, before proceeding to full text review. Once agreement is reached, full text articles are retrieved, and reviewed by two reviewers independently, again assessing eligibility. A nal list of included articles is prepared by each reviewer. If consensus is not reached throughout each stage (abstract screening/full text review) of study selection, a third reviewer (MT) reviews the articles in question. Notes are taken describing decisions for inclusion or exclusion.

Data extraction
Two independent reviewers (JP, BR) extract relevant data. If data is missing upon review of full text, corresponding authors are contacted. Data extraction variables, outlined in Table 4, are converted into simple tables prior to data extraction. Data extraction forms are independently tested by two reviewers (JP, BR) on a random sample of ve studies to ensure accuracy, consistency and validity of captured information (38,46). Relevant references are exported into Endnote X9, including full text. Endnote X9 allows reviewers to collaboratively manage duplicates, group and code references and add annotations and notes. General inductive analysis is used to determine themes from the data (47). Themes are independently generated and categorised by two reviewers (JP, BR). Revision and re nement of themes occurs within the research team through a series of meetings.

Consultation
Emerging themes and preliminary ndings are documented and used to create discussion with two Senior Indigenous Research O cers, on at least three occasions. Preliminary ndings prompt discussion and written notes are taken during consultation meetings (38). Consultation ndings are presented in nal reporting. This consultation phase, originally outlined by Arksey and O'Malley (40) and later re ned and de ned as necessary, by Levac et al. (38) enhances rigour and provides additional sources of information, perspectives, meaning, and increases the applicability of research ndings. Discussion between consultants and the research team re nes themes, aiming to reach consensus on results and ndings.

Discussion
This scoping review aims to provide a comprehensive overview of current practices and strategies described in the literature regarding the collaborative involvement of Indigenous youth in development or evaluation of digital mental health interventions. Researchers, clinicians and technology developers will bene t from these ndings as they assist in establishing best practice processes for engagement of Indigenous youth in digital mental health approaches as well as health research more broadly. As no other review has previously examined processes of development or evaluation in depth, this review aims to assist researchers to determine the 'how' and develop clear methodology for respectful and culturally safe engagement with Indigenous youth.

Availability of data and materials
The materials supporting the article is included as Additional les 1 and 2.

Competing interests
The authors declare no competing interests.