Digital and Hybrid Pediatric and Youth Mental Health Program Implementation Challenges During the Pandemic: Literature Review With a Knowledge Translation and Theoretical Lens Analysis

Background The pandemic brought unprecedented challenges for child and youth mental health. There was a rise in depression, anxiety, and symptoms of suicidal ideation. Objective The aims of this knowledge synthesis were to gain a deeper understanding of what types of mental health knowledge translation (KT) programs, mental health first aid training, and positive psychology interventions were developed and evaluated for youth mental health. Methods We undertook a literature review of PubMed and MEDLINE for relevant studies on youth mental health including digital and hybrid programs undertaken during the pandemic (2020-2022). Results A total of 60 studies were included in this review. A few KT programs were identified that engaged with a wide range of stakeholders during the pandemic, and a few were informed by KT theories. Key challenges during the implementation of mental health programs for youth included lack of access to technology and privacy concerns. Hybrid web-based and face-to-face KT and mental health care were recommended. Providers required adequate training in using telehealth and space. Conclusions There is an opportunity to reduce the barriers to implementing tele–mental health in youth by providing adequate technological access, Wi-Fi and stationary internet connectivity, and privacy protection. Staff gained new knowledge and training from the pandemic experience of using telehealth, which will serve as a useful foundation for the future. Future research should aim to maximize the benefits of hybrid models of tele–mental health and face-to-face sessions while working on minimizing the potential barriers that were identified. In addition, future programs could consider combining mental health first aid training with hybrid digital and face-to-face mental health program delivery along with mindfulness and resilience building in a unified model of care, knowledge dissemination, and implementation.


Background
The COVID-19 pandemic and resultant closures of schools during lockdowns worldwide brought on major challenges for child and youth mental health [1][2][3].A systematic review found that, as a result of school closures, there was a rise in depression, anxiety, emotional and behavioral problems, stress, and suicidal attempts in children and teenagers during the pandemic period [4].Many teenagers reported challenges with coping with their mental health due to isolation from staying at home and a lack of social contact with peers [2].In particular, there were unique challenges for children and teenagers with existing mental health problems when it came to accessing timely basic mental health care services during the pandemic.This was due to pandemic-related closures of medical clinics [5] and school-based health services [2], limited capacity of medical doctors, and prioritization of patients with COVID-19, which left many patients with chronic health problems with lower levels of accessibility to care [6].A study in the United Kingdom found that 26% of teenagers felt that they had reduced access to mental health care [1].Furthermore, a study in Italy found reduced emergency department admissions for mental health problems as patients remained at home and socially isolated distanced themselves to reduce their risk of infection [7].However, it should be noted that not all studies found that everyone had been equally impacted by COVID-19 and had experienced mental health challenges, with some studies finding improvements in some individuals, particularly those without a preexisting mental health condition [8].Nevertheless, child and youth mental health was a critical public health challenge during the pandemic for many.
As a result of the mental health crisis in youth during the pandemic, medical doctors had to quickly transition to digital tele-mental health care services to meet the pressing mental health needs of children and teenagers and increase their accessibility to care [9].Many service providers had to implement digital mental health care for the first time, which came with its unique challenges [9].Before the COVID-19 pandemic, tele-mental health was less prevalent and often used in rural and remote patient settings [10].However, as medical providers adjusted to the "new normal," tele-mental health and other digital mental health approaches became more mainstream [11].Nevertheless, it is also important to examine what other mental health programs, including face-to-face or combined digital programs, were implemented during the pandemic to better understand differences in program preferences and experiences.
Understanding the key challenges and experiences with these different approaches and models of psychiatric mental health care is essential to make recommendations for future best practice guidelines and pandemic preparedness.Understanding the facilitators of effective implementation of youth mental health services in clinical medical settings and how to overcome barriers is necessary for making recommendations for effective tele-mental health and in-clinic program implementation.Moreover, it is important to understand implementation challenges, including barriers to implementation, considering determinant frameworks that assess barriers to implementation rather than solely examining structural process models of implementation that describe how the program was implemented and the specific procedural steps [12].Analyzing studies that used both structural and process frameworks and the models used when implementing studies during the pandemic will provide deeper insights into what was specifically developed, the processes that were undertaken, and the challenges that were experienced.
In addition to implementing psychiatric programs in clinical settings that are administered through clinical mental health professionals, there is also a need to better understand what mental health programs were implemented in the community setting, such as in schools through school-based officials and in charities, and understand and what efforts by key stakeholders to promote youth mental health and build resilience in children and youth (preteenagers, teenagers, and young adults).It is of particular interest to investigate whether stakeholders working to support children (eg, community-based organizations such as the YMCA) and mental health-specific organizations implemented youth mental health programs during the pandemic in schools and the general community setting.It is also of interest to understand any key program implementation challenges to make recommendations for implementation and policy research.
Furthermore, there is a need to evaluate the barriers to and facilitators of psychological programs, including self-guided ones in the home setting that taught youth how to manage their emotions during isolation and times of crisis and uncertainty.In particular, positive psychology and especially mindfulness-based approaches have been found to foster greater gratitude and well-being in children and youth [13][14][15], and it is of interest to evaluate what approaches were used to assist youth during pandemic times of crisis from the perspective of adoption and uptake challenges.In addition, there is a need to evaluate the implementation and knowledge dissemination efforts associated with mental health supportive aid programs such as mental health first aid [16].
Within the context of youth mental health, including psychiatric and psychological supportive programs, little is known about what knowledge translation (KT) strategies and theories were used to educate key stakeholders, including mental health practitioners when they transitioned to new models of care and implemented digital technology.Research is needed to evaluate what KT theories and models were used when disseminating knowledge to key stakeholders.Effective KT is a fundamental element of the public health research process [17].Without effective translation of evidence into practice, research remains simply an academic area without real-world community health impact [18].Understanding the key challenges and facilitators of KT, including implementing evidence-based mental health programs and interventions, is necessary.This way, future recommendations may be made for best practice guidelines during crisis times and for future pandemic preparedness.Given that there was an unprecedented rise in mental health issues during this time, it is important to know whether there were any KT strategies for parents, schools, and medical providers.

Aims and Objectives
The purpose of this literature review was to gain deeper insights into strategies, programs, and services for child and youth mental health during the pandemic period.Recommendations for future program and intervention implementation, research, and best practice guidelines were made.This review had the following aims: 1.To better understand the experiences, barriers, and facilitators regarding youth mental health service delivery, including telehealth, face-to-face, hybrid (combined face-to-face with digital), and school-based mental health service implementation, as well as psychological supportive services during the pandemic.

Overview
A literature review using PubMed and MEDLINE was undertaken to identify relevant studies on youth mental health programs and services, including school-based and hospital-based telehealth or hybrid implementation (combined in-person with digital services), and psychological supportive studies undertaken during the pandemic.Google Scholar and manual hand searches were also undertaken.We included studies that were undertaken during the pandemic period between March 2020 and October 2022.The studies must have mentioned that they were undertaken during the pandemic.The search was then updated and rerun with refined and more specific search terminology after consulting with a medical librarian to include studies that may have been undertaken during the pandemic but published at a later time up until December 31, 2023.Studies that were undertaken before the pandemic but continued throughout the pandemic were also included.The studies must have been published in the English language with public full-text accessibility.The rationale for including studies undertaken during the pandemic was to gain a greater understanding of key implementation challenges specifically during pandemic times of crisis and uncertainty.Google Scholar and manual hand searches were also undertaken to identify any additional studies.The keywords included word variations of "knowledge translation" or "dissemination" or intervention and "mental health" or "resilience" or "stress" and "young adult" or "teenager" or "youth" or "child" and "health services" or "implementation" or "telehealth" or "psychological services," among others.
An example of the search strategy is detailed in Textbox 1.

Screening and Data Extraction
Titles were screened for relevance followed by screening of abstracts against the inclusion and exclusion criteria.The full texts of abstracts meeting the inclusion criteria were further screened.If the full-text articles met all the inclusion criteria, they were included in the literature review.
To ensure that the studies were undertaken during the pandemic period, we screened titles with the words "COVID-19" followed by checking the full texts to ensure that the programs were implemented within a COVID-19 context or with relevance to the pandemic, where lessons could be learned.Where it was unclear, authors of selected papers were contacted directly to confirm.
Data were extracted and summarized in tabular format.This included the study general characteristics, measures, outcomes (mental health, knowledge, and program implementation), KT media, and KT theories and behavior change theories.

Results
A total of 60 studies on youth mental health service or program implementation were included in the final review [9,. Figure 1 illustrates the search and screening process.

Youth Mental Health Service Implementation
We identified and included 60 studies on mental health program initiatives to promote child and youth mental health during the pandemic that focused on the delivery and implementation of a wide range of mental health services, programs, and supports as well as knowledge dissemination during the pandemic.The results are summarized in Table 1.The study types were qualitative studies, case studies, and cross-sectional studies, as well as studies with mixed methodology.The countries spanned Canada, the United States, and Australia.One large study was undertaken in Europe across 8 countries: Austria, Germany, the Netherlands, Slovenia, Switzerland, Italy, Sweden, and the United Kingdom [29].

Stakeholders
Most programs engaged stakeholders, including politicians, not-for-profit organizations, schools, teachers, parents, youth with lived experience, health professionals including general practitioners, psychiatrists, psychologists, social workers, and the criminal justice system [20,25,29,30,35,37,46,79].A study in Europe used the Knowledge to Action framework [80], with stakeholders involved in each stage of the research process from the development and implementation stages to the evaluation stage, including focus groups, surveys, and interviews [37].

KT Media
Several but not all the programs delivered mental health KT interventions through diverse media to their various stakeholders [23,26,29,37,39,41,46].Diverse media included combinations of fact sheets, webinars, Zoom meetings, videos, modules, infographics, and toolkits.For example, Orygen in Australia provided primary, secondary, and tertiary mental health services and education to mental health professionals both on the web and in person along with outreach visits to patients.Their KT media included fact sheets, webinars, videos, web-based modules, and games to increase engagement.Another large study across Europe integrated face-to-face KT using digital tools, including Zoom and a KT app [29].Several studies used a hybrid method involving face-to-face and digital KT media [22,25,29,30,33,37,46].However, most focused on implementing e-mental health programs exclusively on the web, usually through virtual mental health or telehealth [9,19,20,22,24,25,28,32,[34][35][36]42,44].One study focused on using 1 KT medium for translating information on self-care during the pandemic to young cancer survivors to promote their mental well-being using an infographic [30].

KT Theories
A few of the programs applied specific KT theoretical models and frameworks that informed their program implementation [9,31,37,46].For example, the study by Zbukvic et al [46] in Australia used the Integrated Promoting Action on Research Implementation in Health Services model.The model is founded on usability, the context of the KT intervention, facilitation, and the recipients [46].In addition, the DREAM KT program in Canada adopted the Knowledge Transitional Integration Framework.The framework is based on 4 pillars, namely, sustainability, credibility, accessibility, and feasibility.
In addition to established KT models, a few positive health psychology theories or models derived from this field were used [23,28,29,37,39,41,43].For example, a large study across Europe by Hanson et al [29] was informed by positive psychology using acceptance and commitment therapy that informed the Discoverer, Noticer, Advisor model.The study by Zbukvic et al [46] in Australia also integrated the behavior change theory model into the KT program.The program in Canada also focused on developing resilience through emotions, attitudes, and meaning in their youth KT mental health program, whereby they sought to maximize positive experiences in youth with a beginner's mind and creative expression using means such as art, music, and gratitude [37].They also integrated logotherapy through emotion identification into their program.Grounded theory further informed the first stage of their research at the stakeholder interview stage [37].
Space was identified as a critical feature for the successful implementation and delivery of virtual mental health services and programs to children and teenagers [9,24,25,50,51].For example, the study by Doan et al [24] at the Hospital for Sick Children in Canada, which adopted the 6 Pillars framework in their development of a framework for mental health practitioners, emphasized that the space needed to be clean and private for medical providers.
Body language or nonverbal communication cues were also identified as barriers in some studies [9,22,34,45].One study found that it was difficult to motivate patients and that work was needed to build the therapeutic relationship when mental health consultations were virtual as opposed to face-to-face [45].In addition to body language, there were challenges with implementing certain digital mental health interventions, including art therapy programs on the internet during the pandemic [21].
A few studies also found that tele-mental health service implementation was more challenging in younger children [9,19,22,34,36,40,54].Children preferred face-to-face mental health consultations over virtual ones [40].In addition, one qualitative study in France by Carretier et al [22] found that teenagers preferred phone calls over video consultations."Zoom fatigue," feeling tired from using web-based technology for mental health care, was identified as an obstacle in one study in children.In total, 3% (2/59) of the studies made play or art kits for children to keep them engaged.One study recommended offering "play kits" to keep children interested and engaged with the technology [9].Similarly, "art kits" were mailed out to children undergoing mental health therapy, including dialectical behavior therapy in adjunct to virtual telehealth appointments [26].Thus, it seems that sending hands-on engaging resources to children may assist with their participation during web-based mental health sessions.
There were also challenges with managing and adapting to using the digital technology.For example, the case study by Zbukvic et al [46] on KT in workforce development (Orygen) involving 4400 mental health workers found that it was challenging to deliver digital mental health care during the pandemic and that there is a need for a framework with clear guidance on how to best deliver e-mental health care using digital media.They found that levels of readiness and adaptability varied across different stakeholder organizations [46].Physician-level factors included the need for adequate training in tele-mental health [36,40,42,43] as well as readiness to partake in it [24].
A few studies found that physicians needed to be sufficiently trained in the technology when dealing with young patients with mental health problems.The study by Skar et al [43] found that there was higher patient attendance when they had adequately trained physicians.For example, this included leadership training [43] and learning how to undertake virtual interviews [40].
Actual hands-on training in using tele-psychiatry technology and the virtual platform was also emphasized in one study [42].The study by Doan et al [24] also found that there is a need for a safety plan, with adequate preparation during emergencies or unforeseen events.The qualitative focus group study by Parrot et al [37] found that stakeholders who were not previously supportive of web-based mental health platforms found them to be acceptable after they had tried them, indicating that perceptions of digital mental health are more positive and willingness to try it increases if users learn how to apply it.The qualitative study by Goddard et al [26] involving the "Listening and Learning" platform for school alliances found that most providers adapted to using telehealth and virtual meetings on Zoom, Skype, and FaceTime.The study by Craig et al [23] found that there is a need for medical providers to be familiar with navigating digital technology, including screen sharing, implementing Microsoft PowerPoint for greater engagement and knowledge dissemination, and learning how to break social awkwardness on the web through things such as "icebreaker XSL • FO RenderX questions" when implementing cognitive behavioral therapy.They also found that there is a need to implement social apps for social networking [23].Therefore, adequate knowledge dissemination on the use of digital health technology and its successful implementation through gaining interviewing skills and providing sufficient engagement for children and youth across diverse service providers is needed.Overall, most of the studies that assessed acceptability and feasibility found that digital health and tele-mental health were viewed positively and there was a high uptake by youth during the pandemic [20,24,32,34,41,77].The cross-sectional survey involving a needs assessment from the Transforming Research Into Action to Improve the Lives of Students implementation study (N=982 school-based health professionals who were trained) found that school-based mental health professionals were satisfied with the web-based manual that disseminated knowledge on youth coping skills [41].Only one study found that medical providers experienced burnout from implementing telehealth [9].The study by Moorman [34] that analyzed practice data from 40 health professionals and 60 families found that tele-mental health increased accessibility to mental health care for children and teenagers and resulted in a higher attendance.

School-Based and Nondigital Mental Health Approaches
A couple of studies examined the challenges with implementing mental health programs in face-to-face settings such as in schools and clinics.A large study in the United States with 29,000 stakeholders that analyzed data from 400 participants who undertook training in trauma-informed practices found that trauma-informed classroom practices could be successfully implemented through joint efforts between school-based professionals and mental health care providers [47].The mixed methods qualitative interview study with 12 gatekeepers (with longitudinal data from 216 teenagers) by Podar et al [38] in Germany found that there is a need for an integrated mental health care system in schools and that inequities in accessibility exist among young refugees who experience stigma.They emphasized that there should be strong antidiscrimination policies when it comes to youth mental health in schools [38].Thus, implementing programs in schools should maximize accessibility for all students.A case study analysis in the United Kingdom of youth in wards (N=36) found that it was challenging to implement a youth mental health ward in a pediatric setting, which required setting up a new ward and combining physical health with mental health [27].They also found that it required joint efforts in a multidisciplinary team setting involving nurses and pediatric psychiatrists, which led to adopting new leadership and managerial approaches as well as tailoring treatments to individual patients [27].

Hybrid Mental Health Approaches
Some of the studies opted for hybrid approaches when implementing mental health services and programs for children and teenagers [22,25,29,30,33,37,46,76]. The case analysis by McMellon and MacLachlan [33] in Scotland recommended a hybrid program with enhanced access to digital mental health services and technology in schools combined with face-to-face in-person support through greater staff training.The lexical analysis study by Eapen et al [25] in Australia also made recommendations for a hybrid mental health care service delivery for youth in clinics and at home to increase accessibility, ensuring clinical assessment in person combined with web-based support.Another study in Australia (case study) by Zbukvic et al [46] found that diverse stakeholders, including mental health care providers, required web-based training and outreach in-person clinic visits, with KT and dissemination strategies involving videos, fact sheets, modules, and webinars to meet the mental health needs of youths.In addition, a large mental health mixed methods KT implementation study in Europe (ME to WE) involving 8000 stakeholders evaluated KT and dissemination strategies to meet the needs of youth who cared for someone [29].Through extensive knowledge syntheses and a participatory design, they found that youth should receive support from both peers and family in addition to mental health supportive services and respite.They also made recommendations for a mental health app that would support young caregivers [29].Raising awareness of the mental health needs of young carers was also brought up as a theme [29].The focus group study by Parrot et al [37] recommended a hybrid model for in-class and web-based KT for youth mental health by ensuring that teachers offered both the in-class learning version and the web-based one.Behavior change techniques such as reminders to enhance memory were also recommended, including things such as games, booklets, and memory aids.They also found that students preferred a range of lyrics with music as part of a meaningful program [37].To enhance accessibility and engagement, they also recommended more teachers who could offer the program on the web [37].The study by Hou et al [30] found that an infographic, while informative, was only one medium for KT and dissemination for youth mental health and resilience and that other KT media should be explored in the future along with personally tailored interventions.
In addition, one study combined passive KT with active KT, a type of hybrid approach for disseminating knowledge.The study by Power et al [39] involved a KT leaflet for resilience building in children and teenagers combined with a happiness toolkit that required children to build a physical box, emphasizing the importance of real-life relevance for children in addition to a passive leaflet when it comes to participation and engagement.However, this was an early developmental study on a new model of care rather than an implementation study evaluating its barriers and acceptability.
Overall, support services should include a range of resources, including in-person social support and an app.All these studies with hybrid approaches found that accessibility to mental health supportive services or engagement was enhanced when diverse options were offered through in-person support, web-based support, digital applications, and support from family and friends in addition to professional help to accommodate diverse learning needs and preferences.As barriers were noted for digital delivery, hybrid methods were also recommended for accessibility from this perspective.It also appears that active versus passive methods may enhance participatory engagement; however, more research is needed to confirm these findings.

Mental Health First Aid
A couple of studies implemented mental health first aid through virtual platforms and found that knowledge improved [67,75].The study by Olson et al [67] found that participation in suicide prevention training increased when they transitioned to a web-based delivery system due to COVID-19.

Summary of Findings
In summary, it seems that the successful implementation of mental health programs requires hybrid approaches involving both in-person (face-to-face) and web-based sessions.Digital mental health may be successfully implemented if barriers are minimized, such as providing children, teenagers, and their families with adequate access to the internet or providing them with stable Wi-Fi, maximizing privacy using encrypted servers, and finding a suitable space for these meetings.Ensuring adequate engagement by keeping younger children interested through sending them hands-on material to engage with during web-based sessions seems desirable.In addition, medical providers require adequate training with sufficient space and knowledge of web-based learning tools.Finally, a couple of studies noted racial inequities in accessibility to mental health programs [48,51,52,74], highlighting that this needs to be addressed to ensure successful and equitable mental health program and service implementation.

Principal Findings
The objective of this literature review was to broadly gain a better understanding of the types of programs that were implemented during the pandemic for child and youth mental health along with a better understanding of implementation challenges and knowledge dissemination strategies, including KT theoretical models for program implementation.This included clinical programs in health care settings and community-based programs in schools.It also included individual-and family-level preventive strategies for early identification and referral through knowledge dissemination in mental health training programs.The implications of the results of each aim will be discussed in this section.First, we aimed to better understand the key barriers and challenges regarding implementing child and youth mental health programs during the pandemic.Certain factors need to be taken into account, including internet accessibility, to ensure that everyone has equitable access and that there are no technological barriers to timely mental health care for youth.Privacy was also raised as an important barrier in e-mental health among youth, highlighting that secure digital media need to be used.There were issues with Wi-Fi accessibility, emphasizing that a stable internet connection is vital for implementing these programs for youth.Policies could consider funding Wi-Fi for families who may struggle financially with respect to purchasing high-speed, stable internet plans.In addition, having a secure and private space is important for both the practitioners and the patients.However, it is challenging for patients to make room for meetings if they do not have adequate space at home.Nevertheless, from a program implementation stance, it appears that mental health services via telehealth are acceptable for young adults overall.However, it seems that younger teenagers and children may require additional strategies to avoid "Zoom fatigue" and keep them interested and engaged.For these reasons, the programs opted for offering hybrid care to youth or combined media such as apps along with family supportive services, whereas children received art kits or play kits to enhance participatory engagement.
Second, we aimed to better understand what types of mental health programs were implemented during the pandemic by key stakeholders and what KT theoretical models and strategies were adopted during the implementation of these programs.We identified a few initiatives, particularly in Canada and Australia, that worked toward providing mental health care to young adults while engaging with critical stakeholders.Important stakeholders included schools, medical doctors, psychologists, the criminal justice system, families, young adults with lived experience, social workers, charities, and politicians, among others.Some offered training to the stakeholders, and others provided direct mental health support to those with lived experience.
We identified several programs that were implemented for youth during the pandemic, with most being telehealth and digital based, followed by hybrid (mixed face-to-face with digital) and in-person face-to-face programs.However, overall, many programs recommended a hybrid method for delivering youth mental health services, including the use of digital media and face-to-face sessions to increase accessibility and meet the learning pretenses of stakeholders.The digital media included apps, the use of Zoom, and other web-based tools or websites.Some the initiatives used clear KT theories to inform their programs, and 7 of them had used psychological theoretical models.There is a need for more implementation programs to use KT models when training practitioners to use evidence-based methods.Some programs also used theories of behavior change and psychological theories to inform their interventions, such as facilitating positive experiences through meaningful expression and engagement [37].
The use of diverse media for KT rather than one medium appears to be important.In their review of KT interventions for parental knowledge of all childhood health problems published until 2015, Albrecht et al [81] found that most studies used one medium.Thus, the use of digital media in an increasingly digitalized world appears to be an important move toward enhancing accessibility for youth mental health.The pandemic has especially highlighted the urgent need for the transition to web-based methods to enhance accessibility despite different levels of stakeholder acceptability.However, more research is needed to better understand whether the programs and hybrid models are actually effective in improving youth mental health as this was not evaluated in the implementation studies.
Another aim was to understand what mental health first aid training interventions were developed for increasing knowledge of mental health support and understanding any challenges regarding their implementation or adoption.We did not identify many such studies that were undertaken during this period.Initially, we identified 6 studies that were published during the pandemic period, with many finding increased perceived XSL • FO RenderX self-efficacy for providing mental health first aid, but not all led to changes in behavior, including the actual provision of mental health support to someone in distress [82][83][84][85][86][87].However, after following up and closer examination, the studies were not actually undertaken during the pandemic period itself.

Recommendations
On the basis of the knowledge synthesized from this literature review, several recommendations can be made for youth mental health promotion in the postpandemic era and for future pandemic preparedness.A future youth mental health KT tool may also be developed based on these recommendations. 1. Evaluate more hybrid models of mental health for KT among various stakeholders.
2. Reduce the barriers to implementing tele-mental health in youth by providing adequate technological access, Wi-Fi and stationary internet connectivity, and privacy protection. 3. Enhance staff training and preparedness for a future pandemic by having the equipment, knowledge, and skills in place. 4. Undertake more research on youth mental health for future pandemic preparedness and first aid training, including the barriers to and facilitators of effective KT and implementation.
Figure 2 illustrates 4 levels of steps that could be taken for future child and youth mental health and pandemic preparedness.

Limitations
One limitation of this review is that we undertook more of a narrative literature review as, ideally, we would have required 2 screeners for a full scoping review, which was not possible due to resource limitations.We included publicly accessible free articles due to resource limitations.We also did not search gray literature, which could have provided more data on rapidly implemented studies that were not published.There is a possibility that there were more studies on this topic given the breadth of the COVID-19 literature.
However, our overarching aim was to gain a better understanding of the common implementation challenges and KT strategies that were developed in general during the pandemic, and we broadly covered the literature in several key areas spanning KT; implementation; school-based programs; and health care, including telehealth programs.A strength of this review is that we structured our analysis around KT and provided practical "hands on" recommendations for implementation and policy that may be applicable to many future studies, especially when planning for a future pandemic.
We note that there were wide variations in terms of countries and policies during the pandemic, but the overarching implementation issues were common across the studies despite this.In addition, although the studies are generalizable to preand postpandemic times, the focus was on the pandemic period to ensure that we understood what the challenges were during times of uncertainty and crisis, when swift decisions had to be made regarding new implementation issues.

Conclusions
In summary, we aimed to better understand the implementation experiences, challenges, and facilitators of child and youth mental health program services during the pandemic.We found that, while many benefited from digital implementation strategies, hybrid in-person combined support was preferred.
Provider-related challenges were also identified with transitioning to telehealth and learning how to use the technology.Barriers for patients were mainly privacy related and technological, including access to the internet and devices and the ability to communicate efficiently through a screen.
We also aimed to gain a better understanding of the KT intervention strategies, programs, and positive psychology interventions that were developed to promote youth mental health during the pandemic period.We identified KT programs that engaged with a wide range of stakeholders during the pandemic, and a few were KT

Figure 2 .
Figure 2. Future pandemic preparedness regarding pediatric and youth mental health.HC: health care; KT: knowledge translation.
2.Secondary aims were to better understand what types of pediatric and youth mental health programs were implemented, including digital, face-to-face, and hybrid programs; the key stakeholders involved; and what KT theoretical models and strategies (if any) were applied during their implementation throughout the pandemic.
theory informed.Future studies should focus on hybrid systems of KT and youth mental health program delivery and address technological and privacy barriers linked to the implementation stage of youth mental health e-services.©LynnetteLyzwinski, Sheila Mcdonald, Jennifer Zwicker, Suzanne Tough.Originally published in JMIR Pediatrics and Parenting (https://pediatrics.jmir.org),25.06.2024.This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/),which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Pediatrics and Parenting, is properly cited.The complete bibliographic information, a link to the original publication on https://pediatrics.jmir.org,as well as this copyright and license information must be included.