1 Background

The term ‘racially minoritised’, coined by Gunaratnum (2003), recognises that minoritisation is an active process, whereby ‘people are actively minoritised by others rather than naturally existing as a minority, as the terms racial minorities or ethnic minorities imply’ [1]. Racially minoritised groups often face disparities in mental health care access, experiences and outcomes [2, 3]. Young people from these backgrounds are less likely to initiate care and more likely to discontinue treatment prematurely [4, 5]. Despite progress in research, practice and policy, many of these children and young people still experience poor mental health outcomes and have lower access to mental healthcare services [6]. These inequalities are largely attributed to systemic racial bias within healthcare systems [7, 8]. Additionally, racially minoritised families prefer primary care, perceiving it as less stigmatising than specialised mental health services. However, this preference can be challenging when primary care options are not readily available [4, 8, 9].

The poorer outcomes and engagement seen in minoritised groups can also be attributed to a lack of culturally competent care or care that does not align with evidence-based guidelines. Many interventions are based on Western concepts of mental disorder [10], which may not align with diverse cultural perceptions of mental health [11] or broader cultural diversity [12]. Research shows that culturally adapted interventions are more effective than non-adapted ones for racially minoritised people [13-15], as culture shapes beliefs and understandings of mental health [10]. These adaptations enhance the effectiveness, accessibility and acceptability of treatments to individuals with different cultural needs [16, 17], while fostering trust and respect, crucial for a strong therapeutic relationship [17].

To improve mental health outcomes, involving end users and other stakeholders from minoritised groups in research is important. Participatory approaches—a broad category of methods that engage people in the design process—have proven effective, with codesign being a particularly impactful approach. Codesign is a specific form of participatory research that focuses on making decisions in partnership with people who will use, implement and/or otherwise engage with mental health services and interventions [18]. It is a shift away from the traditional design of services and interventions by clinicians and academics ‘for’ users, towards a more collaborative approach of designing ‘with’ users [19]. Codesign values lived experience as essential expertise and draws on principles from participatory design research to ensure that potential end users are active design decision makers throughout the design process [19-21]. Since racially minoritised youth experience barriers to accessing mainstream mental health services [22], involving them in the codesign process allows the other stakeholders to understand the challenges better and tailor interventions accordingly [23].

Notwithstanding these potential benefits, codesign presents several complexities. Blomkamp [24] warns that poorly designed, inadequately facilitated or manipulative participatory projects can heighten distrust among minoritised participants towards key project partners. Mark and Hagen [25] also observed that people are wary of the term ‘codesign’, experiencing ‘codesign fatigue’ due to its inconsistent application and lack of genuine power sharing, participation or partnership. They believe the term has lost its true meaning. Other issues related to the use of codesign, specifically with racially minoritised young people, include challenges in the inclusion of diverse expertise in a safe environment, managing power imbalances and addressing the risk of tokenism, which may prevent their expertise from being genuinely heard and valued [26]. Ensuring that these expertise are heard and valued builds trust and enhances the relevance, utilisation and overall effectiveness of the intervention [27].

To the best of the authors' knowledge, this is the first systematic review of the available literature on codesigning mental health interventions with racially minoritised youth aged 10–24 (in line with the World Health Organization's definition of ‘young people’ [28]). No previous reviews have provided an overview of the current practice of codesign with this group, its impact on outcomes or its approach to addressing factors that support or impede codesign. This study aims to close this gap by addressing the following research questions (RQs):

RQ1. What codesign approaches have been used to develop mental health interventions with young people from racially minoritised populations?

RQ2. At what phase(s) of the developmental process have codesign approaches been used, and how does codesign influence the outputs of each phase?

RQ3. What are the outcomes of codesign for the individual participants?

RQ4. What contextual enablers and barriers influence the process and outcomes of codesign for different stakeholder groups?

2 Materials and Methods

This systematic review protocol was pre-registered with PROSPERO (CRD42023443117). The review has been reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [29]. Please see Supporting Information S1 for PRISMA checklist.

2.2 Eligibility Criteria and Selection of Studies

2.2.1 Participants/Populations

Eligible studies described the codesign of mental health interventions, where the intended end users were principally young people from racially minoritised groups. Codesign participants could be prospective end users or relevant stakeholders including family members, other caregivers, community members and practitioners. We also included studies where ‘young people’ might span a wider age range than 10–24 years, provided that the mean age of the youth participants fell within the targeted age range.

2.2.2 Codesign Condition

A study was considered to involve codesign if the people for whom the intervention aims to help, [we]re involved in decision-making about the intervention throughout the development process [18]. For a study to be eligible, we required this involvement in at least two steps of the developmental process using a typology developed by O'Cathain et al. [18] (see Figure 1).

2.2.3 Interventions

We included studies where codesign activities centred on interventions to prevent or treat common mental health problems (i.e., depression, anxiety, conduct difficulties, trauma, post-traumatic stress disorder [PTSD], obsessive-compulsive disorder [OCD] and/or global psychopathology), as well as studies concerned with codesigning mental health promotion programmes (i.e., where the aim was to promote positive mental health). Relevant interventions were universal, indicated or selective [30], incorporating specific behavioural, cognitive, interpersonal and/or emotion-focused elements [31]. Interventions were delivered by any mode (e.g., in-person, digital/web-based). We included studies where the intended intervention involved direct sessions with young people and/or joint or parallel sessions with parents, caregivers and teachers as long as young people were involved somewhere in the intervention process.

2.2.4 Outcomes

Studies were included if they reported on processes and outcomes related to codesign. Specifically, we included studies that described codesign activities and their influences across different phases of intervention development, the impact of codesign practices on the stakeholders, and the barriers and facilitators to codesign.

2.2.5 Study Design

The review included studies of any design (quantitative, qualitative and mixed-method) if they described the use of codesign in the adaptation or development of the intervention.

3 Results

The PRISMA flow diagram (Figure 2) summarises the process of identifying and selecting studies for inclusion. Out of 54,685 records, 30,117 papers were screened based on title and abstract after removing duplicates, resulting in 133 full-text studies for consideration. After applying eligibility criteria, 116 studies were excluded, leaving 17 eligible peer-reviewed studies. Manual searching of references and citation lists yielded one additional study, bringing the total number of included peer-reviewed studies to 18.

3.5 RQ3: What Are the Outcomes of Codesign for the Individual Participants?

Twelve outcomes were identified and grouped into three broad categories with sub-themes: benefits to (1) the young people, (2) the research team and project and (3) the other stakeholders (see Figure 3).

3.5.1 Benefits to the Young People

Seven studies (39%) reported that youth learned to take responsibility and undertake leadership roles, which empowered them to support their peers and enhanced their self-confidence and self-efficacy, contributing to their personal development and well-being [38-44]. Furthermore, five studies (28%) highlighted that youth improved their educational and career skills and enhanced their employment opportunities in health-related fields [39, 40, 42-44]. Mance et al. [42] reported that youth were recruited as full-time staff to serve as peer leaders for the project and were paid for their time on the project as consultants. Five studies (28%) reported that participation increased young people's knowledge and awareness of mental health issues [39, 40, 42, 44, 45], which they used to raise community awareness and encourage support-seeking through workshops, talks and documentaries [39]. Additionally, three studies (17%) reported improved mental health outcomes among youth, as they became aware of mental health issues, learned problem-solving skills and adopted healthy behaviours [38, 39, 44]. Out of eight studies, only three [38, 39, 41] reported outcomes based on youth feedback gathered through focus group discussions and interviews with the remaining studies, outcomes relying on the authors' reflections.

3.5.2 Benefits to the Research Team and Project

Researchers in eleven studies (61%) noted that involving youth and non-academic stakeholders improved the research process by identifying specific problems, increasing participant recruitment, enhancing data collection, gaining insights about participant experiences and developing successful grant proposals [35, 38, 39, 42, 44-50]. For instance, in one study, stakeholders from the school district offered input and direction on choosing evaluation questions and hypotheses, setting performance standards and determining data collection methods [37]. Sixteen studies (89%) reported that the codesign process enabled researchers to develop interventions that were better tailored to the cultural aspects and specific needs of the target populations [37, 38, 40-46, 48, 50-54]. Authors of four studies (22%) observed that codesign built trust, strengthened community partnerships and facilitated community ownership, which expanded local participant reach, provided logistical support and ensured programme sustainability [38, 42, 44, 50]. Furthermore, based on researchers' reflections, three studies (17%) reported that codesign with service users led to wider and more effective research dissemination [39, 49, 50].

3.5.3 Benefits to the Other Stakeholders

In three studies (17%), it was observed that involving other stakeholders (e.g., family members, other caregivers, community members and practitioners) in codesign fostered a sense of value and engagement by creating opportunities for sharing their expertise, resources and power with the research team [38-40]. Two studies (11%) highlighted that stakeholder involvement deepened stakeholders' understanding of the mental health needs of youth and protective factors that reduced stigma and improved their access to services [39, 40]. Four studies (22%) reported that stakeholders from overburdened or underserved agencies benefited from relevant training provided through the codesign process that strengthened capacity-building efforts within these agencies, with some staff continuing to collaborate with the research team on future projects [37-39, 47]. Additionally, two studies (11%) revealed that involving parents and older community members alongside youth fostered inter-generational connectivity and strengthened parent–child bonds [44, 45].

4 Discussion

This review comprehensively examined codesign approaches in developing mental health interventions for racially minoritised young people. Eighteen studies were identified involving youth and other stakeholders, primarily in early codesign stages using various data collection methods. codesign participation enhanced young people's knowledge, leadership skills and career opportunities. It enabled researchers to develop culturally aligned interventions by exploring youth's lived experiences while ensuring that all stakeholders felt valued through sharing their expertise, power and resources. Although resource limitations, power imbalances and sampling issues were noted as challenges, the process was facilitated by reducing power differentials, encouraging community engagement and stakeholders' collaboration.

The review identified diverse codesign models, highlighting the flexibility of participatory methodologies. Although focused on youth, other stakeholders were engaged to better understand minoritised communities' interconnectedness. Therefore, most studies prioritised community partnership as connections among individuals, families and communities shape community perceptions [22]. Previous research shows that the explanatory models of community influence codesign research structure and service development [55-57].

Our findings indicated a trend of early-stage involvement with limited participation in later stages, consistent with previous research [58] and noted various data collection activities across these phases. Previous studies suggest that early involvement empowers young people to shape research direction, amplifying their sense of impact on outcomes [59, 60], whereas another study indicated that involvement in every stage may not be necessary for meaningful contribution [61]. However, our findings of relatively limited involvement in later stages of codesign also raise questions about tokenism, where youth are given initial expertise but lack real influence over the process and outcomes [62]. This issue, compounded by researchers' authoritative role, reinforces power imbalances and reflects epistemic injustice in mental health research, where the lived experiences of racially minoritised youth are undervalued compared to ‘professional’ knowledge [63].

The studies in this review reported using various codesign activities. Research suggests that the diversity of methods and activities used in codesign is a key strength, as it enables researchers to tailor involvement to the specific needs of racially minoritised youth [58]. Flexible and adaptive participation addresses practical challenges such as low literacy rates, cultural biases and confidentiality concerns. From an epistemic justice perspective, accommodating diverse ways of expressing and validating the lived experiences of racially minoritised youth can create an inclusive environment that respects and amplifies the unique insights these youth bring to the research process [63]. However, details on the adaptation of these activities were often lacking in included studies, with no insights on which activities were most effective and acceptable for these youth.

Building on previous findings [64, 65], this review highlights the outcomes of codesign for young people, research projects and other stakeholders. However, a significant gap exists in the literature as it focuses primarily on the general population, often overlooking the distinct experiences and needs of racially minoritised communities. These communities face unique challenges within the mental health system, where traditional Western models of care may not align with their cultural understandings of mental health or adequately address systemic biases that impact service delivery [7, 8, 10, 11]. As a result, their mental health needs often go unmet, contributing to disparities in access, engagement and outcomes [2, 3]. Codesign offers a way to address these deficits by involving racially minoritised youth as active contributors to research and intervention design, ensuring that mental health interventions are not only culturally and contextually relevant but also responsive to the lived experiences of those most affected by systemic barriers [23]. The studies in this review demonstrate that codesign connected youth, researchers and other community stakeholders, with participants benefiting directly or indirectly. By adopting codesign approaches, researchers developed culturally and contextually relevant interventions grounded in the lived experiences of target populations. This approach also ensured that youth and other stakeholders' expertise were heard and valued, leading to mutual benefits and improved research outcomes [42]. However, only a few studies directly included young people's feedback on intervention outcomes with the majority relying on researcher observations. This may limit the comprehensiveness of the evaluation and potentially overlook important insights from the youth themselves.

This review identified significant barriers and enablers in codesign studies, consistent with previous reviews on codesign with young people [65, 66]. It is crucial to support participants, particularly racially minoritised youth who may experience social stigma and power imbalances within certain community and societal contexts. Addressing these imbalances is essential for effective codesign, as unequal power dynamics can undermine trust and lead to negative outcomes [67, 68].

5 Conclusion

This review highlights the value of codesign in developing culturally relevant mental health interventions for racially minoritised youth. Our findings suggest that continuous engagement with these young people and all stakeholders throughout the codesign process will help to address barriers such as resource limitations, power dynamics and cultural differences. Acknowledging these communities' strengths and unique needs can strengthen trust, balance power and lead to a more effective and inclusive codesign process. Additionally, integrating community-specific frameworks and combining qualitative and quantitative evaluation methods will help in developing effective and culturally relevant interventions.

Author Contributions

Ishrat Shahnaz: conceptualization, writing – original draft, data curation, methodology, investigation, formal analysis, project administration, software. Kelly Rose-Clarke: conceptualization, methodology, validation, supervision, writing – review and editing. Daniel Michelson: conceptualization, validation, writing – review and editing, supervision, methodology. Petra C. Gronholm: conceptualization, methodology, validation, writing – review and editing, supervision.

Conflicts of Interest

The authors declare no conflicts of interest.