Towards Youth Mental Health System Reform: An Evaluation of Participatory Systems Modelling in the Australian Capital Territory

Round 1

Reviewer 1 Report

This manuscript describes a study on the utility of participatory systems modelling (PSM) to address shortcomings in youth mental health programs in the Australian Capital Territory.  In general, it was concluded that the PSM approach could likely improve transparency and trust in policy decision-making and actions, and that a participatory approach would provide a useful modelling effort that would facilitate programmatic improvements, but it was unclear whether the relevant stakeholders held the power to influence the system and hold policy-makers accountable.

As a reviewer, I must first qualify that this paper deals with a topic that is outside of my primary area of expertise; however, my impression was that the manuscript was well-written, logically organized, and for the most part adequately detailed, but I have a few observations that should be considered prior to publication.

1.       At each mention of “young people with lived experience” please be sure to clarify whether you are referring to lived experience with the mental health system, experience with personal mental health issues, or experience with the PSM process. I’m certain that the authors are referring to those having experience with personal mental health problems, but statements such as “…to include more young people with lived experience in the PSM process…” that appears on lines 509-510 could be misconstrued by some readers.

2.       Throughout the manuscript the authors highlight the importance of including youths with lived experience, but their project included only 4 young people in the baseline session and 7 young people in the follow-up.  As a result, the generalizability of the findings seems questionable. This issue should be discussed in detail.  Should this be considered a pilot study rather than a full investigation? If so, please note this in the title and elsewhere.

3.       Related to the above is the fact that only 11 respondents fully completed baseline and follow-up surveys. Are the data on such a small sample really sufficient to draw valid and reliable conclusions?  Please discuss this issue and the potential ramifications of this issue in addition to simply noting it as a limitation in section 4.1.

4.       Near the beginning of the manuscript, the authors present a graphic depicting a model interface containing a number of interventions as well as other information. Is this the exact model that participants evaluated in the present study or were the participants being asked to create a new model? Please clarify.

5.       Within the Methods and Data Analysis sections, the authors note several different tools that were used to collect/analyze data (i.e., Cogniss, Gephi, and NVivo). Given the detail supplied throughout other areas of the manuscript, it would be helpful for the authors also to include some detail on the tools that were utilized so that readers could better understand the current work without having to look for descriptions via internet searches or elsewhere.

6.       The term “stakeholders” is used throughout the paper, but in my opinion, it is not clearly defined (or if it is, I missed it).  Are the stakeholders the Community support professionals, Front-line health professionals, Heath administrators, and young people listed in Table 1? If so, perhaps these stakeholders should be explicitly stated/referenced in the Discussion section. If not, please list who they actually are.

7.       Possibly related to the above is the depiction of the social networking shown in Figure 6. Shouldn’t the nodes be labelled?  Are these the different stakeholders, individuals, or other entities?

8.       With regard to the social network analyses, is this technique typically applied (and considered accurate) for such a small number of participants? The authors may wish to comment on this within the manuscript.

Once the above issues are addressed, I feel the manuscript will be suitable for publication. Thank you.

Author Response

Thank you so much for your valuable feedback. Please see enclosed with our responses to your comments.

Author Response File: Author Response.docx

Reviewer 2 Report

The object of the study, to this reviewer, is a systems dynamics model. The modeling of the youth mental health system using the model is participatory. The paper evaluates the effectiveness of the participatory systems modeling on the Australian Capital Territory. If this reviewer’s understanding is correct, the paper has a major flaw. It does not present the core systems dynamics model. In lines 169-170 the paper states: “The evaluation framework and associated research protocols, which describe in detail the conceptual underpinnings of this study, are reported elsewhere.” That is inadequate and the paper fails to provide the core logic and the context of the study. Consequently, to this reviewer, the paper is verbose, rich, but incoherent. I recommend that the authors present the core systems dynamics model and rework the narrative around it. The paper must stand on its own. The topic and the findings from the study are important. The latter must the organized and presented better.

Author Response

Thank you so much for your valuable feedback. Please see enclosed with our responses to your comments.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

The authors have satisfactorily addressed my concerns, so I feel the paper is ready for publication.

Reviewer 2 Report

Based on the authors' response to my comments and the changes they have made in the manuscript, I recommend acceptance.