BMJ Open Barriers and facilitators to quality mental health care for forcibly displaced children and adolescents in the WHO European Region: protocol for a scoping review

Lars Dumke ®,1 Shobhana Nagraj,2,3 Hanan Abukmail,45 Malte Behrendt,6
Erva Nur Cinar,7 Anastasia Giannaki,8 Jennifer Hall,8 Mohammad Sharif Razai 6,2 Ingo Schafer,6 Gemma Whyatt,2 Eleanor Chatburn © 2,9,10

To cite: Dumke L, Nagraj S, Abukmail Η, et al. Barriers and facilitators to quality mental health care for forcibly displaced children and adolescents in the WHO European Region: protocol for a scoping review. BMJ Open 2025;15:e094285. doi:10.1136/ bmjopen-2024-094285
► Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/ bmjopen-2024-094285).

Received 27 September 2024
Accepted 11 September 2025

© World Health Organization 2025. Licensee BMJ.
For numbered affiliations see end of article.

Correspondence to
Dr Eleanor Chatburn; ec876@cam.ac.uk

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ABSTRACT
Introduction Forcibly displaced children and adolescents in the WHO European Region have high mental health needs, yet few manage to access mental health services and even fewer receive high-quality care. Addressing this gap is crucial, as inadequate mental health support has profound and lasting negative effects on individuals, families and communities. This scoping review aims to identify and synthesise the available evidence on the barriers and facilitators to quality mental healthcare for forcibly displaced children and adolescents in the WHO European Region.
Methods and analysis Quantitative, qualitative and mixed-method studies that examine barriers and facilitators of quality mental healthcare for forcibly displaced children and adolescents in the WHO European Region will be included. Eligible participants include forcibly displaced children and adolescents, mental healthcare providers, policymakers and humanitarian actors in the mental health and psychosocial support field. We will adhere to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews) guidelines. A comprehensive search of databases, including Embase, Medline, PsycINFO, Scopus and Web of Science, will be conducted. We will systematically search for relevant studies published between January 2004 and December 2024. At least two reviewers will independently screen titles, abstracts and full texts. Data extraction will involve systematically charting relevant information from included studies. We will use the WHO Quality Standards for Child and Adolescent Mental Health Services as an analytical lens to map the evidence. Our study will provide a comprehensive overview of the barriers and facilitators to quality mental healthcare for forcibly displaced children and adolescents, and identify knowledge gaps and areas for potential quality improvement.
Ethics and dissemination Ethical approval will not be required since this study will retrieve data from already published research and no new data will be collected. The results of this study will be published in a peer-reviewed journal and presented at international conferences in
STRENGTHS AND LIMITATIONS OF THIS STUDY
= > This scoping review uses the WHO Quality Standards for Child and Adolescent Mental Health Services as analytical framework to identify barriers and facilitators to quality of mental healthcare for forcibly displaced children and adolescents in the WHO European Region.
= > Restriction to studies published in English and German may exclude relevant research in other languages.
= > Limiting the search to the last 20 years (2004-2024)
may omit earlier but potentially relevant studies.
= > The focus on the WHO European Region restricts generalisability to other contexts but allows for an in-depth, regionally specific analysis.
order to disseminate to academic and non-academic stakeholders such as non-governmental organisations, government bodies and community organisations involved in mental healthcare for forcibly displaced persons. Review registration details https://doi.org/10.17605/ OSF.IO/AK74F.
INTRODUCTION
Children and adolescents are at the centre of a growing global mental health crisis.1 The WHO estimates that one in five adolescents in Europe experiences a mental health condition.2 The mental health burden is particularly high for vulnerable groups of children and adolescents who experience an accumulation of risk factors, such as forcibly displaced children and adolescents.3 It is estimated that at least one third of forcibly displaced children and adolescents in Europe are in need of mental health support.4-6 Given the increased rates of mental health problems and their potential long-term negative consequences, improving access to and quality of

(3) Family and community engagement

(4) Smooth transitions

(7) Competent and appropriate workforce

(8) Quality improvement and data collection

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mental healthcare for children and adolescents, especially those in vulnerable groups, has been recognised as a priority in Europe. ' While there are general deficiencies in child and adolescent mental health systems across the WHO European Region,8 studies indicate that forcibly displaced children and adolescents have disproportionately lower access to mental health services, experience differential treatment and receive poorer quality care.910 Despite these critical issues, there is a lack of comprehensive and up-to-date knowledge on the barriers and facilitators to quality mental health services for forcibly displaced children and adolescents in the WHO European Region.
To our knowledge, only one review has comprehensively analysed the utilisation of mental healtli services by children and young people with a refugee background.11 Significant changes in patterns of displacement and an increase in the number of relevant studies in recent years call for an updated and more detailed review. Other reviews have looked at the broad population of migrant youth (ie, not just those who have been forcibly displaced) or have focused only on the perceptions of specific subgroups of forcibly displaced children and youth (eg, unaccompanied refugee minors).12 13 Moreover, no review was identified that brought together the perspectives of forcibly displaced children and adolescents, caretakers, service providers, humanitarian actors and policymakers. Integrating the perspectives of all relevant stakeholders can provide valuable and comprehensive information and avoid an over-emphasis on assumed characteristics of the patient population.14 Furthermore, in order to adequately assess the quality of mental health services, identify potential areas for improvement and address mental healtli inequity, a comprehensive review is needed that examines the current literature on mental healthcare for forcibly displaced children and adolescents against established standards for quality mental healthcare.
Therefore, the aim of the scoping review described in this protocol is to identify and synthesise the available evidence on the barriers and facilitators to quality mental healthcare for forcibly displaced children and adolescents in the WHO European Region. Guided by the WHO Quality Standards for Child and Adolescent Mental Health Services (table 1), we will systematically identify research gaps and provide evidence-based insights to inform implementation strategies for quality mental health services.
METHODS
This scoping review will follow the Joanna Briggs Institute Manual for Evidence Synthesis and will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRIS- MA-ScR).15 As this topic has not been comprehensively reviewed before and we anticipate a wide range of literature, we decided to conduct a scoping rather than a systematic review to explore the extent of the literature
Table 1 WHO Quality Standards for Child and Adolescent Mental Health Services
Quality theme	Quality standard
(1)		Participation and (1.1) Service facilities, location and design empowerment	are planned and implemented with active participation of users (children, young people, families, carers) for easy access of service.
(1.2) Services empower children, young people and their caregivers to make informed decisions about their care and to understand and self-manage symptoms.
(2)		Rights and (2.1) Children, young people, their families safety	and caregivers and staff are treated with dignity and respect, their rights are upheld and they are protected from abuse and harm.
(2.2)		Care provided is safe and does not cause harm.
(2.3)		Services have mechanisms in place to monitor and provide equitable access for all children, young people and their families/caregivers free of discrimination based on their gender, ethnicity, religion, ability, culture or sexuality.
(3.1)		Services include caregivers/families directly in the provision of care when agreed and appropriate.
(3.2)		Services develop effective working relationships with key local organisations and the community to meet the holistic needs of children, young people and their caregivers.
(4.1)		Services develop effective working relationships and referral pathways with key organisations to ensure smooth referrals, handover and good continuity of care, particularly for those who may be at risk of harm and are Co-planned with the children and young people and caregivers.
(5)		Timely support (5.1) Services include caregivers/families directly in the provision of care when agreed and appropriate.
(6)		Developmentally (6.1) Services offer a range of evidence- appropriate and	based interventions, including using evidence-based	creative therapies where appropriate.
(7.1)		Staff are competent and supported to provide care that is high quality and embedded in a strong therapeutic relationship.
(7.2)		Services have sufficient staff to provide appropriate care.
(8.1)		A culture of continuous quality improvement exists through effective governance and activities to monitor, evaluate and respond to quality of service.
(8.2)		Services have adequate resources to enable data collection, analysis and reporting.

and to map and synthesise the existing evidence. The protocol was registered on Open Science Framework (26 September 2024): https://doi.org/10.17605/OSF.IO/ AK74F.
Review question
The research question of the current review is: ‘What are the relevant barriers and facilitators of quality mental health care for forcibly displaced children and adolescents in the WHO European Region and how can they be classified according to the WHO Quality Standards for Child and Adolescent Mental Health Services?’8
Inclusion criteria
The review will include articles that meet the following criteria: (1) quantitative, qualitative and mixed-method researcli exploring barriers and facilitators to quality mental healthcare as defined by the WHO; (2) studies involving forcibly displaced children and adolescents (0-19 years old as defined by the WHO), their families and/or caretakers, mental healthcare providers and/or policymakers and/or humanitarian actors as participants; (3) researcli conducted within the WHO European Region; and (4) articles published in English or German (5) in the past 20 years (since 2004).
Studies will be excluded if they: (1) do not specifically focus on mental healthcare; (2) do not explicitly examine barriers and facilitators of quality mental healtlicare; (3) focus on forcibly displaced adults or focus on the general migrant population without clearly specifying findings for forcibly displaced children and adolescents; (4) are not in English or German and have been published before 2004.
Search strategy
An academic librarian was consulted in the development of the search strategy. To identify relevant articles, a comprehensive literature search will be conducted across multiple databases, including Embase (via Elsevier), Medline (via PubMed), PsycINFO (via EBSCOhost), Scopus (via Elsevier) and Web of Science. A tailored search algorithm based on the elements of our research question (population, concept, context) was developed and adapted for each database. Relevant keywords are presented in table 2, with a full search strategy presented for eacli database in online supplemental appendix 1. Citation-chaining will be used to search the reference lists and citations of all included studies to locate any additional sources. Grey literature sources will be searched, including the WHO Institutional Repository for Information Sharing, Networked Digital Library of Theses and Dissertations Global Electronic Theses and Dissertations Search, Google and libraries and websites of international organisations (see list in online supplemental appendix 2). In addition, experts working for non-governmental or academic institutions working on programmes for mental healthcare for displaced children and adolescents in the WHO European region will be contacted for any unpublished studies. Only literature written in English or German in the last 20 years (since 2004) will be considered for inclusion. These restrictions are intended to ensure that only research that is aligned with the language skills of the research team is included, and that the focus is on tlre most recent findings reflecting recent displacement patterns.
Study/source of evidence selection

	Element	Keywords	
1	Population: forcibly displaced	Asylum seeker* OR Refugee* OR Forcibly displaced	
2	Population: children and adolescents	Child* OR Adolesce* OR Youth* OR Infant* OR “Teen” OR “young people” OR “Young person”	
3	Concept: mental health	“Mental health” OR “Mental disorder” OR “mental ill-health” OR Psych* OR Mental* OR Psychiatric OR psychopathology OR Anxiety OR Trauma* OR PTSD OR “post-traumatic stress disorder” OR Depress* OR Substance OR Alcohol OR Somatic OR Panic	
4	Concept: care	Care* OR Service* OR Treatment* OR Therap* OR Intervention* OR Pathway* OR Support OR Assistance OR Provision OR Counsel*	
5	Concept: quality	Quality OR Access* OR Acceptab* OR Affordability OR Availab* OR Barrier* OR Continuity OR Effective OR Efficient OR Enable* OR Equit* OR Experience OR Facilitat* OR Outcome OR Patient-Centred OR Responsiveness OR Safe* OR Satisfaction OR Standard OR Timeliness OR Use* OR Utili*	
6	Context: WHO European Region	N/A*	

Table 2 Keywords for systematic literature search

*To maximise search sensitivity and avoid missing relevant studies that may not explicitly mention the geographical context in their titles or abstracts, the geographical context will be filtered during the screening process.
N/A, not assessed.

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Following the search, all identified citations will be collated and uploaded to Rayyan and duplicates will be removed.16 The screening of titles and abstracts will be carried out by at least two researchers independently. The full text of selected records will be assessed in detail against the inclusion criteria by at least two independent

Table 3 Draft data extraction instrument	
Category	Data extracted	
Evidence source details and characteristics	
Author, year	
Country	
Aim	
Study type/source (eg, quantitative, qualitative, mixed- methods)	
Population	
Sample size	
Age (years)	
Gender	
Other demographics	
Setting	
Results on barriers and facilitators to quality mental healthcare extracted from source of evidence	
(1) Participation and empowerment	- Barriers:
+ Facilitators:	
(2) Rights and safety	- Barriers:
+ Facilitators:	
(3) Family and community engagement	- Barriers:
+ Facilitators:	
(4) Smooth transitions	- Barriers:
+ Facilitators:	
(5) Timely support	- Barriers:
+ Facilitators:	
(6) Developmentally appropriate and evidencebased	- Barriers:
+ Facilitators:	
(7) Competent and appropriate workforce	- Barriers:
+ Facilitators:	
(8) Quality improvement and data collection	- Barriers:
+ Facilitators:	

reviewers. Reasons for exclusion of articles after fulltext assessment that do not meet the inclusion criteria will be recorded and reported in the scoping review. A third reviewer will resolve any discrepancies between the reviewers during screening or full-text assessment. A PRISMA flow chart will be used to report the results of the search and the process of study inclusion.
Data extraction
A data extraction form will be developed and piloted (see table 3 for draft) in line with scoping review best practice guidelines. 7 The data extracted will include information about the study name and year of publication, study aims, study methods, participants, context and key findings on barriers and facilitators to quality mental healthcare. Any ad hoc modifications to the data extraction form will be detailed in the scoping review. Relevant study characteristics and findings will be extracted from all included
studies, with independent checks on 20% of the extracted data and constant consultations between reviewers. A third reviewer will resolve any discrepancies.
Data analysis and presentation
Narrative synthesis will be used to summarise findings on barriers and facilitators to quality mental healthcare. The findings will be structured in narrative and tabular form, guided by the WHO Quality Standards for Child and Adolescent Mental Healtli Services (see table 1).8 To highlight researcli gaps, the number of studies addressing eacli of tlie quality themes defined in the quality standards may additionally be presented in a visual form (eg, treemap, bar chart).
DISCUSSION
The scoping review outlined in this protocol aims to fill a critical knowledge gap by systematically identifying and mapping evidence on the barriers and facilitators to quality mental healthcare for forcibly displaced children and adolescents in the WHO European Region. Given the discrepancy between the mental healtli needs and adequate support of forcibly displaced children and adolescents, the results of the review can provide important insights for areas of improvement and mitigate mental health inequities. Understanding the specific challenges of mental healthcare for different populations of children and adolescents is a crucial step in developing efficient and effective policies.1 In order to gain a comprehensive understanding, our review will bring together the perspectives of forcibly displaced children and adolescents and other relevant stakeholders, including families, service providers and policymakers. Furthermore, using the WHO Quality Standards for Child and Adolescent Mental Health Services as an analytical framework not only ensures a comprehensive assessment of service quality, but also aligns the findings with internationally recognised standards, thereby providing actionable insights for policy-makers, humanitarian actors and practitioners seeking to improve service delivery/
Limitations

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While the scoping review outlined in this protocol aims to address critical gaps in knowledge, several limitations must be acknowledged. As a scoping review, tliis review does not include a quality appraisal of included studies and may not provide definitive conclusions about the strength of the evidence but will instead focus on mapping and summarising available research. The geographical focus on the WHO European Region limits the review‘s generalisability to other regions where forcibly displaced children and adolescents may experience different barriers and facilitators to mental healthcare. By restricting the review to studies published in English and German, research in other languages may be excluded, potentially resulting in an incomplete representation of the evidence. The temporal restriction to studies published since 2004
may exclude older studies that could still provide valuable insights; however, it was made to capture recent researcli and trends in forced displacement.
Patient and public involvement
Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.
Author affiliations
'Department of Psychiatry and Psychotherapy, University Medical Center Hamburg- Eppendorf Center for Psychosocial Medicine, Hamburg, Germany
"Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
3East London NHS Foundation Trust, London, UK
4Department of Engineering, International Health System Research Group, University of Cambridge, Cambridge, UK
’Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
6Department of Psychiatry and Psychotherapy, University Medical Center Hamburg- Eppendorf, Hamburg, Germany
7Guy‘s and St Thomas’ NHS Foundation Trust, London, UK
8WHO Athens Office on Quality of Care and Patient Safety, WHO Regional Office for Europe, Copenhagen, Denmark
9Norwich Medical School, Department of Clinical Psychology and Psychological Therapies, University of East Anglia, Norwich, UK
'“School of Psychology, Sport and Sensory Science, Anglia Ruskin University, Cambridge, UK
Acknowledgements We are grateful to Dr Veronica Phillips, Assistant Librarian (Research Support, Teaching and Learning), University of Cambridge Medical Library, for assistance with developing the search strategy. JH is a staff member of the WHO Regional Office for Europe. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or the stated policy of the WHO.
Contributors LD and EC generated the idea, developed the research questions and study methods, conceptualised the review approach and developed the manuscript. SN, JH, AG, ENC, IS, MB, GW, MSR and HA contributed to defining the research questions, reviewing and editing the manuscript. LD is the guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Disclaimer The author is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the World Health Organization.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not applicable.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
Open access This is an open access article distributed under the terms of the Creative Commons Attribution IGO License (CC BY NC 3.0 IGO), which permits use, distribution,and reproduction in any medium, provided the original work is properly cited. In any reproduction of this article there should not be any suggestion that WHO or this article endorse any specific organization or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.
ORCID IDs
Lars Dumke https://orcid.org/0000-0002-1180-6849
Mohammad Sharif Razai https://orcid.org/0000-0002-6671-5557
Eleanor Chatburn https://orcid.org/OOOO-OOO2-6745-6737
REFERENCES
1		McGorry PD, Mei C, Dalal N, et al. The Lancet Psychiatry Commission on youth mental health. Lancet Psychiatry 2024;11:731-74.
2		WHO. Addressing child and adolescent mental health. 2021. Available: https://www.who.int/europe/activities/supporting-country- work-around-mental-health/addressing-child-and-adolescent- mental-health
3		Scharpf F, Kaltenbach Ε, Nickerson A, et al. A systematic review of socio-ecological factors contributing to risk and protection of the mental health of refugee children and adolescents. Clin Psychol Rev 2021;83:101930.
4		Blackmore R, Gray KM, Boyle JA, et al. Systematic Review and Meta-analysis: The Prevalence of Mental Illness in Child and Adolescent Refugees and Asylum Seekers. J Am Acad Child Adolesc Psychiatry 2020;59:705-14.
5		Henkelmann J-R, de Best S, Deckers C, et al. Anxiety, depression and post-traumatic stress disorder in refugees resettling in high- income countries: systematic review and meta-analysis. BJPsych open 2020;6:e68.
6		Kien C, Sommer I, Faustmann A, et al. Prevalence of mental disorders in young refugees and asylum seekers in European Countries: a systematic review. Eur Child Adolesc Psychiatry 2019;28:1295-310.
7		European Commission. EU comprehensive approach to mental health. 2023. Available: https://health.ec.europa.eu/non- communicable-diseases/mental-health_en
8		WHO Regional Office for Europe. Quality standards for child and youth mental health services: for use in specialized community or outpatient care across the WHO European region. 2025. Available: https://iris.who.int/handle/10665/380778
9		de Montgomery CJ, Petersen JH, Jervelund SS. Psychiatric healthcare utilisation among refugee adolescents and their peers in Denmark. Soc Psychiatry Psychiatr Epidemiol 2020;55:1457-68.
10		Satinsky E, Fuhr DC, Woodward A, et al. Mental health care utilisation and access among refugees and asylum seekers in Europe: A systematic review. Health Policy 2019;123:851-63.
11		Colucci E, Szwarc J, Minas Η, et al. The utilisation of mental health services by children and young people from a refugee background: a systematic literature review. Int J Cult Ment Health 2014;7:86-108.
12		Demazure G, Baeyens C, Pinsault N. Review: Unaccompanied refugee minors’ perception of mental health services and professionals: a systematic review of qualitative studies. Child Adolesc Ment Health 2022;27:268-80.
13		Place V, Nabb Β, Gubi E, et al. Perceived barriers to care for migrant children and young people with mental health problems and/or neurodevelopmental differences in high-income countries: a metaethnography. BMJ Open 2021;11:e045923.
14		Dumke L, Wilker S, Hecker Τ, et al. Barriers to accessing mental health care for refugees and asylum seekers in high-income countries: A scoping review of reviews mapping demand and supply-side factors onto a conceptual framework. Clin Psychol Rev 2024;113:102491.
15		Peters MD, Godfrey C, McInerney Ρ, et al. Scoping reviews. In: Aromataris E, Lockwood C, Porritt Κ, et al, eds. JBI manual for evidence synthesis. Available: https://jbi-global-wiki.refined.site/ space/MANUAL/355862497/1O.+Scoping+reviews
16		Ouzzani M, Hammady Η, Fedorowicz Z, et al. Rayyan-a web and mobile app for systematic reviews. Syst Rev 2016;5:210.
17		
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Protected by copyright, including for uses related to text and data mining, Al training, and similar technologies.

Pollock D, Peters MDJ, Khalil Η, et al. Recommendations for the extraction, analysis, and presentation of results in scoping reviews. JBI Evid Synth 2023;21:520-32.