Acceptability, feasibility and perceived effectiveness of online and remote mental health and wellbeing interventions during the COVID-19 pandemic: A qualitative study with care-experienced young people, carers and professionals

The COVID-19 pandemic, and associated lockdowns, saw numerous services move to online and remote delivery. This included mental health and wellbeing interventions for care-experienced young people. To date there has been limited consideration of how different stakeholders experienced the receipt or delivery of remote provision during this period. We conducted online one-to-one and small group interviews with: young people with experience of care (n = 3); a young person whose biological parents were foster carers (n = 1); foster and kinship carers (n = 10); and social care and affiliated professionals (n = 9). We further engaged with relevant stakeholder consultation groups to refine and confirm study findings. Five central themes were generated, that reflected participants ’ experience of a range of services, while also serving as recommendations for the future development and optimisation of provision: 1) Awareness: there is a lack of general awareness of mental health provision and understanding of what is available to support care-experienced young people, and a specific lack of knowledge regarding online support; 2) Choice and tailoring: young people need choice and flexibility in identifying pro-vision that best suits their needs, and this includes the decision to receive online, blended or in-person services; 3) Training: carers and professionals need training on how to foster relationships with young people online and how to ensure safety and child protection; 4) Safety, protection and risk: young people need to have safe and private spaces when accessing online services; and 5) Access and resources: care-experienced young people don ’ t always have access to online support, and need appropriate technological devices that don ’ t have prohibitive restrictions. Taken together, the study findings offer insight into how interventions and services may be developed and optimised moving forward to ensure that they are meeting the needs of young people in care, and maximize likely effectiveness.


Background
Care-experienced children and young people are those who are looked after by a governmental local authority, and can include foster care, kinship care and residential care (National Assembly for Wales, 2014).The mental health and wellbeing of this population remains a social care and public health priority.They report a higher prevalence rate of diagnosable mental health problems when compared to non-careexperienced samples (Dubois-Comtois et al., 2021;Engler et al., 2022;Seker et al., 2021), in addition to poorer subjective wellbeing (Long et al., 2017).A recent UK longitudinal study found that individuals who have been in care have excess mortality in adulthood up to 42 years later, with this increased risk being linked to self-harm, accidents and other mental health and behavioural factors (Murray et al., 2020).The COVID-19 pandemic has reportedly exacerbated poor mental health and wellbeing among children and young people in the general population (Creswell et al., 2021;Ford et al., 2021).A range of adverse outcomes have also been cited for individuals in care during this period, largely related to mental health, education and employment (Roberts, Mannay, et al., 2021;Rosenberg et al., 2022;Ruff & Linville, 2021).
In recent years there has been a rapidly expanding range of interventions to support the mental health and wellbeing of careexperienced populations (Evans et al., 2021(Evans et al., , 2023;;Hambrick et al., 2016;Schüller et al., 2022;Sørensen & Sjoe, 2021).A recent comprehensive systematic review and guidelines by the National Institute for Health and Care Excellence (NICE) identified a range of evidence-based approaches that include supporting development of social and emotional competency, in addition to positive parental training programmes that are primarily targeted at foster carers (National Institute for Health and Care Excellence, 2021).However, despite this emerging evidence-base, the vast majority of current interventions are reliant on in-person delivery methods, with minimal consideration of implementation through online or other remote means.While there is some evidence for online mental health and wellbeing approaches for the general population of young people or individuals 'at risk', there is limited systematic consideration of how these work in meeting the needs of diverse groups, including those who have been in care (Garrido et al., 2019;Migliorini et al., 2022;Zhou et al., 2021).
The COVID-19 pandemic, and the associated lockdown measures in March 2020, led to a rapid shift to remote intervention and service delivery, with mental health and wellbeing provision being increasingly delivered online or through a blended format that included some inperson delivery.Given the paucity of extant research on how this type of service provision works for care-experienced young people, it is imperative to examine acceptability, feasibility and perceived effectiveness of such approaches, in order to develop and enhance future provision.Such an exploration needs to take account of how interventions interacted with, and were influenced by, the wider context of young people experiences during this period and how these resonated with prior challenges.This includes reports of social isolation, increased financial insecurity, and growing precarity in the availability of mental health and other services (Greeson et al., 2020;Greeson et al., 2022;Kelly et al., 2020;Roberts, Mannay, et al., 2021;Whitt-Woosley et al., 2022).Importantly, these challenges were experienced differentially by diverse care-experienced young people, such as those who identified as LGTBQ+ (Washburn et al., 2022) or were from a range of socioeconomic or ethnic backgrounds (Ruff & Linville, 2021).There is also a need to consider the perspectives of carers, in addition to social care and affiliated professionals, who cited increased conflict in the home, fewer financial resources, reduced cross-sectoral collaboration, and significant disruption to work-life balance (Loria et al., 2023;Townsend et al., 2022;Whitt-Woosley et al., 2022).

Research aims
The present study explored stakeholders' experiences of delivering, supporting or receiving mental health and wellbeing interventions online or remotely during the COVID-19 pandemic.In some instances, provision included a blended approach, encompassing a combination of online and in-person services.We considered which type of interventions were perceived to be acceptable, feasible and effective to stakeholders, reflecting on current provision and drawing out recommendations.This approach aligns with key guidance on intervention development and evaluation, which maintain that meaningful engagement with stakeholders to understand their experiences, needs and interaction with the delivery context is imperative in maximizing the likely positive impacts of different approaches on intended outcomes (O'Cathain et al., 2019;Skivington et al., 2021).As such, our exploration of stakeholders' views can help to inform the future development, optimization and adaptation of future practice.

Study design
The study used an online, qualitative interview approach with three groups of stakeholders that had direct experience of receiving, delivering, or supporting online mental health provision in the Welsh context: young people; parent and carers; and social care and affiliated professionals.We generated data between April and July 2021.

Sampling and recruitment
We aimed to recruit thirty participants, with ten from each of the target participant groups.Young people were recruited via three organisations that support care-experienced children and young people in Wales: The Fostering Network in Wales; Voices from Care Cymru; and The Roots Foundation Wales.Study information was provided to each organisation, who shared it with their members.With the agreement of the potential participant, contact details were shared by the organisation with the research team and we followed-up via an email or telephone call to arrange study involvement.All young people were recruited through The Fostering Network in Wales.
Foster and kinship carers, and social care and affiliated professionals, were recruited via The Fostering Network in Wales.Study information was promoted via The Fostering Network in Wales e-newsletter, an ebrief to the organisation's networks, at meetings with The Fostering Network's All Wales Foster Carers' Advisory Forum, the Local Authority Fostering Managers' Forum, and the Independent Fostering Providers Fostering Managers' Forum.This was complemented by a more targeted approach to engage additional professionals, and we sent emails to professional groups that had an existing relationship with The Fostering Network in Wales.Again, the organisation compiled contact details and confidentially shared them with the research team to arrange intervention participation.

Sample characteristics
A total of 23 participants took part in the study, all located in Wales.Participants included three care-experienced young people and one young person who was the biological child of a foster carer.The latter individual responded to the information circulated by The Fostering Network in Wales for care-experienced young people to participate in the study.We decided to take an inclusive approach that encouraged engagement with all individuals with relevant experience to share their views, and this young person had lived with both care-experienced young people who accessed services and parents who had supported this process.Young people were aged between 18 and 27 years old.There were ten carers, including eight foster carers and two kinship carers.There were nine social care and affiliated professionals, whose roles included therapeutic and mental health support, and youth participation and engagement.

Semi-structured interviews
Semi-structured interviews were conducted with participants.In one instance, we undertook small group interview with three social care and affiliated professionals from the same organisation.In response to the COVID-19 restrictions, interviews were conducted remotely using the online platforms Zoom and Microsoft Teams.The interviews were guided by a flexible topic guide that mapped onto the study's overarching research questions, addressing: use of online, blended and in-person interventions and services before and during the pandemic; contextual barriers and enablers of implementation; acceptability; perceived effectiveness; and future needs.Prior to data generation, the guides were refined through discussion with young people from The Fostering Network in Wales Young People's Care Forum.Interviews were between 17 and 69 min in length.

Analysis and stakeholder consultation
Interview data were transcribed verbatim by a professional transcription service.We conducted thematic analysis (Clarke et al., 2015).Transcripts were coded with a combination of inductive and deductive codes, with the framework being iteratively refined as coding progressed.Codes mapped onto the study research questions.Codes were compared and contrasted to generate themes, which offered insight into factors that can influence acceptability, feasibility and perceived effectiveness.In the first instance themes were developed according to the three groups of participant type.These themes were then explored across groups to identify commonalities and divergences in perspectives.Data management and analysis was supported by NVivo 12 data analysis software.
Following the analysis of data, the research team discussed preliminary findings with three stakeholder groups to expand and refine the initial interpretation of the data and to develop policy and practice recommendations.In having a range of experiences in relation to online mental health interventions for care-experienced young people, they were able to offer rich insights into the nature and context of the generated data (Alliance for Children's Rights, 2022).
The stakeholder groups mapped onto the groups that served as study participants.The first was with ten foster and kinship carers, who were members of The Fostering Network's All Wales Foster Carers' Advisory Forum.The second was with four care-experienced young people who were part of CASCADE Voices, which is a research advisory group developed through collaboration between the Children's Social Care Research and Development Centre (CASCADE) at Cardiff University and Voices from Care Cymru.The third group was with four careexperienced young people at The Fostering Network in Wales Young People's Care Forum.Content analysis was undertaken with notes from the group sessions.Generally, the stakeholder consultation discussions aligned with the study findings.Reflecting on the study, they also indicated important implications for future research, which are presented in the discussion.

Ethics
Ethical approval for the study was provided by Cardiff University's School of Social Sciences Research Ethics Committee (SREC/3887).Data generation was guided by The Fostering Network in Wales' Digital Risk Assessment for Children and Young People, which supported key considerations around safeguarding and participant wellbeing (Boffey et al., 2021a).Informed consent was obtained from all participants.Online discussions were recorded, with only the audio recording being professionally transcribed.Data were securely stored on Cardiff University's and University of Glasgow's secure network, with all interviews anonymised at the point of transcription.The study intentionally used preexisting organisations to recruit participants to ensure that an infrastructure of support was available to them following participation.They were also provided with the details of a range of mental health and wellbeing resources.

Findings
The findings explore the experiences of receiving, supporting and delivering online and remote mental health and wellbeing services for care-experienced young people during the COVID-19 pandemic, with participants drawing out recommendations to develop and optimise provision moving forward.Data and subsequent recommendations mapped onto five central themes: awareness; training; choice and tailoring; safety, protection and risk; and access and resources.
As context to these themes, participants reported the types of interventions and services care-experienced young people had used prepandemic.Both young people and carers cited using, or supporting the use of, Child and Adolescent Mental Health Services (CAMHS).There were complex narratives about this service, but generally the accounts of participants were characterised by issues of long waiting lists and a lack of access.As the pandemic unfolded, young people indicated using a range of additional or alternative support services online.These included, but were not limited to, applications such as YouTube, Headspace and Calm.There was also an emphasis on creating opportunities for social contact, such as using Facebook or WhatsApp groups to post and connect with messages.Carers similarly referenced engaging with online apps.These were often not explicitly targeted to mental health, but were perceived to have some benefit to wellbeing.A number of them mentioned engaging with educational provision, including that offered by schools.Meanwhile social care and affiliated professionals discussed adapting their services to use online and remote delivery modes to engage children and young people.These included video calls, WhatsApp messages, and telephone calls.Such approaches were used across a wide range of supportive provision, such as social work, youth participation, advocacy and therapeutic services.

Awareness
A central issue around the online delivery of interventions and services was a lack of awareness of provision and an understanding of what is available to support children and young people's mental health, specifically in relation to those with experience of care.This was cited as a ongoing challenge, but was one that had been exacerbated during the pandemic, where a number of services had become unavailable or had rapidly transitioned online and so were now accessible through different means.
Foster and kinship carers recognised that they were unsure where they could secure assistance for the young people that they care for: I'm not saying that it's not well publicised, because I wouldn't be able to tell you whether it is or it isn't, hand on heart.Um, but yeah, I think the more about it is, is that maybe it's not as well publicised inasmuch that it doesn't come straight to your head.And feeling A, B and C, oh yes, that's what … or that's who I need to speak to, if that makes … does that make sense?
For the large part, carers sensed that there were services 'out there' but they did not have the information available on where they could be located, and the COVID-19 pandemic has added additional complexity as to how they could now be found: You know, we don't see many, there may, there may be stuff out there, but we haven't been told about it yet.
As a consequence, carers spent time online trying to navigate the complex landscape of mental health provision, often in a piecemeal fashion to find support that could meet the specific needs of the child they were caring for: So it was kind of unpicking it all, going online, finding bits of information, to try and break it down for her.
Resultantly, there was a clear focus on the need to increase service information, both during and beyond the COVID-19 pandemic.However, this recommendation was qualified by young people, who maintained that information could easily become overwhelming and even burdensome.One young person reflected on the experience of being 'bombarded' with information, and struggling to navigate the complex array of provision on offer: Me and my friends got literally bombarded with e-mails, at one point, from loads of different providers doing loads of different things and it just got like a bit too much.This suggests a need for a more coordinated approach between organisations, with the potential for an ongoing centralised repository that can make it easier to navigate and access services.This was reflected in the data from foster and kinship carers, who recognised that while there was a wealth of materials available from a diverse and disparate range of organisations and websites, it would be helpful to have a more organised, systematic, and centralised hub .To support this process, there was a strong emphasis on the development and sharing of service information being led by care-experienced children and young people themselves.

Choice and tailoring
Participants explored the importance of children and young people having choice and flexibility in identifying the mental health and wellbeing provision that best suited their needs.When exploring the online support that had helped during the COVID-19 pandemic, one young person described the importance of locating something that could meet their immediate and changing requirements: I'll just flick through them [YouTube], erm, until I find something that suits me on the day.
Central to the need for choice was the suggestion that services should not treat care-experienced children and young people as a homogenous group, with one young person recommending flexibility to meet differential needs and experiences:

Needs to be like more age appropriate' [services] and [services] need to figure out what would work for a certain person, not kind of just label us all as one type… needs to be tailored to the individual.
There were a number of key areas identified where children and young people may benefit from choice.These areas were primarily discussed in relation to online mental health provision, but occasionally extended to consider all types of support services.Equally, while participants often provided examples that would have benefitted them during the COVID-19 pandemic, recommendations were often general and applied beyond this period.
First, was choice about when services might be accessed, with some young people wanting the option to contact services at a convenient time and on a 24-hour basis where possible.Second, was choice about the people who deliver services and interventions.As indicated in reference to training, young people mentioned providing training to a diverse range of professionals so they can offer support.Specifically, there was consideration of having the option to have services provided by care-experienced professionals or volunteers who had some understanding of the context of care.One young person spoke about their hesitancy to talk with someone who may not comprehend their circumstances: There are a lot of kind of terms and stuff that you're talking about that people don't know… If I'd, one of my foster siblings had moved on and I had to text [online wellbeing support service], erm, and it was a volunteer that had no idea of the care system, they might be really confused.
Third, was the choice as to whether services should actually be delivered online, in person, or through a blended format.Some young people explored their preference for online provision, citing the importance of convenience: It was good ways of like coping with mental health and stuff'… I might have been better where it was online because you're kind of doing it in the comfort of your own home… I wouldn't have sat there meditating in front of someone or a group of people, personally.
Social care and affiliated professionals maintained that the autonomy to engage at a level that was comfortable to young people, for example switching off their camera or using the mute button within an online platform, could help when they were feeling anxious.One professional felt that as a result services could be more inclusive and equitable: So, if you've got, we always said we'd have a pre-discussion before but if you've got someone who's maybe having difficulties with their mental health.I mean, they could have a carer with them when they were online and it be a discreet thing, they could just be in the room, we wouldn't necessarily know, so to give that support and that maybe a bridging step into getting more involved with organisations, which could potentially improve their mental health, but they might not feel confident enough to take that step initially.Or people that have a physical disability they might find it difficult to travel independently and meet up with people but can then access things online.
In contrast, a number of participants explored reasons why young people may not choose to engage with online services and prefer inperson support.Participants reflected on how face-to-face provision could facilitate more intimate and meaningful relationships, while also offering clarity and structure around the service experience.One young person mentioned appreciating the boundary of the space where services were physically delivered, and that they could clearly leave afterwards:

Structure of going to somewhere and knowing that I was going there to do my counselling and that I would leave…if I still been going, I would have been keen to go back to in-person when I could.
There were also concerns, primarily among professionals, that it was difficult to build relationships online and that digital platforms could not sufficiently account for different sensory needs.Some carers, who lived with younger children or individuals with a complex range of needs, commented that it was challenging to engage online.
To support this process of offering choice and responsively tailoring services to meet needs, foster and kinship carers stated that services needed to take time to fully understand young people's preferences:

They need to communicate with that young person and get to know them before they um, just send a referral off, because, you know, it doesn't happen, everything suits everyone does it?
There was also discussion of how services should be developed through the process of co-production to ensure that they are sensitive to children and young people's preferences.

Training
Social care and affiliated professionals observed that the COVID-19 pandemic had a positive effect on their digital offering of services, and there had been significant progress in the development of online provision and resources.However, all participant groups reported a need for more comprehensive and appropriate training to navigate and utilise online delivery methods, especially if online and blended delivery would continue on a more permanent basis.
Three central training needs were identified.First, from the perspective of social care and affiliated professionals, was the need for skills and techniques to foster relationships with children and young people online.Across the data sources, participants stated that positive, often therapeutically orientated relationships could be challenging to create remotely, especially if there had been no prior contact between the professional and the child.Similarly, there was consideration of how professionals could be better trained and services tailored to remotely support the needs of carers, with foster and kinship carers recognising the lack of assistance they had received for their own wellbeing.One carer noticed the difficulties they had experienced during the transition to remote service provision: But the support really, there was no support, because nobody was allowed to come into your home, nobody was allowed to take the children out.So that was it, you'd get … you'd get a phone call, and that was the level of support really, you know.But if you needed anything, they couldn't help you with it anyway, it was quite, quite difficult really.
Second, there was an evident need to improve awareness and functioning in terms of safeguarding and child protection.Generally, during the COVID-19 pandemic procedures had continued to be applied in the same manner as they had been within the context of in-person delivery, but professionals recognised the challenges of conducting risk assessments online and the lack of guidance available.This was similarly reported amongst kinship and foster carers.
Third, there was a need to further support how to use digital platforms.Foster carers and kinship carers observed that even where appropriate digital technology was available to them, there was a barrier to knowing how to effectively engage with the technology to support young people in navigating online spaces.

I'm not very good with all this, if I be honest, you know, but … I've got the confidence to say it….… It's almost expected that young people should know about it, and some people, they, they don't know how to do it.
A related consideration raised by carers, was how training might be delivered to support their own development.They commented that online training courses may not confer the same benefits as opportunities they had experienced in face-to-face settings: Personally, I'm not one for training online, I have trained online, because I have to, but I don't, particularly, like it… One, because it's so easy, you just tick a box, and, and it's not, um, but, I think you learn more from talking to people, gaining peoples experiences, if you like, in a classroom, or in, in an area where you can talk and chat.
As such, it may be helpful to deliver training in a blended format to allow participants the opportunity to connect with others and build supportive relationships.

Safety, protection and risk
A central concern about online and remote service provision across participants was how to keep children and young people safe.While this mode of delivery conferred perceived benefits in giving young people autonomy to engage at a level they felt comfortable with, it did raise a number of unique safeguarding issues.
Social care and affiliated professionals expressed concern about internet connections failing during online calls and children and young people being left without immediate support, especially if they were in distress.There was an apprehension about professionals not being able to identify potential issues, as paralanguage suggesting emotional stress could not be clearly detected online:

Because you can't, by not having them in the same room as you, you can't pick up on the subtleties, what's going on… Because you know, a lot of the young people we work with, they become very adept at covering, um, how they feel.
There was some suggestion on how to navigate this risk, by settings expectations at the start of any support provision and helping young people to feel empowered to communicate any issues they might have: If a young person decides to switch their camera off, which, again, we give them full autonomy to be able to do, I can't see them.I can't tell if they're engaged, I can't tell if they're okay.Erm, is something we're talking about affecting them on a personal level?And maybe they need some support.

So, it does completely change the dynamic of it.
There was also concern that children and young people may not have access to a private and safe space in their home where they could openly express themselves with professionals.
Beyond ensuring safety within the immediate service interaction, there were challenges around the wider system of communication, which was made difficult by the transition online.Carers maintained that they felt somewhat alienated from the care system during the COVID-19 pandemic, and so struggled to support the children and young people they care for in engaging with services.Indeed, they were not always aware who the young person was in contact with, which service the professional represented, or the aims of various meetings.This created anxiety about what was happening, which reflected wider considerations about keeping young people safe in online spaces and the potential exposure to risk: Well, online, you don't know who you're talking to as well…And so, I'm very wary to do anything online with him, because I don't know who they are, and all that, so I'll, that's my … thing that is.
You know, for him to be able to do stuff online.I mean, if it was online, then I would have to be there, as well, I'm protective of him on that sort of thing, so and I think that's one of the things as well.
These concerns were further exacerbated by carers not being able to engage in deep and nuanced communication with social workers online: So, if, the thing is, you can only write an email factual stuff… I can't tell him my gut feelings… But, if they were here, and we were doing risk assessments, I could explain my gut feelings and then they could word it in a way that, that you know, um, that risk we, we need to be looking at that.

Access and resources
Participants cited the challenge of care-experienced children and young people being able to access services as a consequence of digital poverty.One young person described their lack of access to both the internet and digital devices: Don't have, erm, internet … or they don't have mobile devices or laptops.Erm, there's a lot of poverty in like [Area]… I don't think people realise how extreme it is.But there's a lot of people who … can't, don't have like the things that access all this stuff'.
In some instances, limited resources could lead to computers and other devices being shared within a household, which compounded young people's concerns about being able to privately access services: Financial aspect of it… there's the whole, do they have a phone… cost of the internet… maybe not got access to internet on their phone or they've probably not got their own computer… I think that kind of causes a barrier with online resources...or the whole family share one computer.It's maybe not somewhere that they want to kind of go and deal with their kind of deepest thoughts and stuff.
Even where young people had access to digital devices, they were often not suitable as they had restricted permissions.Foster and kinship carers discussed how technological equipment to support educational engagement during the COVID-19 pandemic was often set-up so that young people could only connect with a small number of pre-approved websites and portals: Compared to what we've had from Social Services, which is zero, um, apart from provided some laptops, which didn't really work, because the school set them up um, so they could only get on the hub … the camera won't work, um, so we've had to use my stuff…one of my iPads or my laptop.
Accordingly, carers would often have to supplement the lack of resources with their own equipment, which may not have been an option in all cases.
This lack of resource reflected wider structural issues around the lack of financial and service support for care-experienced children and young people.This was seen as an entrenched problem that preceded the COVID-19 pandemic, and would likely extend far beyond it.Limited resources were deemed a notable concern for care leavers, with one young person stating, 'you can't really afford to get anything as a careleaver'.In particular, eligibility constraints about service access beyond the age of 25 years meant that many young people were being left without much needed support: But it's getting scarier for me, because I'm getting older and like, I'm twenty-seven this year and I'm not a youth anymore, my youth stopped at twenty-five, with a lot of things.And it's like really scary, it's like, oh God, what am I going to do?' Moving forward, there was a recognised need to ensure requite resources were being provided.There was also some consideration of the additional funding that may be needed to ensure continued high-quality online service delivery.For example, one young person cited an example of best practice, where they received a multi-modal experience from professional providers, including sleep spray, chocolate and other items in advance of their online meeting.However, this required additional funding that could not necessarily be secured in a sustainable manner.

Overview of findings
The present study has explored the experiences of young people, carers, and social care and affiliated professionals in receiving, supporting and delivering online and remote mental health and wellbeing services and interventions.These experiences were shaped by the complex and challenging context of the COVID-19 pandemic (Greeson et al., 2020;Greeson et al., 2022;Kelly et al., 2020;Roberts, Mannay, et al., 2021), which was the timeframe for study conduct.We identified key thematic areas of experience, that served as the basis of recommendations for future service development and optimisation, to ensure high quality, appropriate and acceptable provision moving forward.
Central to the findings were the evident need for children and young people to have choice and tailoring when it comes to the availability of mental health and wellbeing services they receive.This entails flexibility in the delivery team, the mode of delivery, and when services may be accessed.To this end, the findings recommended that professionals should work with young people in care to identify their preferences, ensuring that individuals with experience of care are not treated as a homogenous group with identical needs.Previous research has outlined the issue of 'pseudo-support systems', where services are not always placed to effectively respond to the complex needs of young people in care as they do not sufficiently work to understand their specific preferences and requirements (Fergeus et al., 2019).
It should be noted that previous research has reported that careexperienced young people's disengagement with interventions is often misinterpreted as being the result of their complex circumstances, when the issue may actually be that they feel disempowered to communicate that their preferences are not being addressed (Mezey et al., 2015).As such, mechanisms need to be integrated to ensure that young people feel in a position to exercise choice.Increased awareness of what services and interventions are available and how they may be independently accessed could be supportive of this.Increased information and awareness among carers and other adults who are important to young people can also help them in making decisions about service uptake.
Within the context of choice, participating young people explored the different types of online and remote interventions and services they had been using throughout the pandemic, foregrounding the importance of these spaces in creating positive connections.This included connecting with others who have experience of care (Mannay et al., 2021).The vital role of relationships reflects an expanding evidence-base that documents the significant impact of diverse relationships and types of support on the mental health and wellbeing of those have been in care (Evans et al., 2022;Hassall et al., 2021;Mabille et al., 2021).This emphasis on cultivating relationships was further considered in relation to the nature of interactions between professionals and young people online.There were concerns that relationships not fostered in person could struggle to create a therapeutic connection.This suggests the need for prioritising positive and meaningful relationships, and that where there continues to be a reliance on online provision, this might potentially be combined with some in-person component in the initial phase to build a healthy therapeutic context.
While the findings explored a number of potential benefits of online and remote intervention, such as the autonomy of young people to engage to an extent that felt comfortable to them, there were perceived associated risks.These related to not being able to identify non-verbal cues of emotional distress, leaving a young person being without support if the internet connection failed, or there not being a safe space for young people to privately share their concerns, especially if they related to issues with their carers or home.This could leave professionals and carers feeling unsure in knowing how to balance young people's autonomy with the risk of harm, and how to navigate through the complexity of digital risk assessment.While participants noted that online services were subject to safeguarding procedures in the same manner as in person provision, they felt that this was not a simple process.Resources have been developed in relation to this (Boffey et al., 2021a), but further work would be needed to ensure widespread support.
If mental health provision is to be delivered online or through a blended format moving forward, and beyond the COVID-19 pandemic, there is a need for relevant training for a range of stakeholders.As reflected in other studies, participants recognised that organisations had been largely agile in transitioning services online during the pandemic (Cook & Zschomler, 2020;Ferguson et al., 2022).However, there were still areas of uncertainty, notably in regard to the skill to facilitate online connection and to use technological devices.Training opportunities need to be integrated into professional development programmes so that young people can be supported online.At the resource level, there is a need to make sure that young people, particularly those who are careleavers, do not continue to experience digital poverty, which has been extensively documented in research to date (Munro et al., 2021;Sibilla & Gorgoni, 2022).Moreover, it is essential to acknowledge the discontinuance of many mental health services, both online and in person, for care leavers over the age of 25 years, which can leave them feeling isolated (Roberts, Mannay, et al., 2021).

Implications for future intervention development and optimisation
Reflections and recommendations to improve interventions and services raises important methodological and pragmatic considerations about how they are developed in future.Study participants emphasised the need to co-create approaches with care-experienced children and young people, as they are best placed to identify the mechanisms and delivery approaches that have most leverage in promoting their mental health and wellbeing (Dixon et al., 2019;Mannay et al., 2019;Park et al., 2021).This reflects methodological recommendations from guidance concerning the development, optimisation and adaptation of interventions, which centralise the need for stakeholder involvement throughout (Hawkins et al., 2017;Moore et al., 2021;O'Cathain et al., 2019;Skivington et al., 2021).In working with young people, and other stakeholders, intervention research can aim to increase the likely effectiveness of approaches in positively targeting mental health and wellbeing.

Implications for future research
The study has a number of important implications for future research.Consultations with young people suggested the need for more research on how they can most efficiently access and gain awareness of mental health and wellbeing support.There was also discussion of the importance of understanding the complex issue of online safety.While it was a theme of the current study, stakeholders recommended more indepth exploration.Finally, stakeholders reported the need to replicate the present study across the UK, as it was conducted in the Welsh context.This will allow for comparison of similarities and differences in experiences, and to identify a wider range of best practice.

Limitations
There are a number of limitations with the present study that should be considered when interpreting the findings.First, is the low number of participating young people with experience of being in care.Recruiting this group to take part in research virtually during the COVID-19 pandemic was a challenge, as reflected in the limitations of a number of other research studies conducted online and with this population during this time period (Boffey et al., 2021b;Roberts, Rees, et al., 2021).Second, while participants were recruited through existing infrastructures to ensure they had available support, the sample may have reflected the views of stakeholders most engaged with services and networks.Third, data were generated online, and may have been different if the study was conducted in person.Fourth, the study recruited foster and kinship carers, but recognises that children and young people in care may live in a range of different settings, notably residential care.As such, further research would be needed to explore remote and online service delivery within the context of other types of care placements.

Conclusions
The mental health and wellbeing of children and young people in care remains a priority, especially within the context of the COVID-19 pandemic.During this period, many interventions and services transitioned to be delivered remotely and online.Young people, carers and professionals had mixed experience of this provision, recommending future areas for development and optimisation that included: improved awareness and accessibility; increased choice; training on effectively navigating online and remote spaces; deeper understanding of how to ensure safety while supporting developmentally-appropriate risk; and increased resources.Taking forward these recommendations, and making sure that interventions and services meet the needs of careexperienced children and young people, will support the development of contextually relevant approaches.