Abstract
Background
Integrated youth services (IYS) are a growing model of care where youth can access a range of youth-friendly health and social services within a single location. Located in British Columbia (B.C.), Foundry was the first IYS initiative established in Canada. In this study, we examine service utilization patterns and characteristics of youth reporting suicidal ideation (SI) to better understand and address their care needs.
Methods
We conducted a retrospective analysis of linked health survey and service data collected at Foundry from 2018 to 2023. Descriptive statistics and bivariate analyses compared groups of youth who reported having SI within the past month vs. youth who reported never having SI at the time of their initial visit. Standardized mean differences (SMD) and p-values were calculated to identify statistically significant differences between groups. We plotted monthly proportions of overall youth reporting SI accessing Foundry over the study period and by sex/gender, sexual identity (i.e., LGBTQ+), and age group.
Results
A total of 8,347 individuals were included in the analysis, of which 6,021 (72.1%) reported any lifetime history of SI and 2,975 (35.6%) reporting past-month SI. Youth with past-month SI were more likely to identify as gender diverse (13.3% of youth with SI vs. 4.9% of youth with no SI; SMD: 29.7), and LGBTQ+ youth (45.2% vs. 22.3%; SMD: 52.7). Youth with past-month SI also had higher distress scores (as measured by the Kessler Psychological Distress Scale; 36.7 vs. 27.0 mean score for past-month SI vs. never SI youth, respectively; SMD: 138.5).Youth with past-month SI had more service contact with IYS than those without SI [7.0 (SD: 16.8) vs. 11.2 (SD: 23.2) mean visits; p < 0.0001] and had accessed other mental health/substance use services in the last year (43.4% vs. 20.9%; SMD: 49.7). We found no substantial change in the overall proportion of youth reporting SI over the study period, and by subpopulations, we found a slight increase among females in the last two years.
Conclusions
Many youth accessing Foundry reported having SI, indicating an important opportunity for early intervention. Our findings also shed light on health inequities of self-reported SI, particularly among gender and sexually diverse youth.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12887-026-07543-6.
Keywords: Suicide prevention, Integrated youth services, Service use, Health equity
Introduction
Suicidal ideation (SI), or thoughts of suicide, can be an early warning sign for future suicidal behavior [1]. Research has shown that approximately 60% of youth aged 13–18 years old who develop SI eventually go on to attempt suicide, the majority of whom do so within the first year of experiencing SI [2]. Incident events of SI can occur as early as 8 or 9 years old in children, although most commonly emerges within adolescence [3]. In 2023, the British Columbia Adolescent Health Survey sampled students in Grades 7–12 from 59 of the province’s 60 school districts and found that 18% of over 38,000 youth reported lifetime SI [4]. Since the COVID-19 pandemic, some studies have found a rise in SI and self-harm behaviors among youth aged 12–24 years in Canada [5–8]. Pediatric emergency visits for suicide attempts and ideation have also increased, with trends disproportionately rising among females [9].
Recent data from the Canadian Institute for Health Information (CIHI) indicate shifts in how young people in Canada access mental health care. Between 2018 and 2019 and 2023–2024, physician visits for mental health disorders among youth rose by 8%, and both emergency visits and hospitalizations fell by 31% and 23%, respectively [10]. These patterns may reflect changes in where youth receive care, including greater use of community-based and virtual services, as well as pandemic-related shifts in health care access. A global systematic review of 44 studies published between 2000 and 2017 found that contact with a primary healthcare provider is common among both youth and adults even in the final month before death [11]. In the Canadian provinces of Quebec [12, 13] and Ontario [14], nearly 80% of youth who died by suicide used health services in the year prior to death. One study concluded that youth who died by suicide were most in need of services to address substance use, depression, interpersonal distress, and SI-related problems [15]. These findings underscore the importance of delivering suicide prevention and early intervention within primary care as well as youth-centred community settings such as integrated youth services (IYS) [16].
IYS have emerged as a novel strategy to support youth aged 12–24 with mental health and substance use (MHSU) experiences and outcomes in Canada and globally [17, 18]. IYS are community-embedded and coalesce multiple service streams, such as MHSU, physical health, sexual health, peer support, and social services, all delivered through a single access point. No referrals or parental consent are required to access the range of services. These models are grounded in youth-centered design, with services co-created and informed by youth and families/caregivers to ensure that they are not only accessible but also developmentally appropriate and responsive to their needs [19, 20].
One of the most established examples of IYS implementation is Foundry, a province-wide initiative in British Columbia (B.C.), Canada [21, 22]. Foundry currently operates in 20 communities and has a provincial virtual service, all of which offer integrated health and social services for youth aged 12–24. As part of its 2023 youth mental health strategy, the provincial government committed to expanding Foundry to 35 centres [23]. Similar IYS models have gained traction internationally, including in Australia [24], France [25], Ireland [26], and the United States [27], reflecting a global shift toward more holistic and accessible youth health care. However, despite this rapid expansion of IYS, there remains a critical knowledge gap in understanding the experiences of youth who present with SI within these settings, including how to meet their mental health and social care needs when they visit IYS.
The objective of this study is to describe and compare the demographic, mental health, and service use characteristics of youth reporting past-month SI with those reporting no SI within B.C.’s IYS initiative (Foundry). Specifically, we ask:
How do demographic and mental health profiles differ between youth reporting and not reporting past-month SI?
How do patterns of IYS service utilization differ between these groups, including among youth with single versus multiple visits?
How have the proportions of youth reporting past-month SI changed over time (2018–2023), both overall and by age group, sex/gender, and sexual orientation?
Findings from this work will help identify youth subgroups disproportionately impacted by SI within IYS settings and highlight potential gaps in care to improve targeted policies and service delivery for these populations. The present study and these analyses were not pre-registered.
Methods
Study design and data sources
We conducted a secondary data analysis using routinely collected organizational data from the B.C.-based IYS initiative (Foundry) between May 1, 2018, to January 31, 2023. Data were drawn from four primary data sources in the Foundry Toolbox data: a youth-reported registration form, a youth-reported demographic survey, a youth-reported health survey, and a service provider-reported End of Visit (EOV) form. These data sources were individually linked using a unique identifying number assigned to each youth. The youth-reported demographic and health survey was voluntarily collected one-time at or close to the first IYS visit, representing the baseline measure of health and social status/needs at or close to time of intake. Youth and families/caregivers can opt-out of survey(s) without it impacting the care they receive. The survey is completed electronically on tablets in the waiting rooms or on a personal device. In our cohort, 30% (n = 10,014) of all youth receiving services completed these surveys, and of our final analytic cohort (n = 8,347), 90% completed these surveys within 30 days of their visit (Appendix Fig. 1).
Ethics approval for this study’s use of de-identified retrospective data was obtained from the University of British Columbia Behavioral Research Ethics Board and Providence Health Care Research Ethics Board (H21-01510). This research project and manuscript has undergone a thorough review and approval by Foundry Central Office Data Stewards to ensure that the research methods, data collection procedures, and data management practices complied with established data governance and stewardship policies and procedures. All inferences, opinions, and conclusions drawn in this publication are those of the author(s), and do not necessarily reflect the opinions or policies of Foundry. The study is reported in accordance with the STROBE Checklist guidelines for cohort studies [28].
Study population
A total of 33,471 unique youth accessed services at Foundry during the five-year study period. For our cohort, we included youth who completed demographic and health surveys and had answered the health survey question regarding SI (n = 8,347). Specifically, our study population included youth who completed the question, “when was the last time that you had significant problems with thinking about ending your life or committing suicide?”. This question is derived from a section of the Global Appraisal of Individual Needs Short Screener (GAIN-SS) questionnaire [26, 29] on the health survey. The GAIN-SS questionnaire is a standardized validated scale that measures externalizing and internalizing disorders, including SI, in youth and adolescents [30]. Response options include: “Never”, “12 + months ago”, “4 to 12 months ago”, “2 to 3 months ago”, and “past month”. For our primary analyses, we were interested in comparing outcomes among youth who indicated “past month” (n = 2,975) and “never” (n = 2,326) having SI, which yielded a total analytic sample of 5,301 unique individuals. We selected past-month as the primary exposure variable (rather than longer timeframes) due to its proximal and clinical relevance in capturing service use for more immediate suicide risk. Outcomes by longer timeframes outside of past-month, defined as “Other Lifetime” history of SI (i.e., 2–3 months, 4–12 months, or over a year ago), were combined and are presented as supplemental data (Appendix Tables 1, 2 and 3). Appendix Fig. 1 presents the study flowchart depicting the analytic cohort.
Key variables of interest
Variables were selected a priori based on their availability within the linked surveys and known associations with suicide risk [31]. These included key demographic characteristics, mental health indicators, and service use variables.
Demographics (one-time measure)
Demographic variables included age, sex/gender (female, male, gender diverse; note that sex/gender categories are presented as listed in the data source), sexual orientation, education level, resident status (citizen or permanent resident and temporary), current housing type (insecure or secure), living situation, and guardianship status (parental or non-parental). Insecure housing was defined as either “living on the street”, in a group home, couch surfing, transitional housing, or residing in a homeless shelter. To understand broader social determinants that may influence mental health service use, we also included a “not in employment, education, or training (i.e., NEET)” indicator variable for youth unemployment and social disengagement [32]. This variable was assigned according to whether a youth was employed and/or in any schooling or vocational training at time of survey completion.
Mental health indicators (one-time measure)
Mental health indicators were derived from the self-reported demographic and health survey completed on the first visit. Psychological distress was measured using the Kessler Psychological Distress Scale (K10) [33], a validated 10-item scale scored from 10 to 50, with higher scores indicating higher distress. K10 scores are presented as means (SD), medians (IRQ), and categorized into standard severity ranges: no distress [10], low distress [11–15], moderate distress [16–21], high distress [22–29], and very high distress (30+). Medication use was captured using a Foundry-derived survey item: “I am currently taking any medications (Y/N)”, and could include any type of medication (e.g., birth control, pain control, asthma management). We also assessed a proxy for mental health-specific “service need” at the time of visit using a Foundry-derived survey item: “Do you have other significant psychological, behavioral, or personal problems that you want treatment for or help with? (Y/N)”.
IYS service utilization (repeated measures)
IYS utilization data were derived from the EOV form, which is completed by service providers at the end of each youth’s IYS visit(s). The EOV form captures visit-level information, including date of visit, number and types of services received, and whether the youth reported accessing other mental health services in the past year. Each visit record is linked to a unique, anonymized client identifier, which allowed for us to individually track multiple visits over the study period.
We examined service type accessed at the first and, where applicable, at subsequent visits. We also assessed additional patterns of service use including day of the week, season of visit, and mean number of total visits per youth across the study period. Service types were grouped into the following categories: (1) sexual health; (2) physical health; (3) MHSU services; (4) walk-in counseling; (5) navigation; (6) social services; (7) youth peer support; (8) group programs; (9) two or more services including MHSU; and (10) two or more services not including MHSU. We also examined visit timing relative to March 1, 2020, to capture potential differences in service use associated with the onset of the COVID-19 pandemic. This date approximately marks the introduction of COVID-related public health measures in B.C. that led to temporary IYS centre closures, reduced in-person capacity, and rapid implementation of virtual and hybrid service delivery.
A list of all variables and their corresponding survey can be found in Appendix Table 5.
Statistical analysis
Descriptive statistics for demographics, mental health status, and IYS service utilization are presented among youth reporting past-month SI compared to those reporting never having SI. Means and standard deviations are presented to describe continuous variables, and proportions (%) were calculated for categorical variables. We conducted bivariate analyses to assess differences between comparison groups, which are presented as both standardized mean differences (SMD) of means and p-values from chi-square test with a significance level of less than 5%. A SMD is a commonly applied method when assessing group differences as it does not depend on sample size, as opposed to p-values which become less meaningful for detecting differences within large samples [34]. A SMD score over 0.1 (or d ≥ 10%) was considered a clinically relevant difference between the two groups [34].
We then examined trends of SI by plotting the monthly proportion of new unique youth who completed the survey reporting past-month SI across the five-year study period over the total study population (n = 8,347), presented overall and stratified by age group, sex/gender identity, and sexual orientation. Subgroup variables were selected based on data availability for monthly estimates. To assess whether proportions differed significantly within subgroups, we used chi-square tests with a significance level of less than 5%. We also examined differences in services based on whether youth had a single visit (i.e., did not return) or had multiple follow-up visits. Among these groups, we compared service utilization patterns overall and between youth reporting past-month and never having SI. All analyses were performed in SAS 9.4 and R4.5.1.
We retained all respondents with available response data in our analysis and reported missing values for variables in the tables. Although the study data were likely missing not at random (MNAR), we did not exclude respondents with missing data from the analytic cohort or conduct multiple imputation based on the descriptive focus of the study. This approach is consistent with recommendations for transparent reporting of missing data in descriptive epidemiologic studies where MNAR is assumed [35].
Results
Demographic characteristics
A total of 8,347 individuals who voluntarily completed intake surveys were included in the study. Of this self-selected sample, 6,021 (72.1%) had reported any lifetime SI and 2,975 (35.6%) reported having SI within the past month (see Appendix Table 1 and Table 1, respectively). We found that, compared to those reporting no history of SI, a higher proportion of youth reporting past-month SI identified as gender diverse (13.3% past-month vs. 4.9% never SI; SMD: 29.7, p < 0.0001) and LGBTQ+ (45.2% vs. 22.3%; SMD: 52.7, p < 0.0001). We also found a higher prevalence of past-month SI among youth who were “not in employment, education, or training (i.e., NEET)” (15.5% vs. 9.2%; SMD: 19.1, p < 0.0001), living in insecure housing (8.1% vs. 4.3%; SMD: 16.2, p < 0.0001), and indicating “no” to “always [having] lived with their parents” (41.2% vs. 30.1%; SMD: 23.5, p < 0.0001) as compared to those never reporting SI. The mean age was similar for those with past-month SI as compared to those never reporting SI [18.0 years (3.1 SD) vs. 17.8 years (3.3 SD)].
Table 1.
Study characteristics among youth aged 12–24 years who reported suicidal ideation (SI) in the past month vs. youth who reported never having SI at their visit to the BC-based IYS initiative (Foundry) from 2018–2023
| Never SI (n = 2,326) |
“Past Month” SI (n = 2,975) |
Total (n = 5,301) |
SMDa (%) |
p-valueb | |
|---|---|---|---|---|---|
| Sex/Gender | < 0.0001 | ||||
| Female | 1273 (54.7%) | 1688 (56.7%) | 2961 (55.9%) | 4.2 | |
| Male | 926 (39.8%) | 871 (29.3%) | 1797 (33.9%) | -22.3 | |
| Gender diverse | 114 (4.9%) | 396 (13.3%) | 510 (9.6%) | 29.7 | |
| Prefer not to answer | 13 (0.6%) | 20 (0.7%) | 33 (0.6%) | 1.5 | |
| Sexual Orientation | < 0.001 | ||||
| Heterosexual | 1568 (67.4%) | 1370 (46.1%) | 2938 (55.4%) | -49.4 | |
| LGBTQ+ | 519 (22.3%) | 1345 (45.2%) | 1864 (35.2%) | 52.7 | |
| Prefer not to answer | 176 (7.6%) | 212 (7.1%) | 388 (7.3%) | -1.70 | |
| Missing | 63 (2.7%) | 48 (1.6%) | 111 (2.1%) | -7.5 | |
| Mean Age (SD) | 17.8 (3.3) | 18.0 (3.1) | 18.0 (3.2) | 6.3 | 0.0227 |
| Age Group (%) | 0.0079 | ||||
| 12–14 | 454 (19.5%) | 483 (16.2%) | 937 (17.7%) | -8.6 | |
| 15–18 | 895 (38.5%) | 1193 (40.1%) | 2088 (39.4%) | 3.3 | |
| 19–24 | 977 (42.0%) | 1299 (43.7%) | 2276 (42.9%) | 3.4 | |
| Education Level | < 0.0001 | ||||
| Less than high school | 1236 (53.1%) | 1591 (53.5%) | 2827 (53.3%) | -0.7 | |
| High school | 651 (28.0%) | 967 (32.5%) | 1618 (30.5%) | 9.4 | |
| Some college/certification | 191 (8.2%) | 209 (7.0%) | 400 (7.5%) | -5.0 | |
| University | 115 (4.9%) | 72 (2.4%) | 187 (3.5%) | -14.0 | |
| Missing | 133 (5.7%) | 136 (4.6%) | 269 (5.1%) | -5.2 | |
| Not in Employment, Education, or Training (NEET) | < 0.0001 | ||||
| Yes | 215 (9.2%) | 461 (15.5%) | 676 (12.8%) | 19.1 | |
| No | 1964 (84.4%) | 2373 (79.8%) | 4337 (81.8%) | -19.1 | |
| Missing | 147 (6.3%) | 141 (4.7%) | 288 (5.4%) | -6.9 | |
| Resident Status | 0.0008 | ||||
| Citizen/Permanent resident | 2209 (95.0%) | 2850 (95.8%) | 5059 (95.4%) | 8.5 | |
| Temporary | 95 (4.1%) | 76 (2.6%) | 171 (3.2%) | -8.5 | |
| Missing | 22 (0.9%) | 49 (1.6%) | 71 (1.3%) | 6.2 | |
| Current Housing Type | < 0.0001 | ||||
| Secure | 2108 (90.6%) | 2617 (88.0%) | 4725 (89.1%) | -16.2 | |
| Insecure | 99 (4.3%) | 242 (8.1%) | 341 (6.4%) | 16.2 | |
| Missing | 119 (5.1%) | 116 (3.9%) | 235 (4.4%) | -5.9 | |
| Always lived with parents? | < 0.0001 | ||||
| Yes | 1497 (64.4%) | 1617 (54.4%) | 3114 (58.7%) | -23.5 | |
| No | 699 (30.1%) | 1227 (41.2%) | 1926 (36.3%) | 23.5 | |
| Missing | 130 (5.6%) | 131 (4.4%) | 261 (4.9%) | -5.4 | |
| Guardian Status | 0.0066 | ||||
| Parental | 1296 (55.7%) | 1532 (51.5%) | 2828 (53.3%) | -7.7 | |
| Non-parental | 117 (5.0%) | 180 (6.1%) | 297 (5.6%) | 7.7 | |
| Missing | 913 (39.3%) | 1263 (42.5%) | 2176 (41.0%) | 6.5 |
Gender data categories are listed as described in the data source; Demographics data are obtained from self-reported health survey during initial visit. Gender diverse includes trans female, trans male, non-binary, agender, Two-Spirit, and “not sure/questioning”; LGBTQ+ includes gay or lesbian, bisexual, and questioning; Not in employment, education, or training (NEET) youth is a socioeconomic indicator defined as whether individual was employed and/or in schooling at time of survey; For temporary resident status, this included on a work visa, on a student visa, visitor to Canada, and refugee claimant; Current housing type includes insecure housing was defined by housing responses of living on the street, in a group home, couch surfing, transitional housing, or a homeless shelter; Non-parent includes “other family members”, service agency, social worker (Aboriginal Child and Family), social worker, and “not sure” or “other”
aSMD standardized mean differences. SMD score over 0.1 (10%) indicates a clinically relevant difference; bChi-square p-value of < 0.05 indicate statistical significance
Mental health indicators
Youth with past-month SI also had higher distress scores, with 80.1% having a score over 30 (scale ranges between 10 and 50 points), indicative of the respondent to “likely to have a severe mental health disorder” (see Table 2). In comparison, only 38.1% of youth without any history of SI had a score over 30. The mean K10 scores were an average of 10 points higher among youth with past-month SI compared to those reporting never having SI [score of 36.7 (6.5 SD) vs. 27.0 (7.8 SD), respectively]. It was also much more common for youth with past-month SI to report currently taking prescription medications at the time of visit (43.1% past-month vs. 29.9% never SI; SMD: 26.8, p < 0.0001) and to present with a “mental health need” during the visit (42.2% vs. 25.7%; SMD: 40.6, p < 0.0001).
Table 3.
Mental health status as indicated by self-reported health survey among youth reporting past month SI vs. youth who reported never SI at the time of visit at Foundry (2018–2023)
| Never SI (n = 2,326) |
“Past Month” SI (n = 2,975) |
Total (n = 5,301) |
SMDa (%) | p-value | ||
|---|---|---|---|---|---|---|
| Medication Useb | < 0.0001 | |||||
| Yes | 696 (29.9%) | 1282 (43.1%) | 1978 (37.3%) | 26.8 | ||
| No | 1429 (61.4%) | 1523 (51.2%) | 2952 (55.7%) | -26.8 | ||
| Missing | 201 (8.6%) | 170 (5.7%) | 371 (7.0%) | -11.4 | ||
| K10 Scoresc | < 0.0001 | |||||
| Mean (SD) | 27.0 (7.8) | 36.7 (6.5) | 32.3 (8.1) | 138.5 | ||
| Median (IQR) | 27.0 (21, 33) | 36.7 (37, 41) | 33.0 (27, 39) | |||
| K10 Score Categories | < 0.0001 | |||||
| No distress (10) | 17 (0.7%) | < 5 | 17 (0.3%) | 7.80 | ||
| Low distress (11–15) | 169 (7.3%) | 11 (0.4%) | 180 (3.4%) | -38.2 | ||
| Moderate distress (16–21) | 387 (16.6%) | 49 (1.6%) | 436 (8.2%) | -56.5 | ||
| High distress (22–29) | 687 (29.5%) | 301 (10.1%) | 988 (18.6%) | -53.0 | ||
| Very high distress (30+) | 887 (38.1%) | 2383 (80.1%) | 3270 (61.7%) | 107.8 | ||
| Missing | 179 (7.7%) | 231 (7.8%) | 410 (7.7%) | 0.3 | ||
| MH care need (self-report)d | < 0.0001 | |||||
| Yes | 597 (25.7%) | 1256 (42.2%) | 1853 (35.0%) | 40.6 | ||
| No | 1522 (65.4%) | 1390 (46.7%) | 2912 (54.9%) | -40.6 | ||
| Missing | 207 (8.9%) | 329 (11.1%) | 536 (10.1%) | 7.2 | ||
aSMD standardized mean differences. SMD score over 0.1 (10%) (in bold) indicates a clinically relevant difference
bMedication use is defined by survey question of “I am currently taking any medications (Y/N)”?
cKessler Psychological Distress Scale (K10) scores are scored on a scale of 10–50, with a higher score indicating higher levels of distress
dMental health (MH) care need is defined according to the following question on the health survey: “Do you have other significant psychological, behavioral, or personal problems that you want treatment for or help with? (Y/N)”
IYS service utilization patterns
Youth reporting past-month SI had more contact with IYS than those never reporting SI [3 (1, 10 IQR) vs. 2 (1, 6 IQR) median visits, respectively] and were more likely to have accessed other mental health services in the prior year (43.4% past-month vs. 20.9% never SI; SMD: 49.7; p < 0.0001) (see Table 3). A higher proportion of youth with past-month SI indicated that they would have gone to “no one” had they not come to Foundry, compared with those without SI (38.8% vs. 26.3%; SMD: 25.7, p < 0.0001). Overall, approximately 70% of youth indicated that their reason for visiting Foundry was related to “their feelings” (i.e., stress, anxiety, or depression). Youth with past-month SI were more often coming in for this reason as compared to youth never reporting SI (73.4% vs. 64.7%, respectively; SMD: 17.6, p < 0.0001). Of note, services accessed among the past-month SI group were more commonly any MHSU (29.0% vs. 24.0%; SMD: 11.3, p < 0.0001). There were no clinically meaningful differences between groups with respect to visit days of the week (Monday-Friday) or season (i.e., autumn, winter, spring, or summer). When assessing any changes in visit occurrence before and after the COVID-19 pandemic (using March 1, 2020, as the cutoff), the largest difference was observed among youth with visits spanning across pre- and post-pandemic periods, with proportions higher in the past-month SI group compared to the never reporting SI group (24.3% vs. 18.2%, respectively; SMD: 14.8, p < 0.0001).
Table 2.
Service use characteristics among youth reporting past month SI vs. youth who reported no lifetime SI at the time of visit at Foundry (2018–2023)
| Never SI (n = 2,326) |
“Past Month” SI (n = 2,975) |
Total (n = 5,301) |
SMDa (%) |
p-valueb | ||
|---|---|---|---|---|---|---|
| Total Number of Visits | < 0.0001 | |||||
| Mean (SD) | 7.0 (16.8) | 11.2 (23.3) | 9.4 (20.8) | 27.6 | ||
| Median (IQR) | 2 (1, 6) | 3 (1, 10) | 3 (1, 8) | |||
| COVID-19 Pandemic Groupc | < 0.0001 | |||||
| Pre-pandemic visit only | 979 (42.1%) | 1050 (35.3%) | 2029 (38.3%) | -14.0 | ||
| Post-pandemic onset visit only | 923 (39.7%) | 1203 (40.4%) | 2126 (40.1%) | 1.5 | ||
| Both pre/post visits | 424 (18.2%) | 722 (24.3%) | 1146 (21.6%) | 14.8 | ||
| Prior MHSU Services in Last Year | < 0.0001 | |||||
| Yes | 487 (20.9%) | 1292 (43.4%) | 1779 (33.6%) | 49.7 | ||
| No | 1501 (64.5%) | 1201 (40.4%) | 2702 (51.0%) | -50.6 | ||
| Not sure | 317 (13.6%) | 464 (15.6%) | 781 (14.7%) | 5.5 | ||
| Missing | 21 (0.9%) | 18 (0.6%) | 39 (0.7%) | -3.4 | ||
| Has Family Doctor | 0.0001 | |||||
| Yes | 1570 (67.5%) | 1977 (66.5%) | 3547 (66.9%) | -7.1 | ||
| No | 541 (23.3%) | 799 (26.9%) | 1340 (25.3%) | 7.1 | ||
| Missing | 215 (9.2%) | 199 (6.7%) | 414 (7.8%) | -9.4 | ||
| If Foundry Were Not Available, Youth Would Have Gone to: | < 0.0001 | |||||
| Family/friends | 578 (24.8%) | 586 (19.7%) | 1164 (22.0%) | -15.3 | ||
| Emergency | 19 (0.8%) | 100 (3.4%) | 119 (2.2%) | 18.1 | ||
| Other clinical services | 405 (17.4%) | 372 (12.5%) | 777 (14.7%) | -16.2 | ||
| Mixed/multiple | 428 (18.4%) | 518 (17.4%) | 946 (17.8%) | -4.7 | ||
| Other | 58 (2.5%) | 64 (2.2%) | 122 (2.3%) | -3.0 | ||
| No one | 612 (26.3%) | 1155 (38.8%) | 1767 (33.3%) | 25.7 | ||
| Missing | 226 (9.7%) | 180 (6.1%) | 406 (7.7%) | -13.6 | ||
| Reason for Visit | < 0.0001 | |||||
| Alcohol/drugs | 53 (2.3%) | 83 (2.8%) | 136 (2.6%) | 3.1 | ||
| Eating/nutrition | 39 (1.7%) | 28 (0.9%) | 67 (1.3%) | -6.6 | ||
| Family | 91 (3.9%) | 56 (1.9%) | 147 (2.8%) | -12.4 | ||
| Finances | 11 (0.5%) | 10 (0.3%) | 21 (0.4%) | -2.2 | ||
| Housing | 14 (0.6%) | 30 (1.0%) | 44 (0.8%) | 4.5 | ||
| My feelings (stress, anxiety, depression) | 1506 (64.7%) | 2184 (73.4%) | 3690 (69.6%) | 17.6 | ||
| Physical health | 174 (7.5%) | 100 (3.4%) | 274 (5.2%) | -19.1 | ||
| Relationships | 61 (2.6%) | 49 (1.6%) | 110 (2.1%) | -7.0 | ||
| School/work | 45 (1.9%) | 20 (0.7%) | 65 (1.2%) | -11.3 | ||
| Sexual health | 115 (4.9%) | 73 (2.5%) | 188 (3.5%) | -13.0 | ||
| Otherd | 171 (7.4%) | 315 (10.6%) | 486 (9.2%) | 11.1 | ||
| Missing | 46 (2.0%) | 27 (0.9%) | 73 (1.4%) | -9.0 | ||
| Service Type (First Visit) | < 0.0001 | |||||
| Any sexual health | 85 (3.7%) | 72 (2.4%) | 157 (3.0%) | -7.2 | ||
| Any physical health | 227 (9.8%) | 199 (6.7%) | 426 (8.0%) | -11.2 | ||
| Any MHSU | 559 (24.0%) | 864 (29.0%) | 1423 (26.8%) | 11.3 | ||
| Walk-in counselling | 925 (39.8%) | 1149 (38.6%) | 2074 (39.1%) | -2.4 | ||
| Navigation | 47 (2.0%) | 68 (2.3%) | 115 (2.2%) | 1.5 | ||
| Social services | 31 (1.3%) | 38 (1.3%) | 69 (1.3%) | -0.5 | ||
| Youth peer support | 56 (2.4%) | 73 (2.5%) | 129 (2.4%) | -1.0 | ||
| Groups | 21 (0.9%) | 24 (0.8%) | 45 (0.8%) | 1.0 | ||
| >2 Service types incl. MHSU | 301 (12.9%) | 402 (13.5%) | 703 (13.3%) | 1.7 | ||
| >2 Service types not incl. MHSU | 70 (3.0%) | 82 (2.8%) | 152 (2.9%) | -1.5 | ||
| Missing | < 5 | < 5 | 8 (0.2%) | NA | ||
| Day of Week of First Visit | 0.0289 | |||||
| Monday | 371 (16.0%) | 491 (16.5%) | 862 (16.3%) | 1.5 | ||
| Tuesday | 580 (24.9%) | 781 (26.3%) | 1361 (25.7%) | 3.0 | ||
| Wednesday | 539 (23.2%) | 734 (24.7%) | 1273 (24.0%) | 3.5 | ||
| Thursday | 617 (26.5%) | 665 (22.4%) | 1282 (24.2%) | -9.7 | ||
| Friday | 217 (9.3%) | 302 (10.2%) | 519 (9.8%) | 2.8 | ||
| Saturday or Sunday | < 5 | < 5 | < 5 | NA | ||
| Season of First Visit | 0.9165 | |||||
| Autumn | 717 (30.8%) | 926 (31.1%) | 1643 (31.0%) | 0.6 | ||
| Winter | 670 (28.8%) | 859 (28.9%) | 1529 (28.8%) | 0.2 | ||
| Spring | 438 (18.8%) | 572 (19.2%) | 1010 (19.1%) | 1.0 | ||
| Summer | 501 (21.5%) | 618 (20.8%) | 1119 (21.1%) | -1.9 | ||
aSMD score over 0.1 (or d ≥ 10%)is (in bold) considered a clinically relevant difference between the two groups
bChi-square p-values of < 0.05 (in bold) indicate statistical significance which are presented in bold
cPre-pandemic only group is defined by any and all visits occurring before March 1, 2020, and post-pandemic visit is defined by any first visit and subsequent visits occurring after March 1, 2020
dOther category includes all of above, ADHD, birth control, ‘gender issue’, mental health related
Across both single-visit and multiple-visit youth, those reporting past-month SI had substantially higher distress scores than youth reporting never experiencing SI (Table 4). Among youth with a single IYS visit, 80.7% of the past month SI group had K10 scores over 30 compared with 36.0% of the never SI group. Similarly, among youth with multiple visits, 79.9% of the past month SI group had K10 scores over 30 as compared to 39.5% of the never SI group. These findings suggest that elevated distress among youth reporting SI was consistent regardless of whether youth had only one visit or multiple visits with IYS. Youth with past-month SI were more likely to access any MHSU services as compared to those never reporting SI, regardless of having a single visit (32.3% vs. 27.1%, respectively) or multiple visits (27.8% vs. 22.1%). Youth with past-month SI were also more likely to report “other” reasons for their visit, which reflected a range of intersectional needs such as mental health concerns, attention-deficit hyperactivity disorder (ADHD), ‘gender issue’, birth control, or selecting “all of above”.
Table 4.
Service use characteristics of the first visit by single visit users vs. multiple visit users among youth with “past month” SI and never reporting SI at Foundry (2018–2023)
| Only Visited Once | Multiple Visits (First Visit) | ||||
|---|---|---|---|---|---|
| Never SI (n = 900) |
“Past Month” SI
(n = 831) |
Never SI (n = 1,426) |
“Past Month
” SI
(n = 2,144) |
||
| Gender Identity | |||||
| Female | 468 (52.0%) | 477 (57.4%) | 805 (56.5%) | 1211 (56.5%) | |
| Male | 400 (44.4%) | 267 (32.1%) | 526 (36.9%) | 604 (28.2%) | |
| Gender diverse | 28 (3.1%) | 81 (9.7%) | 86 (6.0%) | 315 (14.7%) | |
| Prefer not to answer | < 5 | < 5 | 9 (0.6%) | 14 (0.7%) | |
| Prior MHSU Services in Last Year | |||||
| Yes | 139 (15.4%) | 285 (34.3%) | 348 (24.4%) | 1007 (47.0%) | |
| No | 642 (71.3%) | 405 (48.7%) | 859 (60.2%) | 796 (37.1%) | |
| Not sure | 113 (12.6%) | 137 (16.5%) | 204 (14.3%) | 327 (15.3%) | |
| Missing | 6 (0.7%) | < 5 | 15 (1.1%) | 14 (0.7%) | |
| Medication Use | |||||
| Yes | 230 (25.6%) | 325 (39.1%) | 466 (32.7%) | 957 (44.6%) | |
| No | 586 (65%) | 434 (52.2%) | 843 (59.1%) | 1089 (50.8%) | |
| Missing | 84 (9.3%) | 72 (8.7%) | 117 (8.2%) | 98 (4.6%) | |
| K10 Score Categories | |||||
| No distress (10) | 10 (1.1%) | < 5 | 7 (0.5%) | < 5 | |
| Low distress (11–15) | 87 (9.7%) | < 5 | 82 (5.8%) | 9 (0.4%) | |
| Moderate distress (16–21) | 164 (18.2%) | 11 (1.3%) | 223 (15.6%) | 38 (1.8%) | |
| High distress (22–29) | 258 (28.7%) | 93 (11.2%) | 429 (30.1%) | 208 (9.7%) | |
| Very high distress (30+) | 324 (36.0%) | 671 (80.7%) | 563 (39.5%) | 1712 (79.9%) | |
| Missing | 57 (6.3%) | 54 (6.5%) | 122 (8.6%) | 177 (8.3%) | |
| Service Type | |||||
| Any sexual health | 8 (0.9%) | < 5 | 77 (5.4%) | 71 (3.3%) | |
| Any physical health | 80 (8.9%) | 21 (2.5%) | 147 (10.3%) | 178 (8.3%) | |
| Any MHSU | 244 (27.1%) | 268 (32.3%) | 315 (22.1%) | 596 (27.8%) | |
| Walk-in counseling | 409 (45.4%) | 396 (47.7%) | 516 (36.2%) | 753 (35.1%) | |
| Navigation | 15 (1.7%) | 8 (1.0%) | 32 (2.2%) | 60 (2.8%) | |
| Social services | 6 (0.7%) | 11 (1.3%) | 25 (1.8%) | 27 (1.3%) | |
| Youth peer support | 22 (2.4%) | 21 (2.5%) | 34 (2.4%) | 52 (2.4%) | |
| Groups | < 5 | < 5 | 21 (1.5%) | 22 (1.0%) | |
| >2 Service types incl. MHSU | 97 (10.8%) | 85 (10.2%) | 204 (14.3%) | 317 (14.8%) | |
| >2 Service types not incl. MHSU | 18 (2.0%) | 16 (1.9%) | 52 (3.6%) | 66 (3.1%) | |
| Missing | < 5 | < 5 | < 5 | < 5 | |
| Reason for Visit | |||||
| Alcohol/drugs | 23 (2.6%) | 25 (3.0%) | 30 (2.1%) | 58 (2.7%) | |
| Eating/nutrition | 17 (1.9%) | 7 (0.8%) | 22 (1.5%) | 21 (1.0%) | |
| Family | 41 (4.6%) | 17 (2.0%) | 50 (3.5%) | 39 (1.8%) | |
| Finances | 6 (0.7%) | < 5 | 5 (0.4%) | 7 (0.3%) | |
| Housing | 6 (0.7%) | 11 (1.3%) | 8 (0.6%) | 19 (0.9%) | |
| “My feelings” (stress, anxiety, depression) | 590 (65.6%) | 645 (77.6%) | 916 (64.2%) | 1539 (71.8%) | |
| Physical health | 63 (7.0%) | 18 (2.2%) | 111 (7.8%) | 82 (3.8%) | |
| Relationships | 27 (3.0%) | 12 (1.4%) | 34 (2.4%) | 37 (1.7%) | |
| School/work | 21 (2.3%) | 6 (0.7%) | 24 (1.7%) | 14 (0.7%) | |
| Sexual health | 27 (3.0%) | 7 (0.8%) | 88 (6.2%) | 66 (3.1%) | |
| Othera | 65 (7.2%) | 76 (9.1%) | 106 (7.4%) | 239 (11.1%) | |
| Missing | 14 (1.6%) | < 5 | 32 (2.2%) | 23 (1.1%) | |
Gender data categories are listed as described in the data source; Demographics data obtained from self-reported health survey during initial visit. Gender diverse includes trans female, trans male, non-binary, agender, Two-Spirit, and “not sure/questioning; Kessler Psychological Distress Scale (K10) scores are scored on a scale of 10–50, with a higher score indicating higher levels of distress. Mental health (MH) care need is defined according to the following question on the health survey: “do you have other significant psychological, behavioral, or personal problems that you want treatment for or help with? (Y/N)”
aFor Reason for Visit, the “Other” category includes all of above, ADHD, birth control, ‘gender issue’, mental health related
Trends in proportion of past-month SI
Monthly prevalence of past-month SI averaged about 38% overall and remained relatively stable for most subgroups, within a 5–10% range over the study period, with modest increases from 2021 to 2023 (see Fig. 1). Significant within-group differences were observed for sex/gender (p < 0.0001) and sexual orientation (p < 0.0001) over the study period. Among females, the prevalence of past-month SI declined from around the onset of COVID-19 pandemic (March 2020) until the final year of observation, when it began to rise again. Gender diverse youth consistently had the highest prevalence (~ 42%), with little change over time. Youth identifying as LGBTQ+ also had a higher prevalence than heterosexual youth (~ 43% vs. ~35%), with both groups showing minimal variation in the last two years of the study period.
Fig. 1.
Monthly proportion of new unique youth with past-month SI who completed survey, overall and by subpopulations from 2018–2023 at Foundry. A Overall; B Age Group 12–14, 15–18, and 19–24 years old; C Sex/Gender* (Female vs. Male vs. Gender Diverse); and (D) Sexual Orientation (Heterosexual vs. LGBTQ+). Chi-square p-values of < 0.05 indicate statistical significance. Note: Gender data categories are listed as described in the data source.
Discussion
Summary of findings
Timely access to effective mental health care services is critical, yet many youth experiencing suicidality can face barriers to care [36]. This study addresses a key gap in the literature by examining characteristics and service use among a subsection of youth reporting SI in an IYS initiative. By leveraging five years of service and survey data, our findings offer insight into how IYS models are engaging youth experiencing SI. We also found marked demographic and social differences among these youth, including a higher representation of gender and LGBTQ+ youth, and those facing socioeconomic vulnerability (e.g., unemployment, insecure housing). These findings align with prior research highlighting that equity-deserving youth are at increased risk for suicidality and are more likely to encounter barriers to care [37, 38]. Notably, we showed that youth with past-month SI access multiple service types including MHSU supports within their initial visits, reflecting both the severity of need and potential service responsiveness.
Service utilization patterns among suicidal youth
Our findings are consistent with other literature that certain equity-deserving groups are disproportionately impacted by SI [4]. However, our data suggest a promising narrative that this subsection of youth who report SI and access IYS are actively engaging in help-seeking behaviors. Our findings revealed early signals of the well-documented “gender paradox” in suicidality, whereby women are more likely to report SI and attempts than men, although men are more likely to die by suicide [39, 40]. To build on this, we show that males not only reported lower rates of SI, but also accessed services less frequently and were less likely to return to Foundry after an initial visit. These findings underscored the need to engage boys and young men in mental health care through targeted approaches.
Youth reporting past-month SI also presented with much higher levels of psychological distress (via K10 scores), a greater perceived mental health need, and accounted for nearly twice the number of total IYS visits compared to youth without a history of SI. These patterns suggest that Foundry may be successfully engaging youth at earlier stages of suicide risk, while also demonstrating an overall higher demand on the IYS initiative. High distress scores may also serve as important clinical indicators for service providers at Foundry, even when SI may not be explicitly disclosed in health surveys.
Integrated approaches to suicide prevention
Addressing underlying distress through integrated, youth-centered care offers a meaningful opportunity to intervene early and respond to the intersecting health and social needs that often accompany suicidality [41]. Integrated care models, like IYS, are increasingly recognized as a promising approach to suicide prevention [42–44]. While evidence on their long-term impact remains limited, our findings suggest that IYS may play a critical role in identifying and supporting youth experiencing SI. The high prevalence of youth presenting with recent or any lifetime history of SI underscores both the mental health needs of youth accessing these services and the potential of IYS to serve as a key entry point for intervention. Recent evidence from an Australian-based IYS initiative similarly found nearly a quarter of all youth present with suicidality, although it is rarely presented as their primary concern upon visit [45].
Our study findings also support an existing body of literature indicating that youth experiencing SI are often high utilizers of health services, particularly within the year preceding a suicide attempt or death [11–14]. Importantly, the prevalence of SI reported in this IYS study cohort was much higher (35.6% for past month; 72.1% any lifetime history) than that in population-based surveys (18% among youth in B.C. annually [4]). While estimates are not representative of the overall youth population accessing Foundry services, there is an overrepresentation of certain subpopulations, including gender diverse and other equity-deserving groups, who remain underrepresented in traditional care systems. Although trends remained relatively steady overall during the study period, we found persistently high proportions of past-month SI among certain groups including gender diverse and LGBTQ+ youth, underscoring the need for ongoing monitoring. These findings highlight the importance of IYS in expanding access, early detection, and tailoring care to the complex needs underlying suicide risk.
Study implications and future work
This study provided an important foundation for understanding how this cohort of youth experiencing SI engage with an IYS initiative (Foundry). The high prevalence of SI among these youth accessing IYS highlights the urgency of embedding evidence-informed suicide care within these settings. Our findings underscore the need for provider training in suicide risk assessment and culturally safe practices tailored to diverse youth populations. By identifying patterns of service use among this population, our work calls on efforts to strengthen early intervention, improve the responsiveness of IYS models, and guide future research on how IYS models can best support youth presenting with suicidality. While one study found that there is a general acceptability of the IYS model among youth in Canada [19], emerging evidence suggests that youth presenting with higher mental health acuity require tailored services to address complex emotions and stigmatization [46]. Suicide prevention efforts have been especially challenged due to barriers related to stigma, in addition to a lack of interventional strategies tailored to youth [47, 48]. An important area for future research is to explore whether the IYS model is effective in reducing social stigma associated with access to services for suicide-related concerns, and whether access to services improves health outcomes over time. Culturally-responsive and youth-driven initiatives that emphasize stigma reduction, community awareness and outreach, and positive youth development are all tangible and meaningful ways demonstrated to promote youth wellness [49, 50].
As part of our commitment to culturally safe and equity-informed research, we acknowledge that race and ethnocultural identity were not included in the present analysis. This decision was made intentionally after careful consideration with Foundry network partners and leaders, recognizing the need for deeper community engagement to ensure these data are interpreted in ways that are meaningful, safe, and do not perpetuate harm. Specifically, we recognized that reporting the race/ethnicity in isolation masks underlying causes of disparities such as colonialism, racism, and other systemic inequities that disproportionately impact racialized communities. Future work will prioritize partnerships with Indigenous and racialized communities to co-develop analyses that center context, lived experience, and data sovereignty principles such as First Nations Principles of Ownership, Control, Access, and Possession (OCAP®).
Strengths and limitations
A primary strength of this study was the availability of youth-reported health survey and linked service utilization data from a large cohort of service-engaged youth in B.C. Given the large sample size, we were able to examine service patterns by subgroups and trends across the five-year study period.
However, there were also several limitations that warrant caution in the interpretation of our findings. Most importantly, our final analytic cohort comprised of less than a quarter of the overall Foundry client population based on the voluntary nature of survey collection (8,347 of the 33,471 visitors; Appendix Fig. 1), which introduces selection bias. We compared the demographic distribution of these groups using the variables available in the demographic survey, which all visitors complete, and found that our analytic cohort was overall slightly younger and had high levels of distress (Appendix Table 4). This may suggest that youth who completed all intake surveys, including the suicide-related question, represent those with greater mental health concern or care needs and were not fully representative of the Foundry IYS population.
Next, the cross-sectional nature of the self-reported survey data limits our ability to track individual changes in service use or health outcomes over time. While service visit data (i.e., EOV forms) allowed us to examine repeated contacts for some youth, these were not longitudinally linked to track shifts in demographics and health outcomes over time. Instead, analyses focused on aggregated patterns, enabling us to assess overall trends in the monthly proportion of youth presenting with SI across the study period. Additionally, our measure of service visit frequency (means, medians), does not adequately represent individual-level patterns of use as many youth enter and exit the cohort at different time points throughout the study period. However, these findings still provide valuable insight into overall service utilization across the study period.
Our cohort represents help-seeking individuals within an IYS initiative in a single Canadian province and is not generalizable to all youth living in B.C. or Canada. For example, youth who access IYS may have increased awareness or knowledge around mental health reporting (especially suicide) compared to the general youth population in B.C. We see this reflected in the high prevalence of youth with lifetime SI within this sample (72.1%) relative to population-level prevalence estimates in B.C. (18% overall) [4]. Service modality data (i.e., virtual vs. in-person) is currently unavailable for this population, which may lead to a further underrepresentation of youth subgroups who require higher accessibility to IYS via remote services. It is also important to recognize that youth experiencing acute mental health crises (and co-occurring conditions) may seek or be directed to services outside of IYS, including involuntary hospitalizations, which may interrupt or prevent intended service engagement within IYS and would therefore not be captured in our data.
Self-reporting of suicidal behaviors may also be underreported due to stigma or social desirability bias [51], particularly among youth, which could lead to an underestimation of SI prevalence. Youth who chose to complete survey data during visits may also have differed systematically from those who did not. As a result, the analytic cohort reflects a non-random, self-selecting sample of youth accessing Foundry services, and findings should be interpreted as a service-engaged population rather than representative of all youth living in B.C.
The use of a single-item measure of SI limits our ability to fully assess youth suicide risk. While additional questions are currently not collected as part of routine clinical data at Foundry, a more comprehensive assessment (e.g., including items on suicidal planning, attempt history, or intent) would better measure levels of risk and inform care decisions. Incorporating validated tools for youth such as the Ask Suicide-Screening Questions (ASQ) Toolkit [51] and the Columbia-Suicide Severity Rating Scale (C-SSRS), could strengthen risk assessment in future IYS data collection and improve quality of clinical decision making. Furthermore, we were limited in our understanding of other clinical subgroups of youth impacted by suicide (e.g., bipolar, or depressive disorders) due to lack of data availability and were unable to assess how suicide may be associated with other mental health conditions.
Finally, we did not have access to linked province-level health administrative data and were unable to assess how youth accessing IYS may also be accessing and utilizing other health services, including emergency care, hospitalizations, and primary care. These broader service patterns are essential for understanding youth pathways or potential barriers to care and remain a key priority for future research.
Conclusions
This is one of the first studies to describe characteristics of youth reporting SI within an IYS setting. Our findings indicated that many youth seeking services through IYS have reported having SI, indicating a major opportunity for early intervention. Our findings underscore the need for culturally safe and youth-centered care for those disproportionately impacted by suicide.
Supplementary Information
Acknowledgements
We would like to thank the youth and family/caregiver engagement team at Foundry who thoroughly reviewed the study and assisted with the co-interpretation of these results. We are also grateful to our community partners, specifically to Toni Carlton, Dr. Harmony Johnson and Dr. Gabrielle Legault for their expertise and guidance, which informed our approach to reporting findings related to race, ethnicity, and equity in the context of suicide. Artificial Intelligence (AI) was not used in the preparation of this manuscript.
Authors’ contributions
KGH led the study conception and design, conducted data interpretation, and drafted the manuscript. GL conducted the statistical analyses and contributed to data interpretation and manuscript revision. KM supported project management, data acquisition, and manuscript revision. AG contributed to study supervision, data interpretation, and critical manuscript revision. JMS and EJ contributed to study supervision, interpretation of findings, and manuscript revision. SPB provided senior supervision, contributed to study design and interpretation, supported data acquisition and funding, and critically revised the manuscript. All authors reviewed and approved the final manuscript.
Funding
This study was funded by the Canadian Institutes of Health Research (#W12–179949). Funders did not have any role in the study design, analysis of data, interpretation of results, or writing of the manuscript.
Data availability
Foundry data contain sensitive health and personal information, including from minors, and the ethics permission for this study and consent procedures used for collecting data restrict data access only to individuals who meet the criteria for access. Hence, no data are available due to ethical and legal restrictions. To gain access to the Foundry data used in this study, researchers would need to go through Foundry’s Data Access Request process which can be initiated by emailing data@foundrybc.ca.
Declarations
Ethics approval and consent to participate
Research ethics approval was obtained by the University of British Columbia/Providence Health Care Research Ethics Board (H21-01510). Participants voluntarily consent to the data being used for research purposes by indicating they have read and understood the purpose of the survey and how data are collected, stored, and reported.
Consent for publication
Not applicable, no individual personal data are reported, only aggregated data (i.e., data cannot be linked in any way back to an individual person).
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Foundry data contain sensitive health and personal information, including from minors, and the ethics permission for this study and consent procedures used for collecting data restrict data access only to individuals who meet the criteria for access. Hence, no data are available due to ethical and legal restrictions. To gain access to the Foundry data used in this study, researchers would need to go through Foundry’s Data Access Request process which can be initiated by emailing data@foundrybc.ca.