We employed Concept Mapping (CM), an integrated mixed-method approach combining qualitative data collection with quantitative data analysis. This approach enables a diverse group of stakeholders to qualitatively articulate their ideas and subsequently quantitatively sort and rate them, allowing for statistical analysis and visualisation of relationships between the identified measures. CM is a robust method for assessing how study participants cluster their conceptual understanding of a given topic by constructing a conceptual framework and visually displaying the clustering [12]. It facilitates the mapping of complex concepts that may not be explicitly identified by participants [13]. Moreover, CM supports a participatory approach by actively involving stakeholders and empowering specific groups, such as frontline workers, while presenting results in a manner accessible to diverse audiences.

The CM case study was conducted in the eastern part of Slovakia, primarily in Kosice, the country’s second-largest city. This location was selected because of the availability of comprehensive care services for adolescents with EBP and the research team’s established personal contacts in the area, which significantly facilitated field access. To ensure a diverse range of perspectives and enhance the generalizability of the conceptual framework, we recruited participants according to the guidelines of [12, 14]. A purposive sampling technique was utilized to select stakeholders representing various hierarchical levels across the three main care categories: preventive-counselling, social care, and healthcare.

A total of 40 stakeholders were initially approached, of whom 33 consented to participate (response rate: 82.5%). Non-participants were predominantly from managerial positions, citing workload as the primary reason for declining participation. The final sample included representatives from 17 institutions, comprising psychologists, special needs educators, educational counsellors, social workers, and child psychiatrists. All participants were female, reflecting the predominantly feminized nature of the sectors involved. Participants' ages ranged from 25 to 65 years. The sample sizes at each stage of CM (brainstorming: 25, sorting/rating: 33, interpretation: 23) were deemed sufficient to meet statistical validity and reliability criteria [15]. Table 1 provides an overview of the number and type of participants (and institutions) based on their participation in particular phases of the CM case study (brainstorming, sorting/rating, interpretation), see next section.

The CM process was conducted between November 2018 and November 2019 and followed five structured steps as outlined by [14]: preparation, brainstorming, sorting and rating, analysis, and interpretation.

Based on performed sorting, we obtained a final 5-cluster solution (see Figure 1): Cluster 1 - Increasing the competencies, possibilities and opportunities for providers and institutions in the system of care, Cluster 2 - Changes at the level of the school and the school system, Cluster 3 - Support for existing services targeting adolescents and families, Cluster 4 - Increasing the transparency and functionality of the system of care at the level of institutions and public administration, and Cluster 5 - Modification and creation of legislative conditions in the system of care for adolescents with EBP. The stress index of 0.233 indicates a strong fit between this cluster map and the data. Typically, the stress index in concept mapping should be between 0.10 and 0.35 according to [14].

Based on participants’ rating, out of 43 proposed measures and interventions, we identified 13 which were rated as highly urgent but not yet feasible and could, according to participants, expose serious barriers that may prevent action (Table 2). Identified measures belong to all 5 clusters. The highest number belongs to Cluster 2 (Changes at the level of the school and the school system), Cluster 4 (Increasing the transparency and functionality of the system of care at the level of institutions and public administration) and Cluster 5 (Modification and creation of legislative conditions in the system of care for adolescents with EBP). During the interpretation step all measures rated as urgent but not feasible were discussed by participants. General consensus was, that even though identified 13 measures spanned all 5 clusters all of them were considered as similarly problematic and thus less feasible due to the need of legislative and/or systematic changes done on the national level which require political will, additional financial and personal resources and takes time.

A large proportion of the identified measures relates to the school system, including reform of educational structures, better teacher training, reduction of class sizes, and strengthening school-based teams. These findings confirm the central role of schools in addressing adolescents’ mental health. International evidence consistently identifies schools as key platforms for mental health promotion, prevention and early intervention [19]. However, the low ratings of feasibility that we found suggest that professionals perceive meaningful changes in schools as difficult to achieve. Findings from our previous qualitative study provide further insight into these challenges, showing that collaboration between schools and professionals is often limited, inconsistent, and dependent on individual initiative [8]. In addition, schools themselves often face capacity barriers, including high workload, lack of specialised staff and limited training in mental health [20–22]. Importantly, the identified measures should not be viewed solely as technical or organisational changes. The capacity of schools to support adolescent mental health is embedded in broader social and working conditions within the school environment [3, 21, 22]. Teacher workload and insufficient professional support may limit teachers’ capacity to recognise and respond to students’ difficulties [8, 20], while adverse school experiences, including schoolwork pressure and bullying, as well as socioeconomic inequalities, are associated with poorer mental health among adolescents [23, 24]. Thus, improving school-based mental health support requires attention not only to service structures and professional competencies, but also to the broader conditions in which students and school staff function. These findings suggest that meaningful school-based change requires broader systemic support and intersectoral cooperation. Beyond strengthening the capacity of schools to respond to adolescents experiencing EBP, emphasis could also be placed on universal mental health promotion as a complementary strategy. WHO [21] recommends universally delivered interventions covering social and emotional learning, with schools representing a suitable setting for such approaches. Universal school-based mental health promotion interventions can reach adolescents across populations while avoiding potential stigma. Evidence from Wang et al. [25] suggests positive effects of universal school-based interventions across various mental health domains. Such population-level approaches should not be viewed as substitutes for accessible specialised care, but as a part of a broader continuum of mental health promotion, prevention and treatment that may reduce the overall burden on already overstretched services.

Second, workforce-related measures were identified as highly urgent but not feasible. These include increasing staffing capacity, improving training, and recognising psychosocial care professionals as high-risk workforce. Such findings point to insufficient human resources as a main barrier in the system of care. Workforce shortages in mental healthcare are widely documented and represent a major barrier to service provision [8, 26]. An increasing demand for services, combined with limited capacity, places significant pressure on professionals and reduces the ability of systems to respond effectively. Workforce barriers are also closely linked to other barriers, such as limited time for collaboration, high workload, and reduced capacity to build relationships with clients, which may negatively affect the quality of care, continuity and interprofessional cooperation, as also reported in previous studies [8, 9, 27]. This suggests that strengthening workforce capacity is a necessary precondition for improving accessibility, continuity and quality of psychosocial care.

Third, a series of measures connected to system fragmentation were rated as highly urgent but not feasible, these focusing on improving coordination and continuity of care, and creation of multidisciplinary services. This suggests that fragmentation of services is perceived as one of the most critical, yet difficult to address, challenges. Our findings regarding insufficient interprofessional collaboration, limited information exchange, and unclear roles and responsibilities confirm previous research on relational barriers within psychosocial care systems [8, 28, 29]. The present case study extends these findings by identifying these barriers as areas perceived not only as highly urgent, but also as difficult to address in practice. At the system level, fragmentation has been identified as a major weakness of mental healthcare systems, particularly in contexts with limited integration across sectors [30]. Integrated and coordinated care models are therefore increasingly emphasised as a key strategy for improving accessibility, effectiveness and continuity of care [31, 32]. Importantly, fragmentation also affects relationships with clients. Previous findings indicate that discontinuity of care, involvement of multiple professionals and inconsistent communication may limit trust and engagement of adolescents and their families [8, 33]. These findings highlight that improving coordination and integration of services may be essential for building more continuous and trust-based care for adolescents and their families. To achieve this goal and to make intersectoral collaboration more feasible it is important to identify potential facilitators. According to systematic review by Cooper et al. [28], facilitators include regular communication across professional and services, joint interprofessional trainings, mutual understanding of services and professional roles, explicit protocols for intersectoral collaboration, designated link person and support from senior management. Together, these facilitators may help to move intersectoral collaboration from informal, person-dependent relationships towards more structured and sustainable forms of cooperation.

The measures identified as urgently needed but not yet feasible covered three different areas, but they all have one thing in common: the problematic implementation of policy-based changes, which require political will, additional financial and/or personal resources and time. Similar implementation barriers have also been described in previous research focusing on psychosocial care systems and perspectives of professionals [8, 34, 35]. The present findings extend this knowledge by showing that such barriers are perceived by professionals as highly urgent, while at the same time difficult to address in practice. First, policy changes regarding the national system of psychosocial care for adolescents usually comprise several ministries. The collaboration between these ministries has been found to be problematic and time-consuming, and to require lobbying [7, 34]. Second, implementation was perceived as less feasible when proposed changes required substantial additional financial resources, personal capacities, or organizational support that were not sufficiently available or allocated [7, 35]. Finally, changes often do not align with the reality as perceived and needs as articulated by people in practice resulting in low feasibility. Thus, care providers may perceive little or no control over the legislative conditions as these can only be changed through political processes. This gap between policy-level changes and the realities of practice may be reduced through a greater recognition of experiential knowledge and more meaningful stakeholder participation. This could be done via bottom-up approaches that actively involve stakeholders directly affected by the system, including professionals, service users and communities, whose experiential knowledge can help identify barriers, needs and opportunities for improvement and enhance the relevance, acceptability and sustainability of interventions [11, 36]. Co-production with young people and their families may recognise them as partners rather than solely as recipients of care. However, it should be realised that meaningful participation requires supportive organisational structures, recognition of experiential knowledge as legitimate expertise, and opportunities for involvement beyond consultation, including policy development, implementation and evaluation [37]. Taken together, these findings suggest that implementation barriers are deeply embedded at the policy and system level and cannot be addressed without long-term intersectoral and political commitment.

One of the crucial strengths of this study was the participatory approach where professionals from the system of care were given the opportunity to provide their insights and propose their solutions along with potential pitfalls in the improvement of the system of care for adolescents with EBP. Another strength is the use of concept mapping, which combines qualitative and quantitative procedures and allows for a structured identification and prioritisation of measures perceived as urgent but difficult to implement.

Several limitations should also be considered. First, the concept mapping methodology is based on subjective assessments of participants and may be prone to social desirability, although we have reduced this risk by creating the subgroup of managers during the brainstorming to minimize the impact of power relations. Second, we only included women in this study, which may have influenced the identified priorities and perceptions of feasibility. Third, the study intentionally focused on care providers; consequently, the findings reflect provider perspectives and do not capture the experiences and priorities of adolescents with EBP and their families. Fourth, as the study was conducted in eastern Slovakia, the findings reflect this specific regional context and should not be considered representative of the national system of psychosocial care. Although EBP was explicitly defined and discussed with participants before brainstorming, their understanding of the concept was not formally assessed; therefore, some variation in interpretation cannot be excluded. Finally, data were collected in 2018–2019, prior to the COVID-19 pandemic, which substantially affected adolescent mental health and psychosocial care systems. As a result, professionals’ perceptions of the urgency and feasibility of the identified measures, as well as the broader policy context, may have changed since data collection.

We found measures related to school systems, workforce capacity, and fragmentation of services to be perceived as highly urgent but not feasible, implying that improvement of psychosocial care for adolescents with EBP requires intersectoral collaboration across the education, social and health sectors, with clearly defined responsibilities. Policies should include explicit allocation of finances and personnel, otherwise implementation is likely to fail even if proposed measures or interventions are perceived as urgent. Incorporating practitioners’ perspectives and experiences can improve feasibility and relevance of the proposed changes, reducing the gap between policy and practice. Future research should examine these priorities from the perspectives of adolescents with EBP and their families, and across different regions of Slovakia.

Our case study identified a gap between the urgency and feasibility of key measures to improve psychosocial care for adolescents with EBP. Our findings point to interconnected challenges related to school systems, workforce capacity, and system fragmentation, all of which require coordinated, resource-supported policy action. Addressing these challenges is essential for developing a more accessible, integrated, and responsive system of care will require coordinated, system-level approaches and long-term commitment.