Background
In recent years, mental health among adolescents has received considerable attention as a public health concern that is important to address both internationally and in Norway [
1‐
4]. Since the 1986 Ottawa Charter for Health Promotion [
5], the focus of public health has shifted from disease prevention only to including health promotion. Scholars advocate for the importance of appropriate attention to mental health within the field of health promotion [
6]. Like health promotion, mental health promotion involves the process of enabling people to increase control over, and improve their mental health; supporting people in adopting and maintaining healthy lifestyles. It seeks to foster and support individual and social resources, competencies and psychological strengths to benefit mental health and wellbeing, complementary to a focus on preventing mental disorders [
7]. What mental wellbeing is or involves is often considered a highly individual matter; it can be argued to be an individual preference. However, there are known commonalities that are important for mental wellbeing. In the current study, Clarke et al.’s definition is the basis for the understanding of mental wellbeing: “a positive and sustainable mental state that allows individuals to thrive and flourish” ([
2,
8], p.).
Adolescents constitute an important population from a public health perspective. Adolescents are expected to acquire knowledge and abilities that will be important for their eventual development into a healthy adult population that can assume adult roles in society. Adolescence is considered a vital transitional period in life that is associated with challenges as well as opportunities for growth, development and health promotion [
9]. Furthermore, adolescence is a critical phase for building a foundation for a future healthy population [
10,
11]. Because approximately 20% of adolescents report that mental health problems affect their daily life [
1,
2], adolescence is an important period in the life course for public health strategies addressing mental health. Public health work strategies and programs that promote good mental health also help to prevent mental illness [
12]. Hence, the promotion of good mental health and the prevention of mental illness are considered complementary strategies.
Health literacy is emphasized as an important social determinant for equity in health and is considered necessary for participation in health promotion activities. Broadly speaking, health literacy involves the ability to make sound health decisions [
13] and is often studied as an outcome of health education [
14]. Mental health literacy (MHL) originates in health literacy and is an emergent area of research in the field of health promotion. It has been identified as an important determinant of both individual and public mental health [
15‐
19]. MHL refers to an individual’s knowledge and ability required to make sound mental health decisions in everyday life [
16]. MHL is a relatively new concept in health promotion research, and multiple definitions and models have been identified [
20]. Recently, MHL has been defined by Kutcher et al. as consisting of the following four components:
“(1) Understanding how to obtain and maintain good mental health; (2) understanding mental disorders and their treatments; (3) decreasing stigma related to mental disorders; and (4) enhancing help-seeking efficacy (knowing when, where and how to obtain good mental health care and developing competencies needed for self-care)” [
17].
The first component of MHL in Kutcher et al.’s definition is referred to in this study as positive MHL (1), understanding how to obtain and maintain good mental health. This component (1) is essential from a health promotion perspective in which the focus is on knowledge of good mental health rather than on mental disorders. Previous research investigating MHL has mainly focused on the three latter components in Kutcher et al.’s definition: the recognition of mental disorders; help-seeking efficacy and help-seeking strategies (e.g., [
16,
18,
21‐
24]). Among adolescents, positive associations have been found between low MHL and mental illness, particularly anxiety and depression [
25]. To the best of the authors’ knowledge, only one study has investigated the relationship between MHL and mental wellbeing. In that study, positive MHL demonstrated a significant and positive relationship with mental wellbeing [
26].
Adolescents spend a large amount of their time at school, and universal mental health promotion in the school setting using a whole school approach is recognized as particularly effective for mental health promotion in this population [
27,
28]. School health services represent an essential part of the whole school approach and play an important role in the field of public health by providing easy access and universal healthcare services to the adolescent population [
29,
30]. School nurses within school health services are uniquely positioned and are expected to promote good mental health at the population level, provide mental health education, and address diverse health problems in the adolescent population [
29,
30].
Several school-based programs aimed at mental health promotion are available internationally [
28] and in Norway [
31]. On behalf of the Norwegian Directory of Health, the Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU North) identified and described six interventions available for Norwegian schools that target mental health promotion and have “sufficient documentation of an effect” (“Respekt”, “VIP”, “Venn1”, “Alfa”, “Zippys venner”, “Olweus”, and “PALS”) [
31]. None of these identified programs have been found to address the role of school health services or school nurses in mental health promotion. Furthermore, the intervention “Mental health for everyone” is designed to promote MHL among Norwegian adolescents; however, it is only labeled “probably effective” according to RKBU’s systematic reviews [
31]. In one study, “Mental health for everyone” had a positive impact on adolescents’ MHL by increasing recognition of mental disorders, prejudice and knowledge regarding where to seek help [
21]. Positive MHL was not included in the study and has not been identified in any studies addressing MHL. There is an explicit need for research that investigates the effectiveness of school-based MHL programs [
18].
MEST – a school-based MHL working strategy for school health services
Consistent with national regulations and professional guidelines [
29,
32], and with financial support from the Norwegian Directory of Health, school health services in Trondheim, Norway, have developed and implemented a universal health education working strategy in upper secondary schools named MEST. MEST has a salutogenic foundation. It was developed in 2014 and has not been previously described or evaluated. The core aim of MEST is to increase adolescents’ positive MHL and to provide resources for mental wellbeing by focusing on adolescents’ assets and the promotion of personal and contextual factors for
good mental health. MEST offers open school seminars, classroom seminars and smaller group discussions with adolescents and is based on voluntary student participation. Thus not all students at a school offering MEST will have participated in MEST. School health services deliver targeted seminars and discussion groups throughout the school year based on the results of an anonymous digital survey that is completed by students at the beginning of each school year. The seminar topics may include, but are not limited to, normal emotional variations, sleep hygiene, stress management, relaxation techniques, body image, self-esteem, and aspects related to autonomy (e.g., making decisions based on one’s own will and recognizing personal limits).
Although the seminars provided at each school may differ, these seminars are based on a common framework that includes the following: 1) a theoretical understanding of the seminar topic, 2) practical age-appropriate examples, and 3) providing adolescents with at least one specific and useful tool related to the subject of the seminar (Holmen N. Description of MEST: a work strategy for school nurses in mental health promotion among adolescents. 2016. Personal written and oral communication, recipient: HN Bjørnsen, 2016 document). MEST differs from previous interventions that aim to promote mental health in schools, such as “Mental health for everyone” [
21], because MEST is a systematic work strategy that focuses on promoting
good mental health and coping with normative stressors and emotional variations instead of preventing mental disorders.
Given the increase in mental health problems in the adolescent population and the importance of mental health promotion initiatives at school, the identification, implementation and evaluation of effective mental health interventions are essential [
33]. The recognition of school health services as an important component in a whole school approach highlights the importance of evaluating mental health-promoting actions initiated by school health services. An initial assessment of MEST is important to determine whether further investment in more rigorous studies of this work strategy is worthwhile. Moreover, further appraisal of whether MEST has the potential for continued evolvement and implementation as a preferred way of systematizing school health services’ mental health-promoting work is important, both for advancing evidence-based practices and for documenting the outcomes of new mental health promotion initiatives.
Aim
The aim of this study was to investigate the potential outcome mean (POM) differences in positive MHL and mental wellbeing between adolescents who participated in MEST and adolescents who did not participate in MEST.
Acknowledgments
The authors would like to thank Professor Roger Brown for statistical assistance and Mr. Kyrre Svarva for assistance in the research process of scanning and preparing the data for analysis. This manuscript was written while the first author was a visiting scholar at the University of Wisconsin-Madison, and the authors would like to thank Professor Susan Zahner and her research team for their valuable professional input and support during the manuscript writing process. We would also like to thank Nina Stiklestad Holmen for constructive discussions concerning MEST and feedback. We extend our thanks to our funders, the Research Council of Norway (grant number 238331) and the Norwegian University of Technology and Science. Finally, we would like to express our gratitude to the adolescents who participated and generously contributed their time, the teachers for their valuable help administering the questionnaire, Trondheim municipality BFT Heimdal and Trøndelag Authority County for their collaboration and the project leaders of “Health Promotion – Worthwhile? Reorienting the Community Health Care Services”, Professor Gørill Haugan and Professor Toril Rannestad.