Promoting Adolescent Mental Health – Positive Mental Health Literacy as a Concept and Working Strategy for School Health Services

Summary Background: Mental health is an integral component of people’s health and wellbeing, and over the last years, adolescent mental health has received considerable attention as an important public health issue. Mental health literacy (MHL) is considered a significant determinant of mental health, with the potential to benefit both individual and public mental health. Research and practice have generally focused on mental ill-health; however, growing evidence shows the long-term benefits of promoting positive mental health. Positive MHL refers to people’s understanding of how to obtain and maintain good mental health. Health is created within the settings of adolescents’ everyday life; thus, schools represent an important arena for promoting adolescent mental health, and school health services are considered central in Norwegian municipalities' public health work. MEST 1 is a universal work and teaching strategy for school health services that aims to promote mental health by improving adolescents’ positive MHL and mental wellbeing. The aims of this thesis were to develop a measure assessing positive MHL among adolescents, investigate the relationship between positive MHL and mental wellbeing, and finally, begin the process of evaluating MEST. Methods: The participants were Norwegian upper secondary school students aged 15-21 years. The data were mainly collected by survey questionnaires, in addition to five focus group discussions (n=29) for the scale development. A pilot study (n=479) was conducted prior to the quantitative data collection at time one, i.e., fall 2016 (T1 n=1888), and the quantitative data collection at time two, i.e., spring 2017 (T2 n=1054), and a cohort (n=357) was followed from T1 to T2. Factor analysis was used for item reduction and assessment of the psychometric properties of the new measure. A linear regression model was used to investigate the relationship between positive MHL and mental wellbeing. Linear treatment effect modeling was used to estimate the average treatment effect of MEST and describe the observed statistical relationship between MEST participation and the levels of positive MHL and mental wellbeing between the MEST and non-MEST participants. Results: The confirmatory factor analysis yielded a satisfactory fit for a 10-item onefactor model referred to as the mental health-promoting knowledge measure, i.e., MHPK-10. Positive MHL was associated with mental well-being in the study population and found to be a significant explanatory variable of mental well-being (p ≤.01). Positive MHL was significantly increased among the MEST participants compared to that among the non-MEST participants (p = .02). No significant difference was found in mental wellbeing between the MEST and non-MEST participants (p = .98). According to the average treatment effect analyses, MEST resulted in a significant 2.7 % (p = .03) average increase in positive MHL in both genders and a 9.7 % (p = .03) average increase in mental wellbeing among the females. No significant treatment effect of MEST was found in mental wellbeing overall (p = .12) or among males (p = .99). Conclusions: The MHPK-10 measure of positive MHL is an important contribution to the literature on measuring MHL. Positive MHL has been identified as an important concept in mental health promotion work by school health services where a positive association was established between positive MHL and adolescents’ perceived mental health. The results supports positive MHL to be included as an integral part of school health services mental health promotion work. These results further support investments in evaluations of MEST as a potential evidence-based working strategy for school health services' mental health promotion work in Norwegian upper secondary schools