Mental Health Promotion in a School Community by Using the Results From the Well-Being Profile

Abstract

This article presents an action research project as a method to combine science and practical expertise in order to develop the practices of the health care system. The project aimed at developing mental health promotion in the school community in general and at finding tools for timely help when mental health is at risk. The underlying idea is that mental health is an integral part of health and by promoting general well-being it is also possible to promote and ensure mental health at school. The study was conducted in a Finnish lower secondary school of 446 pupils where the pupils are aged between 12 and 15 years. The initial survey was conducted using the School Well-being Profile, a tool developed by Anne Konu. A well-being questionnaire was used to identify the areas in need of improvement, providing the basis for planning and implementing development measures together with the local actors. The instrument proved to be a usable way of collecting feedback of the well-being of the school environment. As a result of the action research project, the school’s physical conditions and social relationships improved and appropriate practices for future problem situations were set.

Keywords

mental health promotion action research schoolchildren

Introduction

The article describes the development of a school community’s mental health promotion through action research and the use of School Well-being Profile as a tool. The aim of the study was to improve the school environment with different actors; the goal was to develop the school environment to be mental health promoting and also to build effective early initiative practices for situations in which one’s mental well-being is in danger. The school society is here dealt as a whole, single unit without separating various occupations of the school personnel. This article describes the development of a school community through action research and the use of School Well-being Profile as a tool. The place of study was a lower secondary school of a medium-sized Finnish municipality. All the schoolchildren from Grades 7 to 9 of the municipality attend this school.

Background Literature Review

Statistically, the biggest health issues of schoolchildren are related to mental health. Internationally, the estimated occurrence of adolescents’ mental health disorders ranges from 10% to 30%. The most important issues to do with teenagers’ mental health are depression, substance use, disturbances of attention, and eating disorders. Girls tend to have problems with dealing with their emotions, whereas the problems of boys can be seen as outbound behavior (Hootman & King, 2003; Pössel, Horn, Groen & Hautzinger, 2004; Rønning, Handegaaed, Sourander, & Mørch, 2004).

Alongside home, school is an essential environment of development for an adolescent. Not only does a school day form the basis of the adolescent’s use of time, but it is also the time during which one builds social relationships. In the present individuality-emphasizing culture, school offers a sense of community. Mutual responsibility, respect, trust, and interaction are common issues that pupils deal with in their everyday school life. The working environment of schools affects positively not only the social relationships and self-fulfillment but also the pupils’ well-being and mental health. Being bullied and discriminated against increases the odds for the pupil to face mental health problems later in life as a young adult (The Gatehouse Project, 2010; Pössel et al., 2004; Somersalo, Solantaus, &Almqvist, 2002).

The evidence of the benefits of mental health promotion for individuals, society, and the economy is strong. Mental health should be seen as a positive resource. A wide approach is needed to take both social and environmental factors into account (Geiger, Mauser-Galvin, Cleaver, Petri, & Winnail, 2002; Wand, 2011). Both the school environment and the curriculum have significance in the pupils’ overall health; they can influence their well-being in a positive way (Barry & Jenkins, 2007). The promotion of mental health is something in which the school society and the homes of the pupils should take a part (Barry & Jenkins, 2007, Browne, Gafni, Roberts, Byrne, & Majumdar, 2004; WHO [World Health Organization] European Commission, 2002). Schoolchildren are the main targets of mental health promotion, and thus they are key persons in the mental health promotion of the school society. Being heard and having an opportunity to improve one’s well-being have significance on one’s mental health (Barnekow et al., 2006; Konu, Lintonen, & Rimpelä, 2002).

Method

Strategies: The School Well-Being Profile

The School Well-Being Profile is a tool created in Finland that is used to measure well-being and provide parallel information and feedback on an individual level, on a pupil group level, and on a school level. The profile can also be used to support action research or intervention (Konu, Alanen, Lintonen, & Rimpelä, 2002; Konu & Lintonen, 2006).

The profile is based on Konu’s and Rimpelä’s (2002) well-being model (see Figure 1), which is founded on both sociological and pedagogical literature and health-promoting literature. Its basis is Allard’s sociological well-being model, and it merges learning, education, and teaching together. Well-being is divided into four categories: school conditions, social relationships, means for self-fulfillment, and health status. The important context of the model is the surrounding society: the pupils’ homes and school (Konu & Rimpelä, 2002).

Figure 1

Well-Being Model in School

The School Well-Being Profile consists of 80 structured questions, which are grouped into four sum variable categories in the following way (Konu & Lintonen, 2006).

School conditions: school surroundings such as classrooms, lavatories, school building, and school yard; organising of the teaching and the rules of the school; timetable, working pace, and required services such as health care

The social relationships in the school: relationships among the schoolchildren, between pupils and teachers, and between the school and the homes of the pupils; working in groups effectively and co-operation in the classroom; friends and getting along with them; the impartiality and friendliness of the teachers; the teachers’ interest in students’ well-being; bullying and being bullied; and parents’ interest in school and their cooperation

Means for self-fulfillment: appreciation for every individual’s work, opportunity to influence, the expectations of the teachers, following the teaching, doing the homework, finding individual ways of learning, doing independent schoolwork, getting help in studying and handling school-related problems, the encouragement of the teachers, and interesting electives and club activities

Health status: common colds, neck and shoulder aches, lower back aches, tension or nervousness, irritability or bursts of anger, sleeping difficulties, headache, and exhaustion and fatigue

Konu and Lintonen (2006) have used the instrument in Finnish schools in different grades and have found it applicable for measuring one’s mental health. Since it is a usable way of collecting information on the well-being of the school society, they also recommended its use as a device in development work (Konu & Koivisto, 2011; Konu & Lintonen, 2006; Lintonen & Konu, 2006).

The survey was conducted during a school day. The school nurse handed out the questionnaires and collected them after they were filled in. For technical reasons the Internet survey was not used; instead a printed paper version was used. The surveys were collected in sealed envelopes and sent straight to the researcher. The anonymity of the pupils was thus ensured. The survey, carried out as a part of a class, was taken by 423 of the 426 pupils present that day. The total number of students in the school was 446.

The parents of the pupils were informed of the execution of the Well-Being Profile. The research was endorsed with permission from the ethics committee of the hospital district and the Joint Municipal Authority for Primary Healthcare, the Social Welfare Board, and the Board of Education of the municipality in question. All the pupils, the parents, and the personnel who were personally interviewed for the study signed a form of participation. Permission was also requested from the parents of the interviewed pupils.

Sum variable values, individual variable values, and also the relationship between the background variable values and the sum variables were reviewed from the received answers. Analysis of variance was used to test different class–degrees’ relation to the sum variables. The t test was used to analyze differences in the sum variables between boys and girls. SPSS 14.0 for Windows was used for the analysis (Burns & Grove, 2009).

Strategies: Action Research

The purpose of the action research was to provide practical benefit and usable information on promoting mental health in a school community. It examined the activities of the members of the school community and was used to develop better systems by using multiprofessional and multiorganizational collaborations (Hart & Bond, 1999).

This type of study was based on the development plans and needs of the organization itself. The need for a helping model for lower secondary school pupils was discovered after discussions with the social and health care representatives of the area. These discussions were lead by the researcher. In addition, the basis of this study also laid in the flexibility in action and roles. Both the researcher and members of the school society were active participants in the development. The research process occurred in a cycle: planning, action, and evaluation of the action took turns (Bowling, 2002; Hart & Bond, 1999).

To ensure the success of the development and to motivate the work communities to achieve it, it was important that the actors themselves defined the focus areas and goals. They participated in the decision making throughout the whole process and represented the expertise of their own field of work. The researcher maintained the process by taking actively part in the discussion and providing other participants general knowledge about the development and different methods (Bowling, 2002; Hart & Bond, 1999).

Intervention Applications: The Results of the Well-Being Profile

The school’s Well-Being Profile was looked at from the point of view of the sum variables to see the overall situation, as well as through individual questions when determining the targets in need of development. An example of such a target would be improving the school yard.

The sum variables are shown in Figure 2. Overall best values were given to the pupils’ state of health whereas the school environment scored the lowest values.

Figure 2

The School Well-being Profile Responses in Sum Categories

The lowest values were given to the school environment. A more detailed assessment of the answers revealed that especially air conditioning, room temperature, lavatories, and the school yard were seen as poor. The amount of school work and the schedules received some negative feedback, whereas a quarter of the pupils felt the school rules and regulations were in need of improvement. On the other hand, the possibility of working in peace and the class sizes were felt to be relatively good.

The best values were given to social relationships and to the pupils’ health status. According to the responses, the pupils were fond of their teachers and other school personnel. The pupils felt that they were given enough support by their parents and that the atmosphere in the classroom was mainly positive. The school lunch and breaks were seen as enjoyable pauses during the day. Helping others and interfering in bullying situations were not seen as particularly common actions; indeed, only a third of the pupils reported that classmates come in to aid when a fellow pupil is being bullied. In addition, the responders felt that the teachers were not interested in the pupils; only a mere 22% of the pupils felt that the teachers are interested in their lives.

When it came to health issues, the most common troubles were headache (18% of the responders’ experienced headache at least once a week), tiredness (17%), neck and shoulder ache (15%), and irritability and fits of anger (15%).

Other sources of criticism were the school rules and regulations, which were seen as a barrier to self-fulfillment. Of the pupils, 83% either felt that they could not participate in decision making or did not respond to the question. Because of the fact that the pupils knew their strengths and weaknesses well, they felt they were able to handle school tasks successfully. It was hoped that the number of additional electives would be increased.

The results were then compared with the results received from other Finnish schools that same year (n = 5,380). These results could be found on the Well-Being Profile’s Internet page. When compared with the school of this study, other Finnish schools scored higher in issues such as room temperature, lavatories, the school yard, teachers’ interest in their pupils, and involving the pupils in decision making. On the other hand, factors such as health status, the functionality of the class, and the ability to deal with school tasks were given more positive feedback than by other Finnish schools (“School Well-being Profile in Internet,” 2005).

Intervention Applications: The Well-Being Profile and Action Research as Process and Results

The actual layout of development was elaborated based on the collected data. A development team worked on the data. The team consisted of the researcher, a principal, a primary health care psychologist, two school nurses, a school social worker, a family counselor, a director of the social welfare services, and a nurse, together with a psychologist from a psychiatric outpatient department. The team was responsible for planning the collection of data and processing the data and any feedback gathered from the action. The development work progressed as a cycle where the production of ideas, reflecting them, and further development of them took turns (Bowling, 2002; Hart & Bond, 1999).

When the mapping phase of the Well-Being Profile had been completed and the answers had been collected and processed, goals for a new strategy of action were set. After this, the development function was further planned, executed, and finally estimated with the help of concrete part-time goals, methods, and schedules (Hart & Bond, 1999). The Well-Being Profile was then complemented by interviewing pupils, their parents, and the school personnel. Pupils also had an opportunity to participate in the discussion. The briefing session for them included information on how to improve one’s mental health, the results of the study, and plans for future improvement. The pupils were encouraged to comment and discuss during the briefing.

Ideas for development and new function models of action were brought to the meetings and seminars, which were made up of different compositions. In these meetings and seminars, the new function models were assessed and necessary alternations were made (Hart & Bond, 1999). Participants in the seminars included experts in mental health promotion, the development team and the area’s principals, local policy makers, parents, and school personnel. One of the results of the development project was the networking between the principals and the pupil welfare groups, during the reflecting discussion about the development work. The participants of these meetings were also trained to work with the service map and to form efficient helping models.

The service map, which focused on the various problem situations adolescents have to face, was the fundamental result of the development. The different actors’ descriptions of their own roles in a problem situation were collected in one paper in which the service chain can be seen as a whole. In addition, it displays issues to do with the distribution of the work load and responsibility. The descriptions were made in various branches represented by the development team’s members. The finished descriptions were then presented to the whole development team and through evaluation they were organized to form a single entity. This was then assessed by the actors in their own branches. The work was evaluated based on both the practical experience and the theoretical knowledge of the parties. The progress then continued as the work was further processed. In the end, a finished service map was distributed to all who worked with the pupils in order to be used as a guide in various problem situations. Table 1 shows the service map used in situations where it is needed to help one cope with the most ordinary threats against one’s mental health.

Table 1

A Service Map About Actions to Be Used in Situations in Which One’s Mental Health Is at Risk

	Absences	Violence, Bullying	Substance Use
Teachers	Class teacher notices	Information of a bullying situation	The early intervention model, see below
	→ class teacher or study counselor has a discussion with the pupil	→ the teacher resolves the situation immediately if possible
	→ the information reaches the pupil’s home	→ a discussion where the class teacher, the study counselor, the principal, the bully, and the pupil being bullied are present
	Absences	→ contacting the pupils’ parents that same day (the principal)
	• if more than 50 hours, a principal’s letter to the pupil’s home
	• if more than 100 hours, the principal notifies the child protective services
School welfare personnel	The school welfare personnel deals with the situation	The school welfare personnel deals with the situation	The school welfare personnel deals with the situation, puts it on record
	→ directs it to either to the school nurse or to the school social worker	→ directs it to either to the school nurse or to the school social worker	Role: Coordinates
	Puts it on record	Puts it on record
	Role: Coordinates	Role: Coordinates
Family welfare clinic	Resolving the family situation, supporting the family	Resolving the family situation, supporting the family	Resolving the family situation, supporting the family
School social worker	Estimating the need of help and deciding procedures for the future, together with other actors (either with the school social worker or with other services)	Estimating the need of help and deciding procedures for the future together with other actors (either with the school social worker or with other services)	Estimating the need of help and deciding procedures for the future together with other actors (either with the school social worker or with other services)
	Makes sure the child protective services are notified	In matters to do with education, direction to the family welfare clinic	The early intervention model, see below
	Role: A contact person to the social services	Role: A contact person to the social services	Role: A contact person to the social services
School health care	Charting the physical and mental situation and directing to follow-up treatment	The school health care will ask questions about bullying and about the pupil’s family situation in the health examinations occurring in the seventh and ninth grade	Charting substance use in the physical examinations occurring in the seventh and ninth grade
	In the case that the cause of the problem is not a somatic disease, directing to the school social worker or a mental health worker	In the case of absenteeism or continuing visits to the school nurse, a possible bullying situation will be studied	During the ninth grade, the pupils are required to take part in a substance use questionnaire
		→ contacting the principal or the class teacher, in serious cases the police	→ if there is need, directing to a mental health worker or A-clinic or social welfare services
		→ someone to help in discussions	Early intervention model
		→ involved in a supportive discussion	→ discussion with the pupil (with a coworker)
		In case violence is suspected to occur within the family, directing to the school social worker	→ meeting the family
		→ if there is a need, directing to a doctor	→ drug test
		→ if there is a need, the child protective services should be notified	→ if there is a need, the child protective services should be noted, a discussion and follow-up
		In case of smoking, a nicotinism test and handing out nicotine products to help the pupil quit smoking
School mental health worker	With the school welfare personnel primary assessment of the situation in mental health problems	If there is a need, supportive discussion with the bullies and/or the bullied	Supportive discussions to clear up the situation and to decrease the substance use
	Crisis help, discussions	Taking part in meetings, where the bullying issue is discussed, when asked	Directing to an A-clinic or special health care
	If necessary, directing to follow-up treatment in special health care	If necessary, directing to follow-up treatment in special health care
Special health care	Consultation or in serious mental health problems: Treatment	Consultation or in serious mental health problems: Treatment	If necessary, consulting a youth psychiatrist
			In the case there is a psychiatric disorder, treatment in special health care will begin
			Inpatient care may be necessary in the withdrawal phase, with serious mental health disorders, and when there is a risk of suicide
Teachers	Discussing	If learning difficulties occur, the pupil’s parents will be notified, the impression and participation of the parents will be examined, and a consultation will be held	Information about the crisis situation in either the student’s life or in a bigger context
	→ directing to school health care
Pupil welfare personnel	Pupil welfare personnel processes the issue	Pupil welfare personnel processes the issue, records the issue and directs to further studies	Holding a crisis meeting or organizing necessary support
	Role: Coordinates	Role: Coordinates	Role: Coordinates
Family health clinic	Resolving the family situation, supporting the family	Examinations related to learning disabilities	Supporting the family when needed
School social worker	Charting the need of help and deciding procedures for the future (either with the school social worker or with other services)	Role: Contact person to the social services	Role: Contact person to the social services
	Role: Contact person to the social services
School health care	School health care charts the seventh graders mood and if necessary, uses Beck Depression I questionnaires to do so	Assess whether the question is about a mental health problem; in that case the treatment will continue either with the school’s own mental health worker or in specialist medical care	Participating in crisis support if necessary
	Based on the results of the questionnaires, an appointment with the school’s mental health worker can be made
	Charting eating disorders and sleeping disorders in the health examinations
	If the pupil suffers of a mental disorder, it is the school’s health care’s task to chart the problems, their inconveniences, the situation at the pupil’s home, relationships with friends, hobbies, and somatic symptoms—based on this, the need for help is estimated
School mental health worker	Primary assessment of the situation in mental health problems supportive discussions with the pupil, parents or experts of various fields present if necessary	If problems occur during the meetings, the study advisor, the class teacher, or the principal should be contacted to clear up the situation	Crisis help according to the situation
	Directing to follow-up treatment in special health care if necessary		Participating in crisis meetings if necessary
			Directing to follow-up treatment in special health care if necessary
Special health care	A referral to special health care when:	A surprising collapse in managing the school work or significant inabilities to concentrate could be a sign of a serious mental health problem in the need of special health care.	If the crisis reactions prolong, the treatment will take place in special health care
	• The adolescent doesn’t reach the development stage of others his/her age in a few months with the help of local care or if the symptoms are serious, e.g. difficult depression, self-mutilation, psychosis and eating disorders
	• the treatment will be executed in the psychiatric outpatient department, in a local team or in cases which need inpatient care, the treatment will be organized in youth psychiatric departments
	• the treatment will be done by a multi-professional team with experts of other fields also helping if necessary
	• the treatment includes various therapies, family counseling, medical treatment and psychological studies if necessary
REMEMBER FEEDBACK AND A NOTIFICATION TO THE HOME OF THE PUPIL

Discussion

The Reliability of the Well-Being Profile

In this study, the goal was to develop the school environment to be one that supports and further promotes the well-being and mental health of the pupils. The instrument has been tested in Finnish lower secondary schools, and it can be considered valid for precisely this usage; according to Konu’s background information of the instrument, the school environment and the school’s social relationships are seen as an important part of one’s well-being. This was also the theoretical basis of this study (Barry & Jenkins, 2007; Hootman & King 2003). The profile provided the study with a comprehensive image of the circumstances influencing the pupils’ welfare as well as a clear view of the shortages found in these circumstances. Because of the fact that the pupils responded to the sensitive questions of the study anonymously, the school was provided with a general feedback of its circumstances from the pupils. This also made it possible for the feedback not to identify individual pupils (Konu & Lintonen, 2006; Hermann & Palmer, 2002).

Indeed, the Well-Being Profile used in this study retained the original purpose and meaning recommended by scholars. Although the researcher’s interest was focused on the promotion of mental health, a larger study of mental well-being and circumstances influencing it is justified. It can be argued to be worth studying since general well-being is the very basis of mental health, and vice versa, mental health is an essential part of one’s welfare (Barry & Jenkins, 2007, Konu & Lintonen, 2006). As a final note, an interview section that had separate questions dealing with one’s mental health was included in the action research study.

The Applicability of the Used Methods in Developing Mental Health Promotion

When evaluating the action research, ordinary validities and reliabilities are not applicable; instead, validating is a way of assessing the research. This means that the research can be seen as a process in which one’s understanding of the world develops gradually. Human knowledge of the world is based on linguistic interpretation, which is tied to time, space, and language. The action research used here can be evaluated as a reflexive, dialective, evocative, and workable developing tool (Heikkinen, Huttunen, & Syrjälä, 2007).

In this study, the starting point was the present time during which information was collected from staff members, pupils, and their parents. Based on this collected information as well as the researcher’s theory knowledge, actions for development were planned. These were then reflected in the development team and in the school society (Heikkinen et al., 2007). As a reflective development method, the action research brought the pupils and the school staff more means for influencing and increased interaction situations for both parties. The action research proved out to be a motivating method of development. The members of the development team were able to use their own field of expertise, thus functioning actively throughout the process by coming up with fresh new ideas and evaluating them.

Dialectics on the other hand could be seen in the way the views and theory knowledge of various actors were collected into the action study; pupils, parents, pupil welfare personnel, the development team, and the researcher herself all participated in this (Hart & Bond 1999). The researcher’s task was to merge various perspectives into the finished work, but occasionally she found it challenging to integrate her own knowledge into the material produced by local experts and circumstances. On the other hand, the action research views theory and practicality as two sides of one issue, not as two separate factors (Hart & Bond, 1999). The researcher wrote memos as assistance; she marked down her own observations and conclusions, which she referred to throughout the study.

Study also ought to be credible and convincing. The study was executed side by side with school work, and its material has been collected from several experts who used their own points of view and expertise. Everyday issues seemed to have an effect on the pupils’ mental health; indeed, the purpose of the action research was to take place in the everyday life of common people (Heikkinen et al., 2007; Patton, 1990).

Conclusions

One of the goals of the study was to empower the participants (Hart & Bond, 1999). The action research not only motivated the municipality to improve its environment but also helped various actors to network in order to share ideas and practical aspects of development. Through empowerment, the school nurses and other practitioners of health care and special health care took more responsibility of the well-being of the school society. This also helped them see the importance of their own roles; as experts of health care, they, together with other actors, have a significant responsibility in promoting positive mental health. The practical effects of the action research could be seen as correct treatment of problem situations and as intensification of collaboration. The distribution of work tasks was made clearer with the help of the service map. By getting involved in the school’s circumstances and by increasing the pupils’ opportunities to influence, situations that protect the pupils’ mental health could be developed.

From the point of view of historical continuity, the action research took place at a suitable time as it was used to define the school of this study. The various actors of the municipality had from the very beginning an impression of the necessity of development procedures; this is a factor that also motivated them to participate in the study. The development function did not stop when this study ended but instead continued.

Based on the pupils’ answers, The Well Being Profile pointed out areas in need of improvement in the school conditions. Together with action research, it proved to be a viable way of developing mental health promotion in a school environment.

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