Promoting the Psychological Well-Being of Italian Youth

Abstract

School is potentially one of the most important and effective agencies for the promotion of mental health. For this reason, in Italy, the Mental Health Department of The National Health Institute has developed an intervention based on a structured handbook. The aim of this intervention is to promote the psychological well-being of the students. In this study, we have evaluated the efficacy of this intervention through a quasi-experimental study design of four classes (two were control) of secondary education, including 79 students aged 14 to 16 years (15.35 ± 0.68). Assessments were administered before and after the intervention. The results showed improvement in perceived self-efficacy (p ≤ .001), emotional coping (p = .003), and overall well-being (p < .05). The students’ perception of usefulness was also increased (p < .05); the intervention successfully promoted the idea of life as a continuous process of learning, in change and growth (p < .05). The intervention was effective despite some limitations described by authors related to a lack of involvement of relatives and the team teachers, as well as the absence of homework; however, the adoption of a program promoting life skills, problem solving, and goal definition training is recommended with the use of a revised handbook.

Keywords

school mental health promotion problem-solving and communication skills programs self-efficacy and psychological well-being effectiveness of a structured handbook to promote mental health

Introduction

In Italy, according to the fifth report on youth (Buzzi, Cavalli, & De Lillo, 2002) carried out by the IARD Institute (http://www.cinefogo.com/participants/iard-25), a nonprofit organization of Milan that undertakes sociological research, students feel bored, sad, anxious, confused, and fearful of criticism. According to the sixth IARD report (Buzzi, Cavalli, & De Lillo, 2007), adolescents seem to be lacking the capacity to define personal goals. They also have the tendency to postpone important life choices.

It is a widely held opinion that young adolescents show common problems, such as the existential malaise and lack of self-confidence. Findings also suggest that efforts to foster development of young adolescents’ social-emotional skills may, in turn, reduce their risk for involvement in bullying and violence (Polan, Sieving, & McMorris, 2013).

It has recently become more and more evident that various health programs, such as in the field of guidance and safety of sex, nutrition, substance use, or tobacco use, may prove counterproductive if the information is not accompanied by policies to promote these skills (Slater, 1989). The most important abilities that have been described are self-perception and self-efficacy, coping strategies for problem solving, empathy, and social skills (Barry, Clarke, Jenkins, & Patel, 2013; Busch, de Leeuw, de Harder, & Schrijvers, 2013; National Institute for Health and Clinical Excellence, 2009; St Leger, Young, Blanchard, & Perry, 2010;). The latter abilities, in particular, appear to be very important protective factors in developing risk behaviors.

The evidence shows that the most effective programs are those undertaken as part of curricular school activities aimed at the promotion of social skills and self-efficacy (Greenberg, 2010; Jennings & Greenberg, 2009). The school, in fact, is able to make a significant contribution to the health and welfare of its students (Puolakka, Haapasalo-Pesu, Konu, Åstedt-Kurki, & Paavilainen, 2014), which is widely recognized by international organizations, including the World Health Organization, the U.S. Centers for Disease Control and Prevention, the International Union for the Promotion and Health Education, UNICEF, and UNESCO. Strategies and programs that have been implemented over the past 20 years all over the world have recognized that the community plays an important role in health promotion (Markham & Aveyard, 2003).

In Italy, in light of such evidence, several initiatives have been undertaken in recent years by the Mental Health Department of the National Health Institute (Gigantesco, Del Re, & Cascavilla, 2013; Mirabella, 2010) for the promotion of psychological well-being in young people at school. These initiatives were aimed at promoting life skills, relationships, self-reflection, problem solving, awareness of improvement of skills, and emotional intelligence. These initiatives are based on the elaboration of a handbook structured in several “work units,” where every unit requires one or two meetings which last approximately 1 hour. The elements of these units are problem solving, communication skills, personal and pleasant goal settings, management of irrational beliefs, and others (see the appendix).

In this article, the main features of the program and the results of efficacy of the first pilot study with a quasi-experimental design are described. We compared classes of students who used the initiatives described in the handbook and control classes that did do not use any kind of intervention to promote well-being. The psychological dimensional areas explored were perceived self-efficacy, well-being, and emotional coping.

Method

Components of the Program and Handbook for Students

The program is designed for early adolescents, in particular the students of the first 2 years of upper secondary schools (aged 14-16 years). The program intends to promote the ability to set realistic and challenging goals, define and solve problems, ameliorate communication skills and assertiveness, develop self-discipline, and improve the skills of negotiation and cooperation, as well as the ability to self-manage anger and aggressive behavioral acts. The program is based on the components of social and emotional education and life skills, as suggested by the World Health Organization (Marmocchi, Dall’Aglio, & Tannini, 2004), and of emotional intelligence (Goleman, 1995) but with a greater emphasis on the definition of personal and pleasant goals. The theoretical basis of these initiatives are also supported by those recommended by the “Mental Health Action Plan for Europe” (www.euro.who.int/mentalhealth2005), which emphasizes the importance of a “salutogenic” view of mental health as positive emotional, social, spiritual, and physical well-being. In the United States, many psychiatrists believe that “the most effective methods of intervention all focus on the development of positive emotions and the character traits that underlie well-being” (Cloninger, 2006, p. 72). As a result of this belief, the focus of the intervention is on competence and strengths rather than on the pathologies, such as optimism, resilience, the ability to recognize the origin of the stress with the ability to communicate in an effective way, and making mutually satisfying relationships. All of these components are included in our program, in which the relevant principles and tools are illustrated with suitable examples for youth and with exercises that should be performed by two people or in a small group. It was also recommended to the students to give positive feedback to those that practice the exercises. The handbook includes 18 chapters (see the appendix) with attached forms for exercises and tools to evaluate the effectiveness of the program in practice.

Training of Facilitators

The classroom sessions were conducted by facilitators (or assistants), including students, teachers, and psychologists who have received specific training on the handbook. The facilitators, after reading the handbook, completed the training with experts through two short sessions, each lasting 2 to 3 hours. Two to three follow-up meetings were also planned to discuss any problems that may arise during the program.

Application of the Handbook and Selection of Classes

The application of each “work unit,” or chapter of the handbook, requires approximately 1 hour per week. Since there are 18 chapters of the handbook, some require more time; therefore, there were 24 meetings in all. Thus, the intervention lasted 6 months.

In the school year 2010 to 2011, four classes from two different secondary education schools were involved in testing and evaluation: the Pedagogical High School “Galanti” and the Institute of Linguistics “Pertini” of Campobasso. Before conducting the research, a meeting was held with the headmaster and teachers to clarify the purpose and methods of the research. Out of the four classes, two were included in the experimental program (one class with 20 students belonging to the Pedagogical and one class with 21 students belonging to the “Pertini” school) and two as a control group (there were 19 students each for both institutes). The assessment instruments were administered before and after the intervention.

Evaluation Tools

Three instruments were used:

Perceived Self-Efficacy APEN-G/APEP-G Questionnaire (Caprara, 2004): There are 15 items to assess the perceived self-efficacy. Each answer can be expressed on a 5-point Likert-type scale, from not capable (1) to quite capable (5).

Strengths and Difficulties Questionnaire (SDQ; Goodman, 2001): It assesses the presence of emotional and behavioral problems in adolescents. It consists of 33 items: For the first 25 items the response can be expressed on a 3-point Likert-type scale, from completely true (0) to completely untrue (2), whereas for the remaining items the answer may be expressed on a 4-point Likert-type scale.

Health and Wellness Questionnaire (Mirabella, Del Re, Palumbo, Cascavilla, & Gigantesco, 2010): There are 48 items that assess the presence of positive and negative states of mind and satisfaction with life.

Study Design

The study design used a quasi-experimental approach, since the survey was conducted on classes of preexisting students. Classes were chosen by the headmaster and teachers of the school.

Statistical Analysis

To assess the possible effects of the intervention on the dependent variables, we used two types of tests to compare the hypotheses: (a) The Mann–Whitney test to detect differences between the control and the experimental group (both pre and post) and (b) the Wilcoxon signed ranks test to make the comparison between the pre- and postintervention. The program used for statistical analysis was SPSS Version 19.0.

Results

The classes were composed of a total of 79 students aged between 14 and 16 years (M ± SD, 0.68 ± 15:35), 74 females and 5 males. The analysis included 73 students for one out of three questionnaires because 6 students were absent in the postintervention assessment. In addition, only 1 student did not complete the APEN Questionnaire and the Wellness Questionnaire.

Evaluation of Perceived Self-Efficacy (APEN/G and APEP/G)

The data set for the assessment of self-efficacy include only 72 students because 7 were absent for the second assessment. For the pretest, the average of the ranks in the class of controls was 41.59 (n = 32), whereas the experimental average was 32.42 (n = 40) with a significance of p = .064. In the posttest, the average of the ranks were of 37.7 and 35.49, respectively, with a significance of p = .64. The pre–post comparison in the control group showed an improvement in the average of the ranks (+2.72), but it was not significant (p = .085), whereas in the experimental group, the pre–post comparison showed a greater improvement from the average of the ranks of 4.34 (p = .003). In the experimental group, the analysis of the pre–post individual items showed an improvement in average ranks of the following items: “overcoming the irritation for the wrongs done” (+4.87; p < .001) and “avoiding anger when others behave badly with you” (+7.0; p = .003).

Assessment of Emotional and Behavioral Problems (SDQ)

A statistically significant difference in the pre-post experimental group was observed in the items “I am often unhappy or down in the dumps” (+2.1; p < .05) and “These difficulties are causing you problems in your life every day in the family” (+0.57; p < .05).

Evaluation of Health and Well-Being (Questionario sulle condizioni di salute e di benessere [Questionnaire on Health and Wellness])

A statistically significant difference in the pre–post experimental group was observed in the items “Did you feel useful?” (+3.21; p < .05) and “For me life is a continuous process of learning, in change and growth” (+3.08; p < .05).

Discussion

It is well known that school is potentially one of the most important and effective agencies for the promotion of mental health (Stewart-Brown, 2005; Weare & Markham, 2005). Health promotion in a school context can be defined as any activity undertaken to improve and/or protect the health and well-being of the entire school community. Specifically, initiatives on mental health in schools seek to build social, emotional, spiritual attitudes, and skills in their students. Evidence has shown that the initiatives on mental health are successful if they (a) were well-designed and based on theories and effective practices (Green, Howese, Waters, Maher, & Oberklaid, 2005; Weare & Nind, 2011); (b) linked the school, the home, and the community (Adj, Schrader McMillan, Kiloran, & Stewart-Brown, 2007; Patton et al., 2006); (c), provided consistency in behavioral change by linking students, teachers, families, and communities (St Leger et al., 2010; Weare & Markham, 2005); (d) encouraged relationships based on respect and support among students, teachers, and parents; and (e) enhanced the social life and relationships of their students (Blum, McNeely, & Rinehart, 2002; McNeely, Nonnemaker, & Blum, 2002).

The aim of this intervention is to promote mental health, psychological well-being, and emotional intelligence. The students gave very positive feedback about the program and expressed full acceptance of group work in the classroom. In addition, the students also noted that they had become more experienced in the management of their problems by the end of the intervention. The results of this intervention highlight aspects of improvement in perceived self-efficacy, in coping, and in emotional well-being. In fact, regarding the comparison between experimental versus control classes, we observed an improvement only in perceived self-efficacy in the experimental classes. At the end of the intervention, the students became more adept in overcoming “the irritation for the wrongs done” and in ‘“avoid getting angry when others behave badly toward them.” In the experimental classes, there was an improvement in emotional and behavioral coping. The students reported to be happier and less “down in the dumps” and were also able to cope with emotional difficulties and/or behavioral problems. Finally, the results showed that the intervention resulted in greater improvement of personal well-being since the students had an increased perception of usefulness; they also displayed an attitude of life as a continuous process of learning, in change and growth.

These results also indicated a potential effectiveness of the intervention by using a structured handbook; however, there are some limitations. The major limitation is that the intervention is based on the involvement of teachers and relatives of students, which did not happen in this study. In fact, although the teachers appreciated the meetings, they did not encourage further discussions with other teachers and among the students. Similarly, families were not involved. The facilitators and researchers found great satisfaction in the students’ improvements, but the students reported that they were not supported by their relatives. As a result, an intervention proposed in theory as holistic, it became very fragmented in practice because it involved only the students. In addition, this approach needs additional practice, such as positive communication in everyday life. Undoubtedly due to the lack of involvement of relatives, homework was not practiced. We believe that better results would be achieved if the work done at school had been replicated and reinforced in the family of the students. Another limitation is that in the experimental classes, there were students with evident behavioral problems. In fact, although the teachers were aware that the aim of the intervention was to promote health, they chose the more problematic classes with the implicit aim to see improvement in students with behavioral problems. The data show that there was a trend of improvement in the experimental classes that started at baseline with lower scores than those of the control group (e.g., the total score in the APEN questionnaire). Indeed, in the control groups, the pre–post comparison did not show a significant improvement, whereas in the experimental groups, despite the presence of students with behavioral problems, more consistent improvements were found. Another critical limitation concerns some questionnaires of evaluation that have been considered unspecific, that is, with low sensitivity to change, especially for the SDQ and for the Health and Well-Being.

Other limitations are related to the time needed to complete the program, which was greater than expected, and the break in the continuity of the intervention due to holidays and summer vacations. Last but not least, the absence of a “notebook for homework” was another limitation because it could have helped students, especially considering the lack of support of relatives. These limitations suggest that there may be room for improvement within the handbook, such as a partial revision of the handbook through a more organized reshaping of the meetings. Thus, we suggest that investigators start with two (one in the previous handbook) work units concerning goal definition (to distinguish the smart goals from personal goals) followed by effective communication. In the second part of the handbook, we suggest that work units should be focused on the recognition of the students’ emotions, assertiveness, ability to not procrastinate commitments, management of intense emotions, and impulse control. Finally, we suggest placing in the last part of the handbook a work unit about personal problem solving.

In addition, we suggest that each meeting be more structured to alternate the work based on the content of handbook (i.e., problem solving) with brief moments (3-5 minutes) to pursue stress-reducing activities to decrease tension. In addition, for each unit we suggest specific instructions for homework.

Conclusion

The intervention is effective, as demonstrated by the results obtained on the various dimensions of psychological well-being and, in accordance with literature, especially those dimensions relating to self-efficacy (Durlak, Weissberg, & Pachan, 2010). The satisfaction and enjoyment of the intervention were high. The students described to receiving many psychological advantages as a result of work done in the classroom, in particular “the perception to be improved,” and in all of the dimensions of psychological well-being. Based on these results, this program is also useful because it creates a group climate and facilitates work among peers.

We are convinced that the results would have been even more evident and supported by statistical significance if some limitations were avoided. First, the selection of classes was affected by the choice of teachers who preferred classrooms characterized by students with behavioral problems. Second, the use of some questionnaires that were not specific and might not have detected small improvements was also a limitation.

The authors recommend the adoption of this program aimed to promote life skills and effective communication, problem solving, and goal definition training. Finally, we also propose a revision of the handbook, an adaptation for the lower classes, and the presence of a notebook to assist students.

Footnotes

Appendix

Title of the Handbook: Setting goals and solving problems: Handbook for the promotion of mental health, psychological well-being, and emotional intelligence in school

Work-Unit

Bibliography

Tools

Note. To download the handbook, go to http://www.ccm-network.it/documenti_Ccm/prg_area5/2005-manuale-scuola-depressione.pdf

Acknowledgements

We would like to thank the headmasters, teachers, and students of “Galanti” and “Pertini” Institute of Campobasso; the Director of Regional Assessor of Health, Dr. R. Fagnano; and the Director of Local Health Authority, Dr. A. Percopo. We also would like to thank Dr. A. Gigantesco and Dr. G. Palumbo of National Institute of Health of Rome for their encouragement and support. Finally, many thanks to Professor Gean Marie Vale of British Academia (Campobasso, Italy) and Professor Alycia Yvette Honeck of North Hennepin Community College (Minneapolis, United States) for their help in preparing this article.

Funding: Public Funding, Regione Molise-ASReM €25,000,000.

The authors report no conflicts of interest.

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