To Örebro University

Background: The study was conducted in Region Örebro County, Sweden, where taxes and governmental contributions are the main funding sources. The region has 28 primary healthcare centres and should work with systematic health promotion according to the overarching operational plan. We evaluated the uptake of a 12-month multifaceted implementation strategy based on a leading change model, using internal and external facilitators, reflections from patient representatives and a combined top-down and bottom-up approach to achieve a more health-promoting practice.

Methods: Five intervention centres and five matched control centres were included in a non-randomised parallel group study. An implementation intervention was provided for 12 months to the intervention centres. The clinical process included the use of lifestyle screening forms before patient visits at the healthcare centre, inviting the patient to talk about their habits and provide advice when called for; registering health-promotive activities in the respective medical record. The control centres did not receive any support. Registered lifestyle screening forms and health-promoting activities were collected monthly over the study period (6 months pre-implementation phase, 12 months intervention phase and 6 months post-implementation).

Results: During the 6-month baseline phase, the control centres sent out life-style screening forms to more patients (n = 194) compared to the intervention centres (n = 32). The mean uptake per 1000 visits for health-promotion activities was similar between intervention (39.7) and control centres (38.6) at baseline. The mean uptake per 1000 visits during the 12-month intervention period was 66 (intervention centres vs 38 (control centres). The improvements sustained during the 6-month post-implementation phase: mean uptakes per 1000 visits 136.5 (intervention centres) vs 73.2 (control centres). Data will be analysed further for relative effect.

Discussion and conclusion: While goal setting in operational plans – expecting all PHCCs to work health-promotive – provides direction, practical implementation support helps to achieve them.

Well-being interventions are often designed and delivered based on external assumptions rather than students' perspectives, creating a research-practice gap that risks undermining their acceptability. This study explores students' perspectives on school-based mental health programs in general and on the new program Solution-focused Intervention for Mental health (SIM) in particular to explore its relevance and practical value for the students. Across three feasibility studies conducted over five years, we carried out 18 focus group interviews with students participating in SIM at four upper secondary schools in a medium-sized Swedish city. The material was analyzed using reflexive thematic analysis, which generated two main themes: Doing the right thing and Doing things right in school-based mental health interventions. The first theme reflects students' views that mental health and well-being are important topics in school and that programs should address both mental health problems and mental well-being. The second theme highlights the importance of age-appropriate formats and the need for safe dialogues about mental health. Overall, the study shows that adolescents value school-based mental health initiatives that promote mental well-being and address mental health problems, and that these initiatives are delivered in flexible, student-centered, and psychologically safe ways. These insights suggest that a dual-component approach to mental health may align better with adolescents' expectations, particularly in relation to mental health and well-being literacy. The results can inform the continued development and implementation of SIM and contribute to the design of more acceptable and relevant school-based interventions for adolescents.

BACKGROUND: Evidence-based healthcare recommendations exist for tobacco use, harmful alcohol consumption, low physical activity, and poor diet. However, the uptake of these recommendations in Swedish primary healthcare is poor, and the potential benefits for patients are not fully realized. Our aim was to evaluate the effect (i.e. the uptake) of a 12-month multifaceted implementation strategy to achieve a more health-promoting practice. We hypothesized that primary healthcare centers receiving this strategy would increase and sustain their health-promotion practices to a significantly greater extent than control centers, from baseline to the 6-month follow-up.

METHODS: In a non-randomized parallel group study, 5 intervention centers and 5 matched control centers were compared regarding health-promotion activities delivered in relation to visits to each center. The intervention centers received a multifaceted implementation strategy over at least 12 months based on established strategies, the Astrakan model of leading change, and findings from pre-implementation studies. The main strategies were: using external and internal facilitators to combine bottom-up and top-down perspectives, and emphasizing leadership responsibility for change. Medical record data on health-promotion activities, including prescribed physical activity and use of lifestyle screening forms, were collected monthly for 2 years: 6 months before and after implementation, and during the implementation phase. The implementation strategy effect was estimated using generalized linear mixed models.

RESULTS: During the 12-month implementation phase, the intervention and control sites had 135 002 and 160 987 healthcare visits, respectively; conducted 8839 and 6171 health-promotion activities, respectively; and administered 2423 and 282 lifestyle screening forms, respectively. A statistically significant higher relative uptake rate of health-promotion activities was found in intervention sites compared to control sites after the implementation period compared to before. The effect increased during the active phase, with the intervention sites having on average 1.07 and 2.0 times the uptake rate of the control sites at 1 and 12 months, respectively; this effect was largely maintained during the 6-month post-intervention phase. A significant absolute effect, in terms of difference in predicted uptake per 1000 visits, was evident 7 months into the implementation phase.

CONCLUSION: This multi-faceted implementation strategy was successful in achieving a more health-promoting practice.

Highlights

•  Internet-delivered obesity treatment can help change lifestyle habits

•  Expectations for weight loss were not met

•  Life circumstances made it difficult to commit to treatment

•  Internet-delivered treatment is not for everyone.

Mental well-being is more than merely the absence of mental illness; it is a multidimensional concept that includes both emotional and functional well-being, which are valuable resources during adolescence. In order to develop relevant interventions and policies to strengthen adolescent mental health, a continuous monitoring of the population well-being becomes important. The aim of the study was to examine the level, distribution, and changes in mental well-being over time in a Swedish adolescent population. Current study is based on four waves (2014-2017-2020-2023) of a cross-sectional student survey (N = 16288, Mage = 16.23). The outcome was measured with the Mental Health Continuum Short Form. Ten explanatory factors were chosen to examine differences in mental well-being in the study population: Grade, Sex, Sexual orientation, Socioeconomic status, Country of birth, Visual, Hearing or Mobility impairment, Specific learning disorder and Neurodevelopmental disorder. Differences in mental well-being between groups as well as temporal trends were examined and evaluated through statistical testing and hierarchical multiple linear regressions modeling. Girls, non-heterosexual adolescents, and adolescents with low socioeconomic status or impairments have lower levels of mental well-being than boys, heterosexual adolescents, and adolescents with higher socioeconomic status or without impairments, respectively. A deterioration in mental well-being is seen over time for several groups; however, results of the multivariable analysis indicates that the deterioration is mainly an effect of sex and the significant decline in mental well-being seen among girls. The most significant factor for explaining the variation in mental well-being in this study is socioeconomic status. This study elucidates temporal changes and differences in levels of mental well-being between social groups in the adolescent population. The overall differences are small, but their potential implications for public health warrant careful consideration since they concern a significant part of the population. The results underscore the imperative of promoting mental well-being in adolescents, particularly among vulnerable groups.

A paucity of studies exists that report on the description and testing of school-based interventions set out to promote mental well-being among adolescents, particularly in a Swedish context. The aim of this paper is to describe a new strength-based intervention designed using the core elements of solution-focused brief therapy for coaching within a normative frame of mental well-being. The Solution-focused Intervention for Mental health (SIM) is a nine-week, classroom-based, group intervention that has been developed to be both feasible and effective in addressing the current public health challenge concerning adolescent mental health. The intervention is described in accordance with guidelines for group-based behaviour change interventions. The results of three subsequent studies are presented and they support the intervention's feasibility. These studies demonstrate improvements in student participation, session attendance and ratings, as well as in a mental well-being outcome. The first two studies show small effect sizes and the third shows a medium effect size, thereby further substantiating the efficacy of implementing SIM in upper secondary schools. The program is now ready to be evaluated in a forthcoming randomized controlled trial.

In this cross-sectional study, we aimed to I) investigate the dual-factor model of mental health by forming and describing four participant groups and II) examine associations between mental health status and background factors, school-related factors, stress, and resilience among adolescents in a community population in Sweden. Data were collected through a survey completed by 2,208 students in lower and upper secondary school on the Swedish island of Gotland. After missing data were removed, a total of 1,833 participants were included in the study. The survey included the Mental Health Continuum Short Form (MHC-SF) for the assessment of mental well-being and the Strengths and Difficulties Questionnaire (SDQ) for the assessment of mental health problems. These two measures were combined into a dual-factor model, forming four mental health status subgroups: Vulnerable (47.5%), Complete mental health (36.2%), Troubled (13.9%), and Symptomatic but content (2.5%). Associations between these groups were explored regarding background factors, school-related factors, stress, and resilience through chi-squared tests and logistic regressions. Girls (OR: 1.88) and participants with high stress levels (OR: 2.23) had elevated odds for Vulnerable mental health status, whereas higher resilience (OR: 0.87) and subjective social status in school (OR: 0.76) were factors associated with reduced odds for this mental health status classification. Female gender (OR: 5.02) was also associated with Troubled mental health status. Similarly, a high level of stress (ORs: 4.08 and 11.36) was associated with Symptomatic but content and Troubled mental health status, and participants with higher levels of resilience had decreased odds for being classified into these groups (ORs: 0.88 and 0.81). The findings highlight the importance of interventions to increase resilience, reduce stress, and address stereotypic gender norms as well as social status hierarchies to support adolescents' mental health.

The latest World mental health report states that mental health is an integral component of health and well-being and is more than the absence of pathology. Indeed, the view of mental health is slowly shifting to an emphasis on positive health indicators as national authorities around the world are increasingly adopting the two continua model of mental health (TCM). Adopting the TCM has several important implications for public health practice. One is that the epidemiological surveillance will have to include measures of both mental illness and mental well-being. The purpose of this presentation is to illuminate the conceptual and practical use of the TCM in the analysis of adolescent mental health. The presentation will be limited to a focus on the theoretical underpinnings and methodological considerations made to operationalize and categorize mental health according to the TCM. It will consider the added value of the TCM to epidemiological surveillance as well as its implications for public health practice when it comes to meeting population needs with appropriate interventions. To construct the model, data from population-based regional public health surveys among adolescents including validated measures of both mental ill health and mental well-being was used. The Kessler 6 scale was used to estimate the proportion of adolescents with or without probable serious mental illness (SMI, >13) and the Mental Health Continuum - Short Form was used to estimate the proportion of adolescents with flourishing (FMH), moderate (MMH) or languishing (LMH) mental health according to the original categorization developed by Keyes. Combining these two dimensions of mental health and their respective categories will yield six mental health status groups: Complete mental health = FMH without SMI, Vulnerable = MMH without SMI, Most vulnerable = LMH without SMI, Symptomatic but content = SMI with FMH, Troubled = SMI with MMH, and Most troubled = SMI with LMH.

Viewing mental health from a two continua perspective, this presentation focuses on results of pooled data from a recurrent cross-sectional survey, carried out in ninth and eleventh grade in lower and upper secondary school of Västmanland county, Sweden, 2020 - weeks prior to the Covid-19 outbreak - and 2023. In total, 7908 students participated of which 50% were girls (2020 N = 3880; 2023 N = 4028; response rate≈72%). A compilation of the results according to the two continua model and the six mental health status groups described in the previous presentation shows that 39.0% are categorized as having Complete Mental Health (CMH), 1.6% as Symptomatic But Content (SBC), 36.7% as Vulnerable (V), and 2.9% as being the Most Vulnerable (MV). Further, 12.8% are categorized as being Troubled (T) and 6.9% as Most Troubled (MT). Statistically significant differences are seen between boys and girls in the categories CMH (boys=47.4%, girls=30.8%), SBC (boys 1.0%, girls 2.1%), T (boys 7.2%, girls 18.3%) and MT (boys 3.7%, girls 10.1%). Significant changes over time, between 2020 and 2023, are seen in SBC (0.9% statistically significant increase) and MV (1.9% statistically significant increase). When divided by sex, significant changes over time are only seen among girls: in CMH (5.3% statistically significant decrease), MV (1.9% statistically significant increase) and SBC (1.3% statistically significant increase). No statistically significant changes are seen over time for boys. The result indicates that only four out of ten adolescents have a CMH. The differences between boys and girls are substantial; almost five out of ten boys and three out of ten girls has CMH. This emphasizes the importance of promoting mental well-being, especially among girls. The result also implies the importance of strengthening well-being in the large group without flourishing mental health since the latter can also provide a buffer against mental illness.

The Mental Health Continuum - Short form (MHC-SF) is a self-report measure that has been increasingly used to monitor mental well-being at the population level. The aim of this study was to evaluate, for the first time, the psychometric properties of the MHC-SF in a population of Swedish adolescents. First, the evaluation was performed by examining face validity and test-retest reliability obtained in a pre-study. Then using data from the Survey of Adolescent Life in Vestmanland 2020 (n = 3880) we performed confirmatory factor analysis on different factor structures based on theory and previous research. Model-based estimates were calculated for assessing the internal reliability of the factor structure with the best fit. Convergent validity was assessed by bivariate as well as model-based correlations, and test-retest reliability was evaluated by intra-class correlation coefficients. The results show that the MHC-SF is best described with a bifactor model consisting of a dominant general well-being factor and three specific group factors of emotional, social and psychological well-being. Its overall reliability was high to very high, while the reliability of its subscales was low. A practical implication of the latter is that the subcales should not be used on their own because they are more likely to reliably measure the general well-being factor than the specific group factors. Test-retest reliability of the total scale was acceptable, and convergent validity was supported. In conclusion, we consider the Swedish MHC-SF to be a psychometrically sound instrument for monitoring overall mental well-being in Swedish adolescents.