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Green - Video
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Violet - Government Article

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https://www.studentminds.org.uk/lookingafteryourmentalwellbeing.html

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It's important to notice when your mental wellbeing may be slipping, so that you can take action to boost it.

Here are some questions that you might find helpful to ask yourself if you think that you are experiencing lower mental wellbeing. This is not an exhaustive list of things that you may notice when your mental wellbeing is starting to drop; don't treat it as a checklist where you have to notice a certain number to take action. It's worth taking action as soon as you notice one of these signs.

University can be a busy time, which can make it harder for you to take the time to look after your mental wellbeing. When you're busy, stresses can mount up and really take their toll - so it's important to take the time to prioritise your own mental wellbeing. ​If you have:
Taking the time to look after your mental wellbeing can be a challenge. A powerful way to take positive steps is to write down your intention in a clear, time-specific goal.
Clear, time-specified goals enable us to succeed, as goals can be achieved. Even when goals aren't achieved, this can be used to think specifically about what was difficult and how to adjust these goals to make it easier to try again.

Try choosing one way to prioritise your mental wellbeing this week. It is best to anchor the intention to a known time or other commitment e.g. 'after the biology lecture on Tuesday'. Use the phrase "I will do this specific action on this day at this time." and see how it goes!

Sometimes, the thought of doing anything is just too much. If this describes your situation, don't punish yourself. The great thing about taking small steps is that it doesn't matter how small your goal is. You decide what you want to achieve and what is realistic for you to achieve. That way, the completion of any task - no matter how simple it may seem - is recognised as the achievement that it is.

You may find it useful to record how you felt during/after doing things to support your mental wellbeing in pictures or a journal. Doing this means that you can look back when you next feel low and remind yourself of how the activity helped you.

If you find yourself experiencing mental health difficulties which are preventing you from doing the things you want to do, seek help - whether through friends, family, a doctor, or your university support services.

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​We all have mental health and our mental wellbeing can fluctuate day-to-day . When you're not feeling great, it can feel harder to take action to benefit your wellbeing. However there are small...

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‎TED Health: The case for student mental health days | Hailey Hardcastle on Apple Podcasts

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‎TED Health: The case for student mental health days | Hailey Hardcastle on Apple Podcasts

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School can be rife with stress, anxiety, panic attacks and even burnout - but there's often no formal policy for students who need to prioritize their well-being. Hailey Hardcastle explains why schools should offer mental health days and allow students time to practice emotional hygiene without stigma. Follow along to learn how she and a team of fellow teens transformed their advocacy into law.

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the case for student mental health days | hailey hardcastle

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‎TED Health: The case for student mental health days | Hailey Hardcastle on Apple Podcasts

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School can be rife with stress, anxiety, panic attacks and even burnout - but there's often no formal policy for students who need to prioritize their well-being. Hailey Hardcastle explains why schools should offer mental health days and allow students time to practice emotional hygiene without stig...

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Stop the Stigma: Why it's important to talk about Mental Health | Heather Sarkis | TEDxGainesville

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Stop the Stigma: Why it's important to talk about Mental Health | Heather Sarkis | TEDxGainesville

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Stop the Stigma: Why it's important to talk about Mental Health | Heather Sarkis | TEDxGainesville

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Wellbeing Framework For Schools | NSW Education

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Wellbeing Framework For Schools | NSW Education

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The Wellbeing Framework supports schools to create learning environments that enable students to be healthy, happy, engaged and successful.

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Mental Health for All by Involving All | Vikram Patel | TED Talks

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Mental Health for All by Involving All | Vikram Patel | TED Talks

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Mental Health for All by Involving All | Vikram Patel | TED Talks

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What is good mental health and wellbeing?

Good mental health and wellbeing mean different things to different people and every person has to find their own way to a life that is meaningful and satisfying for them.

Things that can contribute to positive mental health and wellbeing include:

spending quality time with close friends and family

working in a job or finding an activity that is meaningful, which can provide a sense of purpose

learning a new skill such as painting, singing, knitting, or a foreign language which can provide a sense of pride and achievement

finding a hobby (such as gardening, playing sport, cooking, or arts and craft)

giving to others by volunteering, being there for friend in need, or caring for animals

having someone to talk to who can provide support and reassurance

eating healthily and exercising regularly

spending time with people who share similar interests

experiencing new things such as trying different foods, travelling, or meeting new people.

Ways to improve your mental health and wellbeing

Learn to relax and do things you enjoy

Having something to look forward to promotes positive mental health and wellbeing. Everyone is different, so find out what works for you.

Relaxing activities may include:

listening to music

watching TV

playing video games

practicing relaxation techniques such as meditation, yoga or tai-chi

mindfulness techniques are helpful to manage anxiety and negative or intrusive thoughts

gardening

catching up for drinks with a friend

play with pets

going shopping.

Get moving

Exercise is a great way to improve your negative mood. Do whatever you enjoy doing that gets you active, for example:

ride a bike

go for a walk (or run)

go for a swim at the beach or a pool

play a sport you like

kick a football with friends

try yoga

take up a martial art

join a team (rugby, footy, netball etc).

Eat healthy

try to eat a healthy, balanced diet, as it will make you feel calmer

eating regular meals will give you energy and will regulate your blood sugar levels

eating plenty of fruit and vegetables will make you feel healthier. Reducing your sugar intake is better for your health

avoid alcohol and other drugs as they can worsen the symptoms of mental health problems.

Get enough sleep

Stay connected and keep in touch with families and friends

Feeling connected to people is an important part of staying well. It can help you feel confident and valued, and it can support you during difficult times. A lack of contact with others makes people feel lonely and disconnected.

Get involved

Join a local community group in something that interests you. This will also allow you to meet people who have similar interests, for example:

Problem solving

Learn to anticipate problems before they arise, as it will help reduce worry and stress.

You can do this by:

learning to understand your own thoughts and feelings

planning in advance what you might do in situations that cause you stress

identifying at least two people who can help you when you come across a problem in your life

planning for a crisis and tell people what you want to happen if you become unwell.

Set goals

It is important to introduce a regular routine and structure to your days. Setting and achieving goals can help to organise your time, and can give you a sense of purpose in life

Goals can be related to:

Where to get help

See your GP or talk to a mental health worker.

Ring Healthdirect Australia on 1800 022 222.

RuralLink for Rural and remote areas 1800 552 002.

Mental Health Emergency Response Line (external site) - Perth metro callers Ph: 1300 555 788 Peel area callers Ph: 1800 676 822

This publication is provided for education and information purposes only. It is not a substitute for professional medical care. Information about a therapy, service, product or treatment does not imply endorsement and is not intended to replace advice from your healthcare professional. Readers should note that over time currency and completeness of the information may change. All users should seek advice from a qualified healthcare professional for a diagnosis and answers to their medical questions.

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Good mental health and wellbeing mean different things to different people and every person has to find their own way to a life that is meaningful and satisfying for them.

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Why students should have mental health days | Hailey Hardcastle

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Why students should have mental health days | Hailey Hardcastle

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https://youtu.be/1qq7lDL-bzY

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Why students should have mental health days | Hailey Hardcastle

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Understanding mental health and wellbeing | Everymind

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Understanding mental health and wellbeing | Everymind

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Being mentally healthy and living well is important to every single one of us - whether we are living with a mental illness or not.

Defining mental health

Mental health is a positive concept related to the social and emotional wellbeing of individuals and communities.

Having good mental health, or being mentally healthy, is more than just the absence of illness, rather it's a state of overall wellbeing.

The concept is influenced by culture, but it generally relates to:

Enjoyment of life

Having the ability to cope with and 'bounce back' from stress and sadness

Being able to set and fulfil goals

Having the capability to build and maintain relationships with others.

The term 'social and emotional wellbeing' is preferred by Aboriginal and Torres Strait Islander peoples as it reflects a more holistic view of health. It is also used by some people from culturally and linguistically diverse backgrounds, who may have differing concepts of mental health and mental illness.

Everymind uses the term 'mental health and wellbeing' to be inclusive of both concepts.

Influences on mental health and wellbeing

Mental health is influenced by several biological, psychological, social and environmental factors which interact in complex ways. These include:

Structural factors such as safe living environments, employment, education, freedom from discrimination and violence, and access to economic resources

Community factors such as a positive sense of belonging, community connectedness, activities to highlight and embrace diversity, social support, and participation in society

Individual factors such as the ability to manage thoughts and cope with stressors and having communication and social skills to support connection with others.

Tips for mental health and wellbeing

We all know that to keep a car going, we have to fill it with petrol, check the oil and water regularly and give the tires some air. To see a bank balance grow, we need to make steady deposits. But how often do we take the time to reflect on whether we are giving ourselves what we need to flourish and live well?

It can be so easy for us to take our mental health for granted; to prioritise other things; to put it off until next week. It can also seem too big and too hard. But it's not. There are some things everyone can do. The following are some tips to get you started

1. Get enough sleep and rest. Sleep affects our physical and mental health, but can be the first thing we trade in when we get busy or stressed

2. Take time out for things you enjoy. Balance in life is important, so taking time out for things you enjoy can make a difference to how you think and feel

3. Be active and eat well. Our physical and mental health is closely linked, so adding exercise and nutritious food every day can make us feel better

4. Nurture relationships and connect with others. Our connection to others is what builds us up and keeps us strong

5. Learn to manage stress. If you have trouble winding down or managing thoughts you may find relaxation, yoga or writing your feelings down helpful

6. Get involved and join in. Being part of a group with common interests provides a sense of belonging so find out about sporting, music, volunteer or community groups locally

7. Build your confidence. Learning improves your mental fitness and taking on a new challenge can build confidence and give you a sense of achievement

8. Be comfortable in your own skin. Everyone is unique and should be celebrated. Know who you are and what makes you happy.

9. Set realistic goals and deal with tasks one at a time. It is good to be specific when you set a goal to help keep you on track

10. Reach out for help when you need it. Everyone needs support from time to time. Talking to a family member, a friend, your doctor or one of the many services available can make all the difference.

Mental health and wellbeing is important to individuals, families, schools, workplaces and communities. There is a role for all of us to play.

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Understanding mental health and wellbeing | Everymind

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Being mentally healthy and living well is important to every single one of us - whether we are living with a mental illness or not. Defining mental health Mental health is a positive concept related to the social and emotional wellbeing of individuals and communities.

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How to Build Your Well-Being to Thrive | Dr. Beth Cabrera | TEDxGeorgeMasonU

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How to Build Your Well-Being to Thrive | Dr. Beth Cabrera | TEDxGeorgeMasonU

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https://youtu.be/04yBH7q1Zc8

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How to Build Your Well-Being to Thrive | Dr. Beth Cabrera | TEDxGeorgeMasonU

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8 ways teachers can support students' mental health during COVID-19 school returns

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8 ways teachers can support students' mental health during COVID-19 school returns

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As adults, we all have diverse needs and different ways of coping with stressful situations. For children, it is the same. Some children will have dealt well with restrictions and school closures caused by the COVID-19 pandemic. For others, it is challenging to cope with all the changes and uncertainty. Some children will return to school having experienced some level of stress, anxiety, isolation and grief. Some may have experienced increased violence at home.

School teachers and personnel are critical in supporting children's transition back to in-person classroom learning, particularly after extended periods of school closure. In addition to continuing to use the different skills teachers have been using to ensure their students' learning and emotional well-being while schools were closed, the following suggestions might be helpful when schools reopen:

1. Listen to children's concerns

COVID-19 and school closures impacted many children and adolescents' mental health and well-being. As teachers, it is essential to listen to students' concerns and demonstrate understanding as well as empathy. Offer your students the opportunity to have a one-to-one conversation with you to reconnect and discuss any concerns that might have arisen when their school was closed. If a child shares anything that is particularly concerning, please follow the protection or child safeguarding systems in place.

2. Check how children are doing

Before teaching new academic content to students, teachers and school personnel should take time to check how children are doing. Remember that children may have difficulty concentrating at first or may need more time to get back into the routine of learning. Provide opportunities for children to take breaks, move around, and re-connect with their friends and peers.

3. Provide children with accurate information around COVID-19

As children return to school, they may have different thoughts and questions about COVID-19. Children want and need factual information. Use child-friendly and age-appropriate resources available in your country/region that is based on scientific evidence to respond to children's questions about COVID-19 accurately.

While it is important to acknowledge the scale of what is happening globally, make sure to emphasize all the efforts made and precautions taken to reduce risks in the school reopening plans. Do not forget to remind children of school safety protocols, including what to do in case there is a COVID-19 case detected in the classroom.

4. Seek suggestions from children on how to create a welcoming, safe and comfortable classroom

Engage children in making the classroom a welcoming, safe and comfortable space. When doing so, make sure to respect school safety procedures and use available material resources.

Children can provide suggestions; help decorate the walls of the classroom with colourful and welcoming messages and work in small groups so they can support each other to catch up on learning. Let them know that being supportive of each other will help them get through this together. Remember to praise children for their contributions and efforts. Teachers can foster feelings of safety and security by interacting and developing positive relationships with each student and using routines during the day to help children feel safe and secure.

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8 ways teachers can support students' mental health during COVID-19 school returns

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Transitioning back to in-person classroom learning during COVID-19

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Have you ever met with a counselor or therapist and thought, " This is not a good fit? "

It might have had something to do with the theories they use to inform their practice.

Counselors and therapists worldwide receive training about the theoretical underpinnings of mental health. They learn how to use those theories to support their work with clients. These professionals use diagnostic tools based on old and new theories of well-being.

What are these theories, and who created them? That is what you will learn as you continue reading.

Before you read on, we thought you might like to download our 3 Positive Psychology Exercises for free. These science-based exercises will explore fundamental aspects of positive psychology including strengths, values and self-compassion and will give you the tools to enhance the wellbeing of your clients, students or employees.

What are Mental Health Theories?

In the sciences, a theory is more than a simple guess. It is a "coherent group of propositions formulated to explain a group of facts or phenomena in the natural world and repeatedly confirmed through experiment or observation" (Dictionary.com, n.d.).

One could create theories about almost anything, but it is rigorous testing that distinguishes simple theories from scientific ones. Not all theories will survive this type of testing. In fact, the acceptance or rejection of parts of theories is not unusual.

Theories developed 50-100 years ago fall into six broad categories. They still influence us today. You might recognize them as:

Analytical/developmental (Freud, Jung, Erickson, Kohlberg)

Behavioral (Watson, Skinner, Pavlov)

Cognitive (Tolman, Piaget, Chomsky)

Social (Bandura, Lewin, Festinger)

Humanistic (Rogers and Maslow)

Personality (Erickson's psychosocial development theory)

From these, many contemporary theories followed. Some are specific to a domain like development. Others make use of neuroimaging to explain why we do the things we do.

Mental health theories strive to explain human development behaviorally, psychologically, and socially. For many years, researchers focused on alleviating pain or suffering. The approach centered on what was wrong with a person and how to fix it. There was no assumption that a person could strengthen their well-being.

A Look at the Models and Methods

Mental health and well-being experts draw from other areas to inform their perspective. They also review a person's mental health within context. An act could be psychopathological in one cultural context but not in another.

The main areas from which counselors, psychologists, and psychiatrists gain understanding about mental health are (Dasgupta, 2013):

Biopsychosocial - The interplay of biological, psychological, and social factors explains mental illness. This depends on the person and their environment.

Methods

The diagnosis and treatment of mental illness vary, but many therapists use the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This tool provides clear definitions of and criteria for more than 265 disorders. Diagnosis usually includes a physical exam, including lab tests, and a psychological evaluation (Mayo Clinic, n.d.).

There are approximately 20 classes of mental illness covering everything from neurodevelopmental to paraphilic disorders.

Some treatment methods are medications, psychotherapy, brain-stimulation, hospital and residential treatment programs, and substance misuse treatment.

There are three ways to experience therapeutic intervention. Sometimes therapists use a combination of these. Each environment stresses confidentiality and creating a safe space for people to share.

Individual counseling - This is a one-one session with a trained counselor. Depending on the type of therapy used, these sessions can continue for months or years.

Group Counseling - People with similar challenges work together with a trained counselor. The goals are to talk about issues, share knowledge, and solutions.

Family therapy - This method involves helping a family improve their communication. Through the guidance of a licensed therapist, they learn conflict resolution techniques. Not every family member necessarily participates, and it is often short term.

Mental Health Counseling Theories

There are five schools of thought that attempt to explain mental health. Many therapists and counselors operate from one or two of these.

Theories guide the services and interactions therapists have with their clients. This is important to know because it can affect how well you and your therapist "click."

The five schools of thought are:

Humanistic - Three different therapies can help people achieve their highest potential. Client-centered therapy, developed by Carl Rogers, allows the client to investigate who they are at their core. The therapist creates an environment of empathy, acceptance, and genuineness. This encourages the client in their self-exploration. Gestalt Therapy, created by Frederick Perls, is present-focused and involves role-playing. Existential therapy is about ownership of one's life, including all its mishaps. The responsibility of one's life is one's own.

It is easy to understand how a therapist influenced by one of these theories might interact with a client. Positive psychology practitioners, for example, primarily follow humanistic theories. One would expect this therapist to be empathetic and stress ownership and responsibility. The sessions would include a healthy dose of self-exploration, especially related to developing strengths.

A List of Popular Mental Health Theories

Every theory of mental health comes from one of the above five areas or a combination of them. Here is a brief overview of theories derived from those broader categories.

Network theory explains that "mental disorders arise from direct interactions between symptoms" (Borsboom, 2017). The biological, psychological, and societal influences facilitate the connection between Psychopathological symptoms.

Cognitive-behavioral Therapy (CBT) focuses on assisting the person in changing destructive thoughts and behaviors. It is a type of psychotherapy that helps a client to quickly identify and manage problems. The approach is goal-oriented and often involves homework. The homework helps to reinforce the in-person sessions. It is the "gold standard in the psychotherapy field" (David, Cristea, & Hofmann, 2018).

Operant conditioning still is a popular approach. Whether used by therapists or physical trainers, it involves identifying the cue-routine-reward pattern. The goal is to change the person's behavior by changing the routine and sometimes the reward. It is often used in the treatment of OCD through exposure therapy.

Exposure therapy allows the person to engage with the source of their anxiety in a safe space. The goal is to slowly, and incrementally, increase the person's exposure to their fear. There are several variations of exposure therapy (APA, n.d.).

It is useful in the treatment of:

Phobias

Panic Disorder

Social Anxiety Disorder

Obsessive-Compulsive Disorder

Post-traumatic Stress Disorder

Generalized Anxiety Disorder

Classical conditioning also remains a popular treatment for phobias through the use of systematic desensitization. This is a variant of exposure therapy (Grace College, 2016).

Popular Mental Health Theories on Well-Being

The Self-determination Theory of motivation (SDT), and more specifically, the Basic Psychological Needs Theory (BPNT) posit that autonomy, competence, and relatedness are the primary supports for well-being and optimal functioning (SDT, n.d.) If anyone of these is faulty, then the person's well-being decreases. Intrinsic motivation increases through the satisfaction of having these needs met (read more about intrinsic coaching here).

The Broaden and Build Theory of Positive Emotions (Fredrickson, 1998, 2000) changed the discussion around emotions. Many of the psychological theories and research before this dealt with negative affect. These are emotions like anger, fear, sadness, guilt, and shame (Stringer, 2013).

Fredrickson argued that negative emotions create a sort of tunnel vision. Positive affect widens one's perspective. Positive emotions like awe, joy, and gratitude expand one's experience within the environment. The theory doesn't advocate ignoring negative emotions. Instead, it discusses the ramifications of continuing to ignore positive ones.

The focus of the PERMA Theory of well-being (Seligman, 2011) is helping people to thrive. It promotes building skills that allow one to flourish (Positive Psychology Center, n.d.). Many contemporary theories attempt to help a person reduce suffering. PERMA theory of well-being states that well-being consists of five elements:

1. Positive emotion - These emotions increase our hedonic happiness.

2. Engagement - This is the flow that Mihaly Csikszentmihalyi discusses. Being engrossed in one's pursuit is the reward.

3. Relationships - Support is critical to our survival and emotional well-being.

4. Meaning - Serving or working in a capacity that contributes to something larger than ourselves gives us a sense of purpose and meaning.

5. Achievement - We enjoy pursuing accomplishments for the sake of doing so.

Each of these contributes in varying degrees to a person's ability to flourish. Positive psychology therapists and coaches often use this as a backdrop for their sessions.

A Take-Home Message

There are several mental health theories, but they all come from one of five schools of thought. They are behaviorism, biological, psychodynamic, cognitive, and humanistic.

In recent years, there has been a move toward studying how people flourish. This is positive psychology. Unlike previous years, this field of research explores what humans already do well. Doing this type of research helps others to increase their opportunities to thrive.

If you seek the help of a therapist or counselor, it is important to know the basis for their approach. You do not want to see a behavioral psychologist to flesh out how you can find meaning in your life. They are better suited for helping you change, develop, or extinguish a habit.

The continued study of mental health, including the more positive aspects, is critical to each person's well-being.

What are you doing today to flourish in your life?

If you enjoyed reading about mental health theories, why not head on over to mental health books for even more reading material.

We hope you enjoyed reading this article. Don't forget to download our 3 Positive Psychology Exercises for free.

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What are Mental Health Theories? (Incl. List)

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Have you ever met with a counselor or therapist and thought, " This is not a good fit? " It might have had something to do with the theories they use to inform their practice. Counselors and therapists worldwide receive training about the theoretical underpinnings of mental health.

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A new approach to mental health in universities | Conrad Hogg | TEDxUWA

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A new approach to mental health in universities | Conrad Hogg | TEDxUWA

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https://youtu.be/203NKw-G-oY

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A new approach to mental health in universities | Conrad Hogg | TEDxUWA

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https://fenwayhealth.org/the-importance-of-mental-health-awareness-month/

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Fenway Health: Health Care Is A Right, Not A Privilege.

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The Importance of Mental Health Awareness Month - Fenway Health

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May is Mental Health Awareness Month, also known as Mental Health Month. It has been observed each May in the United States since 1949. It has never been more

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Comprehensive School-Based Mental and Behavioral Health Services and School Psychologists

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Comprehensive School-Based Mental and Behavioral Health Services and School Psychologists

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National Association of School Psychologists (NASP)

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Mentally healthy children are more successful in school and life. Good mental health is critical to children's success in school and life. Research demonstrates that students who receive social-emotional and mental and behavioral health support achieve better academically. School climate, classroom behavior, engagement in learning, and students' sense of connectedness and well-being all improve as well. Mental health is not simply the absence of mental illness but also encompasses wellness promotion; social, emotional, and behavioral health; and the ability to cope with life's challenges. Left unmet, mental health problems are linked to costly negative outcomes such as academic and behavior problems, dropping out, and delinquency. Mental and behavioral health problems not only affect students' short-term classroom engagement, but also interfere with long-term development of positive relationships and work-related skills.

There is a growing and unmet need for mental and behavioral health services for children and youth. According to the U.S. Department of Health and Human Services, one in five children and adolescents experience a mental health problem during their school years. Examples include stress, anxiety, bullying, family problems, depression, learning disability, and alcohol and substance abuse. Serious mental health problems, such as self-injurious behaviors and suicide, are on the rise, particularly among youth. Unfortunately, many children and youth do not receive the help they need, and disparities in access to care exist among low-income communities and minoritized youth. Among the 3.8 million adolescents ages 12-17 who reported a major depressive episode in the past year, nearly 60% did not receive any treatment, according to a 2019 report by the Substance Abuse and Mental Health Services Administration. Of the adolescents who do get help, nearly two thirds do so only in school.

Schools are an ideal place to provide mental and behavioral health services to children and youth. Schools provide an ideal context for prevention, intervention, positive development, and regular communication between school and families. Schools also offer caring relationships and regular, consistent connections between students and staff both in person and virtually. School-employed mental health professionals (i.e., school psychologists, school counselors, school social workers, and school nurses) know the students, parents, and other staff, which contributes to accessibility of services. Research shows that students are more likely to seek counseling when services are available in schools. In some cases, such as rural areas, schools provide the only mental health services in the community. Comprehensive, culturally responsive school mental health services can help address inequities in access and help reduce the stigma associated with receiving mental health services by making it part of the fabric of the school system.

Comprehensive school mental and behavioral health services support the mission and purpose of schools: learning. All services provided in schools should be appropriate to the learning environment; those that are not risk being ineffective or even counterproductive. Just as children are not simply small adults, schools are not merely private clinics with white boards. Being trained to work within the school culture is essential to being effective (and cost-effective). School psychologists have specialized training in child development, mental health, learning, diversity, culturally responsive services, and school systems and law. Their unique expertise lies in how these elements interact to shape children's behavior, learning, and overall adjustment.

Comprehensive school mental health services are essential to creating and sustaining safe schools. Increased access to mental health services in schools is vital to improving the physical and psychological safety of our students and schools, as well as academic performance and problem-solving skills. Culturally responsive school mental health supports that encompass social-emotional learning, mental wellness, behavioral health, resilience, and positive connections between students and adults are essential to creating a school culture in which students feel safe and empowered to report safety concerns, which is proven to be among the most effective school safety strategies. Additionally, in the aftermath of a crisis, school-employed mental health professionals provide supports that facilitate a return to normalcy, are sustainable, and can help to identify and work with students with more intense or ongoing needs.

Providing a continuum of school mental and behavioral health services is critical to effectively addressing the breadth of students' needs. Comprehensive mental health services are most effective when provided through a multitiered system of supports (MTSS). MTSS encompasses the continuum of need, enabling schools to promote mental wellness for all students, identify and address problems before they escalate or become chronic, and provide increasingly intensive, data-driven services for individual students as needed. Access to adequate staffing of school-employed mental health professionals, like school psychologists, is essential to the quality and effectiveness of these services.

School psychologists provide a continuum of services that connect mental health, behavior and learning, school and home, and school and community services. Meeting the full continuum of student needs requires collaboration and coordination. Typically, community providers offer supplementary or intensive services that go beyond school capacities. An MTSS approach facilitates collaboration while ensuring that services provided in school are appropriate to the learning context and those that are provided after school hours are appropriately linked to and supported in the school setting. Partnerships are most effective when they are coordinated by school-employed mental health professionals, are defined by clear memoranda of understanding, and reinforce an appreciation for the unique contribution each group makes to creating more seamless and comprehensive service delivery. This not only reduces gaps, redundancy, and conflict, it also reduces stress on families and supports their roles as primary caregivers and decision makers regarding their child's development.

School psychologists are part of a team of school-employed mental health professionals who provide these services. Improving staffing ratios for these professionals is critical to adequately supporting students' mental and behavioral health. For more information on school-based mental health services and the role of school psychologists, visit www.nasponline.org.

Please cite this document as:

National Association of School Psychologists. (2021). Comprehensive School-Based Mental and Behavioral Health Services and School Psychologists [handout]. Author.

© 2021, National Association of School Psychologists, 4340 East West Highway, Suite 402, Bethesda, MD 20814, 301-657-0270, www.nasponline.org

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Comprehensive School-Based Mental and Behavioral Health Services and School Psychologists

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Mentally healthy children are more successful in school and life. Good mental health is critical to children's success in school and life. Research demonstrates that students who receive social-emotional and mental and behavioral health support achieve better academically. School climate, classroom behavior, engagement in learning, and students' sense of connectedness and well-being all improve as well.

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Graduate School of Education, Nazarbayev University, Nur-Sultan, Kazakhstan

Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan

Psychological Counseling Center, Nazarbayev University, Nur-Sultan, Kazakhstan

The purpose of this study is to map the literature on mental health and well-being of university students using metadata extracted from 5,561 journal articles indexed in the Web of Science database for the period 1975-2020. More specifically, this study uses bibliometric procedures to describe and visually represent the available literature on mental health and well-being in university students in terms of the growth trajectory, productivity, social structure, intellectual structure, and conceptual structure of the field over 45 years. Key findings of the study are that research on mental health and well-being in university students: (a) has experienced a steady growth over the last decades, especially since 2010; (b) is disseminated in a wide range of journals, mainly in the fields of psychology, psychiatry, and education research; (c) is published by scholars with diverse geographical background, although more than half of the publications are produced in the United States; (d) lies on a fragmented research community composed by multiple research groups with little interactions between them; (e) is relatively interdisciplinary and emerges from the convergence of research conducted in the behavioral and biomedical sciences; (f) tends to emphasize pathogenic approaches to mental health (i.e., mental illness); and (g) has mainly addressed seven research topics over the last 45 years: positive mental health, mental disorders, substance abuse, counseling, stigma, stress, and mental health measurement. The findings are discussed, and the implications for the future development of the field are highlighted.

Introduction

The entrance to the university marks a period of transition for young people. Through this transition, students face new challenges, such as making independent decisions about their lives and studies, adjusting to the academic demands of an ill-structured learning environment, and interacting with a diverse range of new people. In addition, many students must, often for the first time, leave their homes and distance themselves from their support networks ( Cleary et al., 2011). These challenges can affect the mental health and well-being of higher education students. Indeed, there is evidence that a strain on mental health is placed on students once they start at the university, and although it decreases throughout their studies ( Macaskill, 2013; Mey and Yin, 2015), it does not return to pre-university levels ( Cooke et al., 2006; Bewick et al., 2010). Also, the probabilities of experiencing common psychological problems, such as depression, anxiety, and stress, increase throughout adolescence and reach a peak in early adulthood around age 25 ( Kessler et al., 2007) which makes university students a particularly vulnerable population.

The interest in mental health and well-being in university students has grown exponentially in the last decades. This is likely due to three interrelated challenges. First, although university students report levels of mental health similar to their non-university counterparts ( Blanco et al., 2008), recent studies suggest an increase and severity of mental problems and help-seeking behaviors in university students around the world in the last decade ( Wong et al., 2006; Hunt and Eisenberg, 2010; Verger et al., 2010; Auerbach et al., 2018; Lipson et al., 2019). Some researchers refer to these trends as an emerging "mental health crisis" in higher education ( Kadison and DiGeronimo, 2004; Evans et al., 2018). Second, psychological distress in early adulthood is associated with adverse short-term outcomes, such as poor college attendance, performance, engagement, and completion (e.g., King et al., 2006; Antaramian, 2015), and others in the long term, such as dysfunctional relationship ( Kerr and Capaldi, 2011), recurrent mental health problems, university dropout, lower rates of employment, and reduced personal income ( Fergusson et al., 2007). Third, there is a widespread agreement that higher education institutions offer unique opportunities to promote the mental health and well-being of young adults as they provide a single integrated setting that encompasses academic, professional, and social activities, along with health services and other support services ( Eisenberg et al., 2009; Hunt and Eisenberg, 2010). However, the majority of university students experiencing mental health problems and low levels of well-being are not receiving treatment ( Blanco et al., 2008; Eisenberg et al., 2011; Lipson et al., 2019) and, while universities continue to expand, there is a growing concern that the services available to provide support to students are not developing at an equivalent rate ( Davy et al., 2012).

In response to the increasing volume of research on the mental health and well-being of university students, there have been several attempts to synthesize the accumulating knowledge in the field and to provide an illustration of the theoretical core and structure of the field using traditional content analysis of the literature (e.g., Kessler et al., 2007; Gulliver et al., 2010; Hunt and Eisenberg, 2010; Sharp and Theiler, 2018). This study aims to extend the understanding of mental health in university students by providing a bird's eye view of the research conducted in this field in recent decades using a bibliometric approach. Bibliometric overviews provide an objective and systematic approach to discover knowledge flows and patterns in the structure of a field ( Van Raan, 2014) reveal its scientific roots, identify emerging thematic areas and gaps in the literature ( Skute et al., 2019) and, ultimately, contribute to moving the field forward. Accordingly, this study employs several bibliometric indicators to explore the evolution of the field based on publication and citation trends, key actors and venues contributing to the advancement of research on mental health and well-being of university students, and the structure of the field in terms of patterns of scientific collaborations, disciplines underlying the foundations of the field, and recurrent research themes explored in the literature. This is important because, despite significant advances in the field, research on mental health and well-being remains a diverse and fragmented body of knowledge ( Pellmar and Eisenberg, 2000; Bailey, 2012; Wittchen et al., 2014a). Indeed, mental health and well-being are nebulous concepts and their history and development are quite intricate, with a multitude of perspectives and contributions emerging from various disciplines and contexts (see section "Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview"). Therefore, mapping research on mental health and well-being in university students is essential to identify contributions and challenges to the development of the field, to help guide policy, research, and practice toward areas, domains, populations, and contexts that should be further explored, and to provide better care of students at higher education institutions ( Naveed et al., 2017).

Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview

This section provides an overview of the different perspectives adopted in the literature to conceptualize mental health, well-being, and other relevant constructs in order to identify the glossary of key terms that will be used in the search strategy to create a comprehensive corpus of documents on mental health and well-being in university students for this bibliometric review.

Perspectives on Mental Health and Mental Illness

There is no general agreement on the definition of mental health. For a long time, the term mental health has been used as a euphemism for mental illness ( Manwell et al., 2015). However, mental health and mental illness are regarded as distinct constructs nowadays and two main perspectives differentiating between mental health and illness are available in the literature. The continuum approach considers that mental health and mental illness are the two opposite poles of a continuum. Thus, there are various degrees of health and illness between these poles, with most of us falling somewhere in between. The categorical approach, on the other hand, represents mental health and illness as a dichotomy. People who manifest mental illness symptoms would belong to that category and labeled correspondingly, while those absent of these symptoms can be considered as mentally healthy ( Scheid and Brown, 2010).

Disciplinary Approaches to the Conceptualization of Mental Health/Illness

Conceptualizations of mental health/illness are largely dependent on the theoretical and paradigmatic foundations of the disciplines from which they emerge. In this context, the field has progressively evolved through the accumulation of knowledge generated in a diverse range of disciplines in the biomedical, behavioral, and social sciences. Biomedical disciplines are grounded in the medical paradigm focused on disease and (ab)normality and often emphasize dichotomous conceptions of mental health/illness ( Scheid and Brown, 2010). Research on mental health and well-being in this domain has been traditionally conducted from a psychiatric perspective, which aims to understand the dysfunctionality in the brain that leads to psychiatric symptoms and to also offer a pharmacological treatment to correct neuronal dysfunctions. Consequently, psychiatrists have historically considered mental health as a disease of the brain (e.g., depression), similar to any other physical disease, caused by genetic, biological, or neurological factors ( Schwartz and Corcoran, 2010). While the prevalence of psychiatric approaches to mental health is currently incontestable, the development of other biomedical disciplines has tremendously contributed to the progression of the field in recent decades. For example, Insel and Wang (2010) argue that insights gained from genetics and neuroscience contribute to the reconceptualization of "the disorders of the mind as disorders of the brain and thereby transform the practice of psychiatry." (1979). In addition to that, other disciplines such as behavioral medicine have made important contributions to the field, although it has recently argued that mental health and behavioral medicine should be as two separate fields ( Dekker et al., 2017).

Within the behavioral sciences, the study of mental health focuses on the distinct psychological processes and mechanisms that prompt thoughts, feelings, and behaviors ( Peterson, 2010). Clinical psychology has the longest tradition in the psychological study of mental health and tends to focus on the assessment and treatment of mental illness and disorders that can alleviate psychological distress or promote positive states of being ( Haslam and Lusher, 2011). However, significant contributions to the field have also emerged from other branches of psychology less focused on psychopathology, including personality and social psychology, psychoanalysis, humanistic psychology, and cognitive psychology ( Peterson, 2010). Despite the diversity of theories, principles, and methodological approaches to understanding mental health within the behavioral sciences, these disciplines acknowledge that mental health have a biological basis and reside in the social context, and tend to prioritize continuum approaches to mental health ( Scheid and Brown, 2010).

Perspectives from the social sciences complement the biomedical and behavioral approaches by considering the influence of social and cultural environments in mental health/illness ( Horwitz, 2010). For example, sociologists are interested in how social circumstances (e.g., level of support available) affect levels of mental health/illness and how social structures shape the understanding and response to mental health issues [see Compton and Shim (2015) for an overview of the social determinants of mental health]. Similarly, medical anthropologists attend to the mental health beliefs and practices that form the cultural repertory within and across populations ( Foster, 1975). Beyond sociology and anthropology, social researchers in the fields of business and economics, family and ethnic studies, and educational research have also played a key role in advancing research on mental health in different directions.

The Importance of the Context in Mental Health

Certainly, most notions of mental health/illness in the literature derive from prevailing psychiatric and psychological traditions developed in Western countries ( Gopalkrishnan, 2018). However, cultural values and traditions do shape how mental health and mental illness are conceptualized across contexts ( Vaillant, 2012). In this regard, Eshun and Gurung (2009) pointed out that "culture influences how individuals manifest symptoms, communicate their symptoms, cope with psychological challenges, and their willingness to seek treatment." (4). Fernando (2019) argued that issues related to the 'mind' developed and are often interpreted very differently in non-Western and Low- and Middle-Income Countries (LMICs). For example, cultures explain the manifestation of certain feelings and behaviors based on a range of motives including biological, psychological, social, religious, spiritual, supernatural, and cosmic. Failure to acknowledge alternative non-Western approaches to mental health and mental illness has resulted in imbalances of knowledge exchange and the permeation of dominating Western narratives into LMICs (i.e., so-called medical imperialism) ( Timimi, 2010; Summerfield, 2013). To address this issue, scholars have advocated for a greater willingness to embrace pluralism in the conceptualization of mental health and illness, which might help people to engage with particular forms of support that they deem to be appropriate for them, and to explore how knowledge and practices developed in LMICs can benefit those living in higher-income countries (i.e., knowledge "counterflow") (see White et al., 2014).

Prioritizing Positive Mental Health: The Science of Well-Being

Despite the diversity of disciplinary and contextual approaches to mental health, current definitions of mental health have two things in common. First, mental health is considered from a biopsychosocial point of view that incorporates biological, psychological, and social factors. Second, mental health implies something beyond the absence of mental illness (e.g., Bhugra et al., 2013; Galderisi et al., 2015). An example is the definition by the World Health Organization which refers to mental health as "a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community" ( World Health Organization, 2004). This definition contributed to substantial progress in research and practice in the field as it expanded the notion of mental health beyond the absence of mental illness and integrated the presence of positive features ( Galderisi et al., 2015).

Research on positive mental health is relatively new but has grown rapidly in the last decades fueled by advocates of positive medicine and psychology, who have argued for a change of paradigm from medical and psychopathological-oriented models of mental health that focus on disorders and illness toward more strength-based approaches, which pay more attention to what is right about people and positive attributes and assets ( Kobau et al., 2011). In this regard, the term mental well-being has been progressively incorporated into the study of mental health to account for the positive aspects of mental health beyond the absence of negative factors. While there is not a universally accepted definition of well-being, two perspectives have dominated the discourses on well-being in the literature: subjective well-being (SBW) and psychological well-being (PWB). SWB is based on hedonic perspectives of pleasure and represents "people's beliefs and feelings that they are living a desirable and rewarding life" ( Diener, 2012). SBW is strongly linked with the idea of happiness and is typically understood as the personal experience of high levels of positive affect, low levels of negative affect, and high satisfaction with one's life ( Deci and Ryan, 2008). PWB is grounded in Aristotelian ideas about eudaimonia, i.e., self-realization, with the ultimate aim in life being to strive to realize one's true potential ( Ryff and Singer, 2008). PWB has been broadly defined as a state of positive psychological functioning and encompasses six dimensions: purpose in life (i.e., the extent to which respondents felt their lives had meaning, purpose, and direction); autonomy (i.e., whether they viewed themselves as living in accord with their own convictions); personal growth (i.e., the extent to which they were making use of their personal talents and potential); environmental mastery (i.e., how well they were managing their life situations); positive relationships (i.e., the depth of connection they had in ties with significant others); and self-acceptance (i.e., the knowledge and acceptance they had of themselves, including awareness of personal limitations) ( Ryff, 1989).

Integrating Mental Health, Mental Illness, and Well-Being

The contribution of positive mental health frameworks to the advancement of the field has been undeniable. However, definitions that overemphasize positive emotions and productive functioning as key indicators of mental health have been recently challenged because of the potential they have to discriminate against individuals and groups that, for example, might not be able to work productively or function within the environment because of individual physical characteristics or contextual constraints ( Galderisi et al., 2015). To address these issues, Keyes has successfully integrated the notions of mental illness, mental health, well-being, and other related terms in the literature into a conceptual framework that allows for a more comprehensive understanding of mental health ( Keyes, 2005, 2007; Keyes and Michalec, 2010). The model argues that neither pathogenic approaches focusing on the negative (e.g., mental illness) nor salutogenic approaches focusing on the positive (e.g., well-being) can alone accurately describe the mental health of a person ( Keyes and Michalec, 2010). Instead, the model proposes that mental illness and well-being represent two correlated but differentiated latent continua in defining mental health. More specifically, mental illness and well-being lie on two separate spectra, the first going from absent to present mental illness and the second running from low to high well-being ( Slade, 2010). The absence of mental illness, therefore, does not necessarily imply high levels of well-being. Correspondingly, low levels of well-being do not always indicate the presence of mental illness. Further, in this model, mental health is defined as not only the absence of mental illness, not the mere presence of high well-being. Complete mental health (i.e., flourishing) is a result of experiencing low mental illness and high levels of well-being. Incomplete mental health (i.e., languishing), on the other hand, refers to the absence of mental illness symptoms and low reported levels of well-being. Two other conditions are possible within this framework. Incomplete mental illness (i.e., struggling) refers to high levels of well-being accompanied by high mental illness symptoms. Lastly, complete mental illness (i.e., floundering) accounts for low levels of well-being and high mental illness symptoms ( Keyes and Lopez, 2002).

The Present Study

In light of the complexity of the constructs of mental health and well-being and the multiple theoretical, disciplinary, and contextual approaches to their conceptualization, this study seeks to map out the terrain of international research and scholarship on mental health and university students for the period 1975-2020. More specifically, this study aims to provide new insights into the development and current state of mental health research in university students by mapping and visually representing the literature on mental health and well-being of university students over the last 45 years in terms of the growth trajectory, productivity, and social, intellectual, and conceptual structure of the field. First, the study describes the development of research mental health and well-being in university students examining the trends in publication and citation data between 1975 and 2020 (i.e., growth trajectory). Second, the study identifies the core journals and the research areas contributing most to the development of the field, as well as the key authors and countries leading the generation and dissemination of research on mental health and well-being in university populations (i.e., productivity). Third, the study outlines the networks of scientific collaboration between authors, and countries (i.e., social structure). Fourth, the scientific disciplines underlying the intellectual foundations of research on mental health and well-being in university settings (i.e., intellectual structure) are uncovered. Fifth, the study elucidates the topical foci (i.e., conceptual structure) of the research on the mental health and well-being of university students over the last 45 years.

Materials and Methods

A bibliometric approach was used in this study to map the literature on mental health and well-being in university students over the last 45 years using metadata extracted from four indexes of the Web of Science (WoS): The Science Citation Index-Expanded (SCI-Expanded); the Social Sciences Citation Index (SSCI); the Arts & Humanities Citation Index (A&HCI); and the Emerging Sources Citation Index (ESCI). Several reasons justified the selection of the WoS database in this study. First, the WoS remains as the standard and most widely used for bibliometric analysis ( Meho and Yang, 2007). Second, the WoS is a multidisciplinary database and includes publications on mental health and well-being emerging from distinctive research areas and disciplines published in more than 20,000 journals ( McVeigh, 2009). Using specialized databases such as PubMed would introduce biases into the search strategy favoring biomedical research disciplines. Still, it is important to note that interdisciplinary databases such as WoS and Scopus discriminate against publications in the Social Sciences and Humanities and publications in languages other than the English language ( Mongeon and Paul-Hus, 2016), so the picture provided by WoS is still imperfect. Third, while other databases might provide wider coverage, WoS includes publication and citation information from 1900. For example, Scopus has complete citation information only from 1996 ( Li et al., 2010). Moreover, Google Scholar provides results of inconsistent accuracy in terms of citations, and citation analyses in PubMed are not available ( Falagas et al., 2008). Fourth, WoS has demonstrated better accuracy in its journal classification system compared to Scopus database ( Wang and Waltman, 2016).

The methodological approach used in this study is presented in Figure 1 and further elaborated in the following paragraphs.

Search Strategy

To create a comprehensive corpus of documents on the mental health and well-being of university students, three parallel searches were performed, which accounted for the multiple approaches and perspectives that have been used in the field, as identified in the Section "Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview." All the searches were conducted in the last week of January 2020. The first search aimed at capturing research on mental health broadly and included one single keyword in the topic field: ["mental health"]. The second search was implemented to capture research focusing on pathogenic approaches to mental health. Key terms used in the literature to refer to the negative side of mental health, as well as the most frequent mental health problems experienced by university students, were introduced in this search in the title field: ["mental illness," "mental disorder ∗," "mental distress," "psychological distress," "psychopathology," "depression," "anxiety," "stress," "suicide," "eating disorder ∗," "substance use"]. In the third search, keywords reflecting salutogenic approaches to mental health were input. These included terms related to mental health from a positive mental health perspective (i.e., well-being). These key terms were added in the title field and included the following: ["well-being," "wellbeing," "wellness," "life satisfaction," "happiness," "positive affect," "purpose in life," "personal growth," "self-determination"].

To retrieve research relevant only to higher education students, another set of keywords was imputed in all three searches in the title field. These included: ["university," "college," "higher education," "tertiary education," "post-secondary education," "postsecondary education," "undergrad ∗ student," "grad ∗ student," "master's student," "doctoral student," "Ph.D. student"]. The Boolean operator OR was used between keywords in all the three searches to secure a higher number of relevant hits. Also, asterisks were used as wildcards to account for multiple variations in several keywords (e.g., disorder and disorder-s). All searches were limited to journal articles published between 1975 and 2020 (both inclusive). No restrictions on language were implemented in the search.

The search strategy retrieved a total of 6,356 hits ( n search 1 = 2782; n search 2 = 2814, n search 3 = 760). After the removal of duplicates, 5,561 research articles were finally selected and retained for the study. For each of the documents obtained in the search, the authors extracted metadata about the title of the paper, the year of publication, the journal, the number of citations, and the authors' name, organization, and country. Also, the title, the abstract, the author's keywords, and cited references were retrieved.

Data Analysis Procedures

The corpus of the literature was then analyzed using descriptive and bibliometric approaches to provide an overall picture of the evolution and current state of the research on mental health and wellbeing in university settings. Frequency counts of the number of publications and citations per year were obtained to describe the growth trajectory of research on the mental health and well-being of university students. Rank ordered tables were produced to describe the productivity of the field in terms of core journals and research areas, as well as leading scholars and countries contributing to the development of the field.

Bibliometric analyses in VOSViewer software were implemented to examine and visually represent the social, intellectual, and conceptual structure of the field. VOSViewer is a freely available computer software for viewing and constructing bibliometric maps. In VOSViewer, the units of analysis are journals, publications, citations, authors, or countries, depending on the focus of the analysis. The units of analysis are represented in the maps as circular nodes. The size of the node accounts for volume (e.g., number of publications in the dataset by an author) and the position represents the similarity with other nodes in the map. Closer nodes are more alike than nodes far apart from each other. The lines connecting nodes represent the relationship between nodes and their thickness indicates the strength of that relationship. Finally, the color of the node denotes the cluster to which each node has been allocated. Nodes are clustered together based on relatedness ( Van Eck et al., 2010). The software uses a distance-based approach to constructing the bibliometric maps in three steps ( Van Eck and Waltman, 2014). In the first step, the software normalizes the differences between nodes. In the second step, the software builds a two-dimensional map where the distance between the nodes reflects the similarity between these nodes. In the third step, VOSViewer groups closely related nodes into clusters ( Van Eck and Waltman, 2014).

A series of co-authorship analyses were performed to examine the social structure of research on mental health and well-being in university students. In these analyses, the units of analysis were authors and countries/territories. Each node in the map represents an author or a country/territory and the lines connecting them reflect the relationship between nodes. Clusters represent networks of scientific collaboration, which might be interpreted as groups of authors or countries frequently publishing together (e.g., research groups in the case of authors).

Co-citation analysis of journals was implemented to explore the intellectual structure of the field. Here, the units of analysis were journals in the dataset and the map reflects co-citation relationships between journals. Two journals are co-cited if there is a third journal citing these two. The more times a pair of journals are cited by other journals, the stronger their co-citation relationship will be. Frequently co-cited journals are assumed to share theoretical and semantical grounds. Therefore, in our study, clusters of frequently co-cited journals can be interpreted as disciplines underlying the foundations of research on mental health and well-being in university students.

Finally, a co-occurrence analysis of keywords was used to uncover the conceptual structure of the field. The units of analysis, in this case, were the authors' keywords. The more often two keywords appear in the same record, the stronger their co-occurrence relationship. Clusters of co-occurring keywords represent in this study the topical foci (i.e., knowledge base) that have been addressed in the literature in mental health and well-being in university students in the last 45 years.

Findings and Discussion

Growth Trajectory: Evolution of Publications and Citations in the Field

The developmental patterns of a particular field can be well demonstrated by trends in publications and citations. The 5,561 publications in the dataset have been cited 87,096 times, with an average of 15.6 citations per item. Figure 2 shows the growth trajectory of publication data of research on mental health and well-being in university students from 1975 to January 2020. Overall, the trends demonstrate a gradual increase in the scholarly interest in the mental health of university students over the last 45 years that can be organized in three stages: an emergence stage, in which publications rose slowly (1975-2000); a fermentation stage, with a notable increase in publications in the field (2000-2010); and a take-off stage, during which the number of records published per year in the field has almost risen 10 times (2010-2020). The steady increase of publications in the last 15 years coincides with the first calls for attention on the increase and severity of mental problems and help-seeking behaviors of college students ( Kadison and DiGeronimo, 2004; Evans et al., 2018), potentially indicating a growing interest in exploring the epidemiology of mental disorders and the role of universities in promoting the mental health and well-being of students. A similar pattern has also been observed in a recent bibliometric study examining global research on mental health both in absolute terms and as a proportion of all papers published in medicine and across disciplines, which certainly reflects an increase in the general interest in the field ( Larivière et al., 2013).

Productivity I: Core Journals and Research Areas

In total, 1,560 journals published the 5,561 records included in the dataset. Table 1 presents the ten core journals in the field. The Journal of American College stands out as the main publication venue in the field, accumulating around 5% of the publications in the dataset ( n = 270). Psychological Reports and Journal of College Student Development also stand out, publishing 119 and 102 studies, respectively. The Journal of Counseling Psychology ranks fourth in the list with 83 records. Despite being an interdisciplinary and relatively young journal, Plos One appears in the top five journal publishing research on mental health and well-being in university students.

The top research areas contributing to the publication of research on the mental health and well-being of university students are presented in Table 2. Nearly half of the records in the dataset are published in psychology journals. Another influential research area in the field is psychiatry, which captures almost 20% of the publications. Journals on education and educational research also accumulate a considerable number of publications in the field (15%). Other relevant research areas in the field are connected with health and medicine, including public environmental occupational health, substance abuse, general internal medicine, neurosciences neurology, health care sciences services, and nursing. Finally, the field is also grounded, although to a lower extent, in the publications emerging from journals in the social sciences, family studies, and social work research.

All in all, the productivity analysis for journals and research areas showed that most research on mental health and well-being in university students is disseminated in journals in the "psy disciplines"' (i.e., psychology and psychiatry) ( McAvoy, 2014), which is consistent with previous research on mental health in general populations (e.g., Haslam and Lusher, 2011). However, our findings demonstrated that the volume of research in psychology doubles that of research emerging from psychiatric journals. This contrasts with the findings by Haslam and Lusher (2011), who demonstrated that psychiatry journals had a greater influence on mental health research compared to clinical psychology journals and that psychiatry journals accumulate a higher volume of research and citations on mental health research. This is probably because our study includes publications emerging from all branches of psychology, unlike the study by Haslam and Lusher, which included only journals in the field of clinical psychology. Additionally, mental health services in higher education are typically provided by counseling centers led and staffed by non-medical professionals (e.g., psychologists, social workers, counselors, and family therapists) who tend to adopt developmental models of practice grounded in the behavioral sciences and focused on adjustment issues, vocational training, employment, and other personal needs rather than diagnosis and symptom reduction, more common in the biomedical sciences (i.e., psychiatry) ( LeViness et al., 2018; Mitchell et al., 2019).

Productivity II: Leading Authors and Countries/Territories

The 5,561 publications in the dataset were published by a total of 16,161 authors from 119 countries worldwide. Table 3 shows the researchers with the highest number of publications in the field. D. Eisenberg appears as the most productive researcher, followed by K. Peltzer and S. Pengpid. Authors on the list come from diverse geographical backgrounds. Five of the authors work at three different American universities (University of Michigan, Harvard Medical School, and Boston University), two researchers work at KU Leuven University (Belgium), and two other authors are affiliated to the same two universities in Thailand and South Africa. Other prolific researchers are affiliated with higher education institutions in the Netherlands, Egypt, and Germany.

Countries and territories leading research on mental health and well-being of university students are presented in Table 4. The United States is the indisputable leader in this field, publishing more than half of the records in the dataset. This is nearly 10 times the number of publications produced in China, which occupies the second position in the ranking and accounts for nearly 6% of the volume of research in the dataset. Three predominantly English speaking countries/territories complete the top five of the ranking: Canada (265 records), Australia (254), and England (243). The rest of the countries in the list are situated in Europe (Spain, Germany, Turkey), Western Asia (Iran), Africa (South Africa), and East Asia (Japan), which demonstrates that research on college students' mental health and well-being is a matter of concern in different regions of the world, at least to some extent.

Overall, the productivity analysis for authors and countries indicated that the research of mental health and well-being of university students occurs in a variety of locations around the world, especially in developed countries, and in a very prominent way, in the United States. This is not surprising since it is in those countries where better infrastructures and more abundant resources for research are available ( Wong et al., 2006), and a more lasting tradition in the study of mental health, in general, exists ( Gopalkrishnan, 2018). However, Larivière et al. (2013) found that the productivity of the United States on mental health research has dropped significantly and remained stable in other two English speaking countries (the United Kingdom and Canada) since 1980. On the contrary, the number of publications from European countries and the five major emerging national economies (Brazil, Russia, India, China, and South Africa), has experienced remarkable growth, and collectively account nearly for half of the publications in the field. Still, the predominance of knowledge generated in the developed world today, which tends to be grounded on psychiatric and psychological perspectives, might be eclipsing non-traditional views on mental health and well-being that are popular in other regions of the world and, therefore, limiting the development of effective initiatives that align better with local norms, values, and needs in LMICs ( Timimi, 2010; Summerfield, 2013).

Social Structure: Networks of Scientific Collaboration

Research collaboration is regarded as an indicator of quality research and a means to improve research productivity and academic impact (i.e., citations) ( Kim, 2006; Abramo et al., 2009). In particular, international research collaboration is considered a key contributor to the social construction of science and the evolution of scientific disciplines ( Coccia and Wang, 2016). There is recent evidence that national and international research collaborations have been accelerating in recent years ( Gazni et al., 2012; Wagner et al., 2015), especially in applied fields such as medical and psychological disciplines ( Coccia and Bozeman, 2016). In this study, co-authorship analyses were performed to find out patterns in the scientific collaboration between researchers and countries/territories on the mental health and well-being of university students.

Figure 3 demonstrates collaborative ties among authors who published at least 5 articles in the dataset ( n = 179). The map shows the existence of multiple productive collaborative networks of five or more researchers contributing to the development of the field. The largest collaboration network (red cluster) represents an international research group composed of 15 scholars affiliated to universities in the United States, Belgium, and Netherlands. This cluster groups some of the leading scholars in the field, including R. P. Auerbach, R. Brauffaerts, R. C. Kressler, and P. Cuijpers. Moreover, researchers in this cluster lead The WHO World Mental Health International College Student (WMH-ICS) Initiative, a large scale international project aimed at promoting the mental health and well-being of college students around the world through generating epidemiological data of mental health issues in university students worldwide, designing web-based interventions for the prevention and promotion of mental health, and disseminating evidence-based interventions ( Cuijpers et al., 2019). The second biggest cluster (green) represents an intra-national research network that includes 10 researchers from eight different higher education institutions in the United States. The dark blue cluster represents an institutional collaborative network, including nine researchers from the School of Public Health, Puerto Rico. Other prominent clusters in the map represent collaborative research networks between eight (olive color) and seven researchers (turquoise, violet, orange, and mellow mauve). This contrasts, however, with the limited collaboration that exists between clusters. Only four of the clusters on the map demonstrate some kind of scientific collaboration in the field (light blue, pink, brown, and yellow).

Cross-country collaboration networks in mental health and well-being of university students study are presented in Figure 4. Research collaborations between countries with 20 or more publications were considered in this analysis ( n = 45). The United States occupies the central position of the map and shares collaborative ties with all other countries/territories, forming a cluster together with China, South Korea, and Taiwan. Overall, the results suggest that international collaborations in the field are framed to a large extent by cultural, linguistic, and geographical proximity. For instance, the largest cluster (red) is formed by two European countries (Spain and Portugal) and other South American countries with whom they share historical and cultural backgrounds. Other European countries form the purple cluster. Similarly, the blue cluster clearly brings together predominantly English-speaking countries and territories, while the green cluster agglomerates a range of Asian countries.

Collectively, the results of our study suggest that research collaboration in the field of mental health and well-being in university students remains relatively scarce and localized to date. The social structure of the field at the author level could be described as an archipelago formed by a large number of islands (research groups) of different composition and size but with few bridges connecting them, which suggests a relatively fragmented research community. Moreover, while the existence of international collaborative networks was evident in the analysis, they seem to be formed within national borders, between researchers in neighboring countries/territories, or between countries that share cultural, linguistic, and historical heritages. This may be due to the important role that cultural and traditional values play in the conceptualization of mental health and well-being across contexts ( Eshun and Gurung, 2009; Vaillant, 2012; Fernando, 2019). Also, language differences, divergent cross-national institutional and organizational traditions, and increased costs of extramural collaboration, have been found to complicate the formation and continuity of research partnerships in health research ( Hooper et al., 2005; Freshwater et al., 2006). Nevertheless, limited within- and between-country research collaboration arguably poses challenges to the development of a field in terms of lost opportunities to challenge assumptions taken for granted and move toward fresh perspectives, push boundaries in methods and techniques, meet diverse groups of people from differing cultures and get immersed in those cultures, share information, resources, and skills, and address common mental health problems through the pooling of resources ( Rolfe et al., 2004; Freshwater et al., 2006).

Intellectual Structure: Disciplines Underlying the Foundations of the Field

Interdisciplinarity is considered as a valuable approach to address the complex and multidimensional nature of health and well-being ( Mabry et al., 2008). Buckton (2015) argues that the integration of medical, psychological, and social sciences have contributed to generate "new insights into theory, practice, and research in mental health and development." (3). To examine the disciplines underlying research on the mental health and well-being of university students, a journal co-citation analysis was performed. In this analysis, only journals with at least 50 citations were considered ( n = 593). The nodes on the map represent journals and their size reflects the number of co-citation relationships with other journals. Colors account for journal clusters, which agglutinate journals with higher co-citation relationships and stronger semantic connectedness. Clusters were interpreted and labeled accounting for the WoS categorization of the journals with the highest co-citation links within each cluster. For example, if the Journal of Personality and Social Psychology, the Journal of Counseling Psychology, and Personality and Individual Differences clustered together, this group was interpreted as the personality, social, and counseling psychology cluster.

In general, the findings of this study suggest that research on mental health and well-being in university students is interdisciplinary, to a certain extent, and mainly emerges from the convergence of research conducted in the behavioral and biomedical sciences, as it has been suggested elsewhere ( Schumann et al., 2014; Wittchen et al., 2014b). More specifically, the map shows that the research in the mental health and well-being of university students is constructed through the integration of knowledge generated in five interconnected disciplines (see Figure 5). To the left of the map, the red cluster integrates journals on personal, social, and counseling psychology. To the right, the blue cluster represents the contribution of psychiatric journals to research to the formation and development of the field. At the top, the yellow cluster groups journals on substance abuse and issues related to alcohol consumption, addiction, and interpersonal violence. At the bottom of the map, journals covering topics on eating behaviors, sleep, and other issues related to physical health converge on the green cluster. At the center of the map is the purple cluster, which includes journals in the area of clinical psychology and behavioral therapy.

More broadly, the findings suggest that biomedical sciences contribute to a large extent to the composition of the field. Psychiatric research emerged in our study as an obvious building block in the study of university students' mental health and well-being, which is not surprising considering the historical contributions of biomedical disciplines to mental health research ( Schwartz and Corcoran, 2010). Within the behavioral sciences, personality and social psychology, which explores processes and mechanisms through which social phenomena influence mental health and well-being ( Sánchez Moreno and Barrón López de Roda, 2003), appears as a key discipline underlying the foundations of the field. Surprisingly, clinical psychology journals occupy a central position in the map and demonstrate co-citation relationships with journals from all other clusters but make up the most dispersed network and account for a considerably lower volume of co-citation relationships in the field. This suggests that clinical psychology journals are more subordinate to journals in other disciplines in terms of citations flows, and ultimately, play a less unique role in research on the mental health and well-being of university students, as suggested by Haslam and Lusher (2011). Interestingly, research arising from the social sciences (e.g., sociology and anthropology) does not seem to make a distinctive contribution to the intellectual structure of the field, which suggests that the influence of social contexts and cultures on university students' mental health and well-being (e.g., inequality, social norms, public policies, cultural beliefs, and values) is an underexplored research area. Still, the density of co-citation network relationships within and between clusters is particularly noteworthy, considering the lack of common language between disciplines, the absence of a shared philosophy of practice on mental health, and the tensions between medical, psychological, and social explanations of mental distress ( Bailey, 2012).

Conceptual Structure: Topical Foci Addressed in the Literature Over the Last 45 Years

The topical foci of research on the mental health and well-being of university students during the 1975-January 2020 period are presented in Figure 6. The map offers a visual representation of the co-occurrence analysis of author keywords of all the publications included in the dataset. Only the most frequently occurring keywords (25+ occurrences) were considered in the analysis ( n = 84). Items that were not related to others and do not belong to the existing clusters were excluded. The size of the nodes indicates the occurrence of author keywords in the dataset and the thickness of edges represents the co-occurrence strength between pairs of keywords.

The most frequent keywords in the dataset, excluding students' descriptors (e.g., college students and university students), refer to common mental health challenges experienced by university students such as depression ( n = 612), anxiety ( n = 353), and stress ( n = 341). Salutogenic-related keywords such as well-being and life satisfaction occurred less often ( n = 138, n = 113, respectively), suggesting that pathogenic approaches to the exploration of mental health issues in higher education are more widespread. More broadly, seven general themes seem to summarize the topical foci of interest in the field of mental health and well-being of university students over the last 45 years. First, there has been a general interest in positive mental health, as denoted by frequently co-occurring key terms such as well-being, self-esteem, life satisfaction, social support, emotional intelligence, and happiness (red cluster). Second, mental disorders stand as another theme widely addressed in the literature, with a special emphasis on depression, anxiety, and to a lesser extent, suicide and suicidal ideation (green cluster). A third topical area in this field has been substance abuse, most predominantly alcohol consumption (blue cluster). The fourth theme reflects college counseling for mental health, including interventions and protective factors such as mindfulness, stress management, spirituality, and help-seeking (yellow cluster). Other topics reflected in the map are mental illness stigma (purple), stress (e.g., psychological distress and coping) (light blue), and mental health measurement (orange).

Conclusion

This study provides a comprehensive overview of the research on university students' mental health and well-being in the last 45 years using bibliometric indicators. In general, the results reveal interesting trends in the evolution of the field over the last four decades and promising scientific patterns toward a better understanding of the mental health and well-being of university students internationally. First, the interest in the mental health and well-being of university students has grown in the last decades and in a very significant way during the last 10 years, indicating that this area has not still reached its maturity period and will continue developing in the future. Second, research in the field is relatively interdisciplinary and emerges from the convergence of research conducted in several disciplines within the behavioral and biomedical sciences. Third, research in this field is produced by a community of productive researchers coming from several regions around the world, most notably in the United States, which secures a generation of scholars that will continue shaping the field in the years to come. Fourth, over the last 45 years, researchers have been able to address a multitude of research topics in the field, including positive mental health, mental disorders, substance abuse, counseling, stigma, stress, and mental health measurement.

However, this study also identified some issues that could be hindering the development of the study of the mental health and well-being of university students. For example, the research available overrepresents theoretical and disciplinary approaches from the developed world. Additional studies on the field from developing economies and LMICs are needed to provide a more comprehensive picture and ensure a fair representation of the multiple perspectives available in the field. Such studies would inform administrators and practitioners on how to broaden and enrich available programs and initiatives to promote mental health and well-being in higher education contexts in order to offer alternative forms of support that university students find appropriate for their social and cultural values. Moreover, the research community contributing to the development of the field is relatively fragmented. There are multiple research groups but little research collaborations between them and, at the international level, these connections tend to be limited by geographic, cultural, and language proximity. In this context, more actions like the WMH-ICS Initiative could provide a partial solution to this problem by strengthening national and international research partnerships and facilitating knowledge exchange across regions. Also, special issues in the core journals in the field inviting cross-cultural studies on the topic could contribute to promoting research collaboration across regions and research in less represented countries. The field would also benefit from a greater volume of research from the social sciences and humanities exploring the influence of social, cultural, economic, and educational factors on the conceptualization, manifestation, and experience of mental health and well-being. Moreover, more studies emerging from disciplines such as sociology, anthropology, business, and education, would likely increase the permeability of positive mental health concepts into the field and contribute to the promotion of salutogenic approaches to the study of mental health and well-being of university students.

This study has several limitations. First, publications were retrieved only from the WoS database, which limits the generalizability of the findings. Second, WoS provides stronger coverage of Life Sciences, Biomedical Sciences, and Engineering, and includes a disproportionate number of publications in the English language ( Mongeon and Paul-Hus, 2016). This could partially explain the low number of publications emerging from the Social Sciences, the Arts, and the Humanities, and research conducted in non-English speaking countries in the present study. Third, only journal articles were retrieved for analysis, excluding other relevant publications in the field such as reviews, book chapters, and conference proceedings. Future studies could replicate the findings of this study using alternative databases (e.g., Scopus and PubMed) or a combination of them, as well as different filters in the search strategy, to provide an alternative coverage of research conducted in the field. Nevertheless, we believe that the bibliometric approach used in this study offers novel insights about the development and current status of the field and some of the challenges that undermine its progression.

Data Availability Statement

The datasets generated for this study are available on request to the corresponding author.

Author Contributions

DH-T and LI contributed to conception and design of the study, organized the database, and performed the statistical analysis. DH-T, LI, and JS wrote the first draft of the manuscript. NL, AC, AA, YN, and AM wrote the sections of the manuscript.

Funding

This research was funded by the Nazarbayev University Faculty-Development Competitive Research Grants Program (Reference Number 240919FD3902).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Footnotes

References

LeViness, P., Bershad, C., Gorman, K., Braun, L., and Murray, T. (2018). The Association for University and College Counseling Center Directors Annual Survey. Available online at: https://www.aucccd.org/assets/documents/Survey/2018%20AUCCCD%20Survey-Public-June%2012-FINAL.pdf (accessed February 24, 2020).
Google Scholar

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Mental Health and Well-Being of University Students: A Bibliometric Mapping of the Literature

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The purpose of this study is to map the literature on mental health and well-being of university students using metadata extracted from 5,561 journal articles indexed in the Web of Science database for the period 1975-2020.

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Focusing on Student Well-being in times of Crisis

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Focusing on Student Well-being in times of Crisis

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Focusing on Student Well-Being in Times of Crisis

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One teacher recommends supporting student safety through three Cs: communication, consistency, and control.

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Mental Health Program | Department of Health website

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Mental Health Program | Department of Health website

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Student wellbeing encompasses the overall health of a student, including their social, mental, physical, and emotional health. Enjoyment and satisfaction

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Evidence-based mental health and wellbeing programs for schools

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Evidence-based mental health and wellbeing programs for schools

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5 Steps to Mental Health and Wellbeing: A Framework for Schools and Colleges

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5 Steps to Mental Health and Wellbeing: A Framework for Schools and Colleges

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https://youtu.be/Q5nCXZkcvOo

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5 Steps to Mental Health and Wellbeing: A Framework for Schools and Colleges

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The Five Ways to Wellbeing - boosting mental wellbeing

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The Five Ways to Wellbeing - boosting mental wellbeing

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https://youtu.be/_gJ5V525SCk

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The Five Ways to Wellbeing - boosting mental wellbeing

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Evidence suggests there are 5 steps you can take to improve your mental health and wellbeing. Trying these things could help you feel more positive and able to get the most out of life.
1. Connect with other people

Good relationships are important for your mental wellbeing. They can:

help you to build a sense of belonging and self-worth

give you an opportunity to share positive experiences

provide emotional support and allow you to support others

There are lots of things you could try to help build stronger and closer relationships:

2. Be physically active

Being active is not only great for your physical health and fitness. Evidence also shows it can also improve your mental wellbeing by:

raising your self-esteem

helping you to set goals or challenges and achieve them

causing chemical changes in your brain which can help to positively change your mood

Read about exercise guidelines and workouts to help improve your fitness and wellbeing

3. Learn new skills

Research shows that learning new skills can also improve your mental wellbeing by:

boosting self-confidence and raising self-esteem

helping you to build a sense of purpose

helping you to connect with others

Even if you feel like you do not have enough time, or you may not need to learn new things, there are lots of different ways to bring learning into your life.

Some of the things you could try include:

4. Give to others

Research suggests that acts of giving and kindness can help improve your mental wellbeing by:

creating positive feelings and a sense of reward

giving you a feeling of purpose and self-worth

helping you connect with other people

It could be small acts of kindness towards other people, or larger ones like volunteering in your local community.

Some examples of the things you could try include:

saying thank you to someone for something they have done for you

asking friends, family or colleagues how they are and really listening to their answer

spending time with friends or relatives who need support or company

offering to help someone you know with DIY or a work project

volunteering in your community, such as helping at a school, hospital or care home

5. Pay attention to the present moment (mindfulness)

Paying more attention to the present moment can improve your mental wellbeing. This includes your thoughts and feelings, your body and the world around you.

Some people call this awareness "mindfulness". Mindfulness can help you enjoy life more and understand yourself better. It can positively change the way you feel about life and how you approach challenges.

Read more about mindfulness, including steps you can take to be more mindful in your everyday life.

Further information

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Read about 5 steps you can take to improve your mental health and wellbeing.

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The Stanford Encyclopedia of Philosophy combines an online encyclopedia of philosophy with peer-reviewed publication of original papers in philosophy, freely accessible to Internet users. It is maintained by Stanford University.

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https://plato.stanford.edu/entries/education-philosophy/

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Student mental health and well-being: Supporting students in transition from school to university

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Student mental health and well-being: Supporting students in transition from school to university

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Updated by Katie on 19 July 2019 with additional u seful resources and insights.

Starting university can be a wonderful and exciting time for students as they acquire new knowledge, meet new people, learn about themselves and others, and form lasting friendships. It can also be layered with difficulties that can originate in the transition period as students leave one life behind and begin another. For international students arriving from another country, the difficulties can be even more acute. The way in which schools and universities manage this transition period can have a significant and long-lasting impact on students' mental health and well-being.
This blog sets the context to this issue and provides an overview of guidance and available resources.
'I have less support and do feel lonely because at school you had everyone every day ... I can feel very lonely and depressed at times and if everything is going bad at the same time I break down and can't seem to function properly. I'm in robot mode' (student)¹
The transition from school to university can be challenging for any student-it is often the first time that they live away from home and are expected to look after their own basic needs. This can be accompanied by significant pressure to succeed academically while living up to the narrative of university being a time of intense social activity and enjoyment. Alcohol and peer pressure can also form integral parts of students' early university experiences, making these other stresses harder to bear.

International students
'It was kind of difficult to relate to the locals, I still find it a bit difficult sometimes ... because we have different experiences, we have different cultural knowledge and background' (international student)²
International students can encounter the additional challenge of being in a new country surrounded by a different geographical and cultural context, without the protective factors and familiar normative controls and reference points of home. Challenges can include adjusting to a new social environment; practical, logistical and legal challenges related to issues such as insurance, immigration status and finances; culture-shock; language-barriers; difficulties finding friends who share their religion or background; homesickness; adjusting to a different climate; adjusting to different teaching methods and academic environment; financial or academic pressure; racial hostility or discrimination by peers and others on campus.

Student mental health
'His worst thing was failure, he hated failure, and I suppose failing first year at uni[versity] was obviously a massive trigger' (friend of student)³
Only 17% of people do not experience a diagnosable mental health issue at some stage during their life ⁴

We know that living with a mental health condition can be devastating. We also know that early interventions and the right support can change the trajectory of a person's life. Schools and universities everywhere are ideally placed to provide this support and to transform people's lives.

International research suggests that the mental health of adolescents and university students has deteriorated over recent decades, with levels of distress, anxiety and depression on the rise. Transition to university can, if not managed well, be a significant risk factor for students' mental health. Studies suggest that mental ill-health amongst first-year students is high. In one example, 10% of students involved in a study in Spain had suicidal thoughts in their first year and 30% suffered mental illness. ⁶ Other studies demonstrate how the particular challenges that some international students face can exacerbate pre-existing mental ill-health and/or lead to low mood, anxiety and depression. ⁷ Studies also indicate that some international students may be less likely to seek mental healthcare on campus, particularly those who come from cultures in which mental ill-health is particularly stigmatised. This reluctance may also be linked to being ill-equipped to recognise risk factors or mental illness or having concerns about meeting a counsellor who offers culturally relevant treatment. ⁸

Six ways that schools and universities can support students through this transition

1. Prepare students from an early stage for practical and cultural changes. Also, talk with them about maintaining good mental health and seeking help when needed

Preparing students as early as possible, and well in advance of their move, is important. Some schools do this by holding student and parent sessions, and universities often arrange pre-orientation or summer school programs for international students. These often address practical issues like paying bills, registering for healthcare, preparing for cultural adjustment and changes in climate, and navigating differences in application processes. It is also important for these sessions to focus on issues like identity, resisting peer pressure, resilience in the face of adversity, maintaining good mental health and seeking help when needed. Although most schools and universities are doing something to prepare students for transition before they arrive at university, there is relatively little evidence on what good practice looks like, and although some institutions are doing excellent work in this area, examples of particularly good practice are often hard to find. Further work is needed to explore how both institutions can be more proactive in this preparation stage.
Resource tip:
- This Student Minds Know before you go toolkit helps students to anticipate, identify and navigate situations they will encounter when entering university.

2. Implement robust and effective transition programs and consider how to embed these throughout student life

Student orientation programs at university are critical and common-place. There is a wealth of guidance on how to build these programs, and although this guidance is helpful for supporting students with academic and practical issues, it does not always explore in sufficient depth the less tangible issues related to student mental health and well-being. Identifying resources that do address these is critical. There are fewer resources that focus specifically on supporting international students, but many universities that often include immigration and career planning workshops; host family programs; student mentorship program/ambassador program; cultural interaction programs connecting international students with local students; and courses for students helping them to build their resilience, manage their transition, and know themselves, their identity, race and culture.

As with the pre-arrival programs, more evidence is needed on what good practice looks like for international students, how to build orientation programs that genuinely support student well-being, and how to embed these programs throughout student life so that support and information is provided on an on-going basis, and not just in a students' first few weeks.

The transition from school to university is not the only transition that students will make and many institutions are now also looking at how they can support students who move from one school to another, take part in an exchange programme, and graduate from university. When designing a transition program for international students, institutions draw on evidence of successful programs for students moving between international schools (see resource tips below).
Resource tips:
3. Adopt a whole-school / university approach and involve your students in this approach

Focusing on transition is necessary but not nearly enough, and professionals in this field are increasingly urging institutions to take a whole-school or whole-university approach, by which they mean taking a holistic view, involving all members of the community and weaving prevention, identification and response throughout the fabric of the institution. Key to this is creating a culture of care or an eco-system in which students and staff support each other, every person feels able to be their true selves regardless of their background or health, and the culture of the institution is such that the experience of working or studying in it enhances, rather than diminishes, people's lives.

'Nothing about us without us' ⁹

As a first step, always involve your students in these discussions and co-produce policies and resources with them. Involving and consulting with students in this way will provide valuable insight into the current weaknesses and strengths of an institution's approach to well-being and how this can be improved in a way that best meets students' actual needs.

Adopting this approach involves looking not only at policies and practices related to mental health and well-being but also at policies related to issues like leave and mitigating circumstances requests, use of digital devices, equality, diversity and harassment. It requires institutions to look at how they organise advisory systems in schools and tutor or seminar systems in universities, what the impact of financial support is on students receiving it, how the curriculum addresses well-being, what it does to support staff and volunteers, how its governors, head, president and trustees lead on issues and how the institution supports social interactions.

This approach also requires institutions to review the way in which they respond to critical incidents such as suicide, which can have a significant impact on the culture of an organisation. Preparing for these incidents and developing response plans are key and will support on-going prevention work. It also requires partnerships and close cooperation with key local agencies so that students and staff can receive as integrated an experience as possible. This can be done, for example, by carrying out a local mapping exercise.

Considering how institutions can leverage technological advances, data and learning analytics could also help to strengthen its approach. For example, it could help institutions to diversity and improve access to services that can be delivered both digitally and in person, enhance risk assessments of individual students and enable the organisation to triangulate data and spot signs of distress at an early stage.
Resource tips:

Universities UK's Step Change Framework advocates a whole institution approach to student mental health, including useful guidance on how to achieve this

The JED Foundation encourages universities to take a holistic approach when building upon existing student mental health, substance abuse and suicide prevention efforts

See what other universities are doing as showcased by the What Works Well-being Centre

Learn how to develop a response plan to critical incidents relating to mental health, including suicide, from The Samaritans, and see this Protocol from the International Taskforce on Child Protection and Farrer & Co. for advice on how to address allegations of abuse and how to carry out a local mapping exercise

Read this Student Minds Co-production guide for advice on how to co-produce mental health strategies for students in universities and take a look at their project developing a Mental Health Charter for universities

Check out Mind and Minds@work for guidance, training and resources related to staff mental health and well-being

Take a look at this 360 degrees school programme by Young Minds for guidance on how to put well-being at the centre of your school

4. Develop the intercultural competence of your staff and strive for cultural diversity among your counsellors

It is important that staff in schools and universities are culturally aware and interculturally competent. Culture plays a central role in determining how students perceive their surroundings, how they understand issues like sexual assault and mental illness, how they deal with authority and perceive power, how they cope with challenges, and how they can develop resilience.

Without an understanding of the role of culture in student well-being, and how culture shock can impact on student mental health, staff will be less able to identify symptoms of distress, respond appropriately or provide effective support to students that originate from a culture that is different from their own. Intercultural competence is a feature of a number of international school accreditation frameworks including ours at CIS, The Council for the Advancement of Standards in Higher Education (CAS) also require faculty that interact with international students to receive regular and on-going training on the role of culture in mental health, and how to support students from different cultures.
Resource tips:

A CIS Mental Health & Well-being Workshop includes training for both school and university staff on how to support students that are suffering from abuse or mental ill-health in a culturally competent way

Universities UK intends to develop a toolkit to help universities co-create local responses to the needs of their international students

5. Provide opportunities for students to seek help at an early stage and strengthen your systems so that you can proactively identify students in need of support

" In a caring and compassionate organization, you are not only ill once you have filled out a form" ¹⁰

Many universities provide excellent support to students who are proactive in seeking help. However, there is a concern that many students in need of support are not able to reach out proactively. These students often never come to the university's attention or only do so once the risk has escalated to dangerous levels. We know, for example, that a significant proportion of students who commit suicide are not previously known to university student services. ¹¹ Further work is needed to look at how schools and universities can make it easier for students to seek help. Efforts to do this should include building trusting relationships between staff and students, having a system where students have formal and regular one-to-one or small group sessions with (non-academic) advisors or tutors, putting in place visible, accessible, culturally-relevant and high-quality counselling services and helplines at university, offering multiple avenues for disclosure, using peer support programs, and removing the stigma around mental health. Reviewing the institution's core values and these are communicated to students and staff is also key: for example, does the institution encourage young people to aspire to perfection, set unrealistic goals, or imply that an individual's value is exclusively linked to their academic and professional success? Given the societal context in which we live, it can be easy to promote these messages without realising it, but these messages can make it harder for young people to seek help and admit that they are struggling. They can also make it much more difficult for young people to manage disappointment when they do not obtain the goals set for them. On the other hand, organisations that prioritise and place value on issues like individual well-being and the quality of relationships can foster protective relationships where students feel comfortable seeking help. Talking about how to identify and manage distressing emotions and having values such as equality and diversity, kindness and compassion run through the fabric of your institution can enhance these protections.

We also need to look at how schools and universities can proactively identify students who are not able to seek help or refer themselves to student services. Training for all staff (not just teaching staff) on spotting signs of mental ill-health, harm and abuse across cultures is also critical. Holding regular meetings with staff from different areas of your institution, including medical, safeguarding, academic, residential and support staff, to talk about individual students is another important way of triangulating information. Having in place clear and centralized reporting lines and recording systems that enable concerns to be triangulated and patterns to be spotted at an early stage, is key. Whilst schools are increasingly doing this through digital record-keeping systems, universities have to manage much larger quantities of data which they can struggle to centralise and triangulate. New developments in learning analytics have the potential to significantly change the way that universities record and analyse well-being data. Student focus groups and well-being surveys can also provide valuable insight, as can social events that enable staff to identify students who might be struggling and involving students in well-being committees and policy development.
Resource tips:

Peer support programs: student mental health and Digital leaders program

Remove the stigma around mental health - Place2Be and The Charlie Waller Memorial Trust provide resources, training and guidance

Universities may want to draw on learning from early alert committees, tailoring these to focus on student well-being as much as academic success.

Learn about how you can become a 'suicide safer university' with this guidance from Universities UK and Papyrus

Check out the following digital record keeping systems for schools: My Concern and Isams

Learn how universities and apply learning analytics to improve student well-being and mental health with this JISC report and this article.

6. Strengthen connections between schools and universities

The more that schools and universities collaborate to address student well-being, the easier the transition will be for students. Discussions around this topic are too frequently limited either to just schools or to just universities. Including both groups can build connections, improve understanding of the other, generate new ideas and strengthen information sharing. For example, when a school needs to share information about a vulnerable student with a university, they often don't know who at the university they should share that information with, or how it will be stored or used.

Greater cooperation between schools and universities will also increase the knowledge and understanding that each institution has of the other, which in turn will help to dispel unhelpful myths. It will also help schools to prepare students, let them know what to expect and encourage those with mental health needs to seek help from their university at an early stage. Current disclosure rates are low. Research suggests that in the UK, for example, only 37% of students disclose or intend to disclose mental health conditions to the universities to which they apply. ¹² Schools and universities should set out clearly to students what the benefits are of disclosing and how that information is going to be shared.
Resource tips:

This article outlines these issues in further detail

This blog sets out the rights of students in the UK to disclose mental health conditions in their university application form, and this blog sets out the benefits of disclosure

How is CIS supporting its members in this area?

We held our inaugural Student Well-being Workshop in November 2019 in Bilbao for universities and schools, which included sessions on mental health, digital well-being, intercultural competence, sexual abuse and violence, peer on peer abuse and transitions.

We are gathering data from our membership to understand more about the specific challenges that students face and how our members can meet these. As part of this we are hosting a series of roundtables looking at supporting students in the transition to university, from which we will be publishing a series of case studies showcasing good practice in some of our member institutions. Finally, following a summit in London with global educational leaders, we will be forming a committee to focus on how CIS can help its members to strengthen student well-being throughout education, from early years through to university.

As you can see there's a lot to cover on this subject and we are excited about the potential for our work to make a real difference to student safety and well-being. If anyone would like to know more about our work to address student safety and well-being or be involved, please contact Katie Rigg.
References:
1 Wrencha, A, Garretta, R and King, S, Guessing where the goal posts are: managing health and well-being during the transition to university studies, 2013

² Belford, N, International Students from Melbourne Describing Their Cross-Cultural Transitions Experiences: Culture Shock, Social Interaction, and Friendship Development, 2017

³ Stanleya, N, Mallonb, S, Bellc, J and Manthorped, J, Trapped in transition: findings from a UK study of student suicide, 2009

Schaefer, Jonathan D; Caspi, Avshalom; Belsky, Daniel W; Moffitt, Terrie E, Enduring Mental Health: Prevalence and Prediction, 2016

5 Twenge, J, Roger, M, Joiner, T, Increases in Depressive Symptoms, Suicide-Related Outcomes, and Suicide Rates Among U.S. Adolescents After 2010 and Links to Increased New Media Screen Time, 2018; Collishaw, S, Maughan B, Natarajan L, Pickles A. Trends in adolescent emotional problems in England: a comparison of two national cohorts twenty years apart. et al., 2010; Stallman, University counselling services in Australia and New Zealand: Activities, changes, and challenges, 2012; Hunt, Eisenberg, Mental health problems and help-seeking behavior among college students, 2010, Papyrus and Universities UK, Suicide Safer Universities, 2018, Thorley, C, Not by degrees, Improving student mental health in UK universities, 2017

⁶ Blasco MJ, Vilagut G, Almenara J et al. Suicidal Thoughts and Behaviors: Prevalence and Association with Distal and Proximal Factors in Spanish University Students, 2008

⁷ Rosenthal, D., Russell, J., Thomson, G, The health and wellbeing of international students at an Australian university. Higher Education, 2008

⁸ Lee, M, Shedding Light on Asian American and Asian Students' Mental Health Needs, 2018

⁹ Charlton J, Nothing about us without us, 2000

¹¹ Papyrus and Universities UK, Suicide Safer Universities, 2018

¹² Thorley, C, Not by degrees, Improving student mental health in UK universities, 2017

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Student mental health and well-being: Supporting students in transition from school to university

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It's not always easy to find guidance or resources to help support students making the transition from school to university, so Katie Rigg has pulled some together, with particular focus on international students. She outlines six important approaches to consider along with resource tips and useful links for each.

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COVID-19 and Student Well-Being: Stress and Mental Health during Return-to-School - PubMed

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COVID-19 and Student Well-Being: Stress and Mental Health during Return-to-School - PubMed

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. 2021 Jun;36(2):166-185.

doi: 10.1177/08295735211001653.

Affiliation

¹ University of Calgary, AB, Canada.

Free PMC article

Kelly Dean Schwartz et al. Can J Sch Psychol.

Free PMC article

. 2021 Jun;36(2):166-185.

doi: 10.1177/08295735211001653.

Affiliation

¹ University of Calgary, AB, Canada.

Abstract

Students have been multiply impacted by the COVID-19 pandemic: threats to their own and their family's health, the closure of schools, and pivoting to online learning in March 2020, a long summer of physical distancing, and then the challenge of returning to school in fall 2020. As damaging as the physical health effects of a global pandemic are, much has been speculated about the "second wave" of mental health crises, particularly for school-aged children and adolescents. Yet, few studies have asked students about their experiences during the pandemic. The present study engaged with over two thousand ( N = 2,310; 1,288 female; M age = 14.5) 12- to 18-year-old Alberta students during their first few weeks of return-to-school in fall 2020. Students completed an online survey that asked about their perceptions of COVID-19, their fall return-to-school experiences (84.9% returned in-person), their self-reported pandemic-related stress, and their behavior, affect, and cognitive functioning in the first few weeks of September. The majority of students (84.9%) returned to school in person. Students reported moderate and equal concern for their health, family confinement, and maintaining social contact. Student stress levels were also above critical thresholds for 25% of the sample, and females and older adolescents (age 15-18 years) generally reported higher stress indicators as compared to males and younger (age 12-14 years) adolescents. Multivariate analysis showed that stress indicators were positively and significantly correlated with self-reported behavioral concerns (i.e., conduct problems, negative affect, and cognitive/inattention), and that stress arousal (e.g., sleep problems, hypervigilance) accounted for significant variance in behavioral concerns. Results are discussed in the context of how schools can provide both universal responses to students during COVID-19 knowing that most students are coping well, while some may require more targeted strategies to address stress arousal and heightened negative affect.

Keywords: COVID-19; coping; health and wellbeing; high school; junior high school; mental health; participants; secondary education/adolescence; social and educational environment; stress.

Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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References

Adams Z. W., Sumner J. A., Danielson C. K., McCauley J. L., Resnick H. S., Grös K. P. L. A., Welsh K.E., Ruggiero K. J. (2014). Prevalence and predictors of PTSD and depression among adolescent victims of the Spring 2011 tornado outbreak. Journal of Child Psychology and Psychiatry, 55(9), 1047-1055. 10.1111/jcpp.12220 - DOI - PMC - PubMed

Allen A. N., Kilgus S. P., Burns M. K., Hodgson C. (2019). Surveillance of internalizing behaviours: A reliability and validity generalization study of universal screening evidence. School Mental Health, 11(2), 194-209. 10.1007/s12310-018-9290-3 - DOI

Bokszczanin A. (2007). PTSD symptoms in children and adolescents 28 months after a flood: Age and gender differences. Journal of Traumatic Stress, 20(3), 347-351. 10.1002/jts.20220 - DOI - PubMed

Bond L., Butler H., Thomas L., Carlin J., Glover S., Bowes G., Patton G. (2007). Social and school connectedness in early secondary school as predictors of late teenage substance use, mental health, and academic outcomes. Journal of Adolescent Health, 40(4), 357-366. - PubMed

Centers for Disease Control and Prevention. (2020, April 10). Coronavirus disease 2019 in children - United States, February 12-April 2, 2020. https://www.aspca.org/news/justice-served-case-closed-over-40-dogfightin...

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national center for biotechnology information

# data[].attributes.attachment_link.title
COVID-19 and Student Well-Being: Stress and Mental Health during Return-to-School - PubMed

# data[].attributes.attachment_link.description
Students have been multiply impacted by the COVID-19 pandemic: threats to their own and their family's health, the closure of schools, and pivoting to online learning in March 2020, a long summer of physical distancing, and then the challenge of returning to school in fall 2020. As damaging as the p ...

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Positive psychology is the scientific study of happiness with the goal of identifying the qualities required for happiness and wellbeing. Csikszentmihalyi and Seligman (2000) introduced this new branch of psychology, proposing that psychologists should 'learn how to build the qualities that help individuals and communities, not just to endure and survive, but also to flourish'.

The Pillars of Wellbeing

Seligman's research revealed five essential pillars of wellbeing (PERMA); a sixth pillar was later added to represent the impact that physical health can have on mental health (PERMA-H).

The pillars of wellbeing are shown below, along with examples of each one.

Positive Emotions

Being positive and grateful

Having self-control and emotional intelligence

Engagement

Showing creativity and curiosity

Being intrinsically motivated

Relationships

Having empathy and compassion

Showing forgiveness, leadership, and kindness

Meaning

Understanding your core values

Having a sense of purpose

Accomplishment

Embracing a growth mindset

Being confident when making decisions

Health

Understanding the mind-body connection

Being resilient

Positive Education

Positive education aims to improve learners' wellbeing by teaching or strengthening each pillar of wellbeing. Teachers at Geelong Grammar School, home to the Institute of Positive Education, have been teaching students to develop the character strengths associated with wellbeing for the last ten years. Students' wellbeing has been seen to improve while they are at the school and is still evident years after graduation when compared to students from similar schools (Institute of Positive Education, 2019).

Improving Students' Wellbeing

Heathfield School began to include wellbeing education in their curriculum in 2018 and became the first school in Europe to implement the Flourishing at School programme. The online platform uses questionnaires to monitor students' wellbeing throughout the year against the six pillars described above. The goal is for students to flourish in all areas. By identifying areas in which this is not yet happening, online or school-based interventions can be put in place. It offers a proactive approach to mental health and wellbeing by providing opportunities to develop the character traits that promote wellbeing rather than waiting and reacting to a problem when it occurs.

In 2021, Heathfield School extended its wellbeing programme to include Flourishing lessons that are taught to all students in the school for one hour every fortnight. Each half-term focuses on a different pillar of wellbeing. Lessons are used to model and practice the techniques that will enable students to flourish in each pillar. The school's Flourishing curriculum has been developed by the institute of positive education and uses resources and techniques that have emerged from research.

A Whole-School Approach

To successfully promote and support students' wellbeing in schools, discreet lessons and interventions are not enough. Wellbeing must be a focus and priority throughout the whole school and for the whole community.

Heathfield School has adopted a three-stage approach to promoting students' wellbeing: Live It; Teach It; Embed It.

All staff have been educated about the pillars of wellbeing and the techniques that are taught in Flourishing lessons. They are encouraged to prioritise their own wellbeing and are offered Flourishing sessions to support this.

All students receive Flourishing lessons every fortnight, with each half-term focussing on a different pillar. Tutors and peer mentors support students to monitor their wellbeing through the Flourishing at School programme. Students receive targeted support if there is a pillar in which they are not yet flourishing.

The school is developing an implicit curriculum that promotes the collective wellbeing of the whole school community. This implicit curriculum includes:

Recognising and building upon students' strengths and positive characteristics

Supporting students to manage their relationships with peers

Modelling failure as a learning tool

Encouraging reflection and gratitude

Teaching grounding techniques

Providing opportunities to contribute to the wider community

Offering healthy food choices and access to daily physical activity

Providing all staff with mental health training

Praising effort and defining success as the accomplishment of personal goals

‍

# data[].attributes.attachment_link.description
Positive psychology is the scientific study of happiness with the goal of identifying the qualities required for happiness and wellbeing. Csikszentmihalyi and Seligman (2000) introduced this new branch of psychology, proposing that psychologists should 'learn how to build the qualities that help individuals and communities, not just to endure and survive, but also to flourish'.

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Promoting the healthy development of all students, as well as enabling all students to reach their full potential, is a priority for educators across Ontario. Students' health and well-being contribute to their ability to learn in all disciplines, and that learning in turn contributes to their overall well-being.

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Effective health promoting school for better health of children and adolescents: indicators for success - BMC Public Health

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Effective health promoting school for better health of children and adolescents: indicators for success - BMC Public Health

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Research article

Open Access

Published:

BMC Public Health 19, Article number: 1088 (2019) Cite this article

17k Accesses

14 Citations

Metrics

Abstract

Background

Improvement of health literacy, health behavioural change, creating a supportive physical and social environment to be more conducive to health should be the focus of child and adolescent public health. The concept of Health Promoting School initiated by World Health Organization aims to move beyond individual behavioural change and to consider organisational structure change such as improvement of the school's physical and social environment. The aim of this study is identification of the key indicators for successful implementation of Health Promoting School by analysing the findings of the school health profile based on the structured framework of Hong Kong Healthy School Award Scheme and the health status of students investigated by the Hong Kong Student Health Survey.

Methods

This is a retrospective correlation study. Analysis of variance (ANOVA) was utilised to analyse for significant improvement of school health profile measured at baseline ( n = 104) and among those schools implemented the Hong Kong Healthy School Award Scheme ( n = 54). Those indicators showing statistical significance were chosen to be part of the core indicators reflecting effective Health Promoting School. Each of those selected core indicators was then correlated with the related student health outcomes measured by the Hong Kong Student Health Survey Questionnaire to further identify the core indicators.

Results

A total of 20 core indicators among all the six Key Areas of Health Promoting School (6 indicators under action competencies, 2 under community link, 2 under physical environment, 2 under social environment, 4 under healthy school policies, 1 under services of school health protection) have been identified with the method mentioned above.

Conclusions

This study has identified the indicators with most significant impact on a wide range of health related outcomes. Those are key indicators for motivating positive change of the schools and students. They can be considered as school performance indicators to help schools embarking their Health Promoting School journey as another key education objective.

Peer Review reports

Background

In 2011, the United Nation adopted 'The Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases (NCD)', and actions to reduce risk factors and creating health promoting environments became the focus of this agenda [ 1]. Behavioural, environmental, occupational, and metabolic risks factors such as high cholesterol, high blood pressure, obesity, smoking and alcohol, can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention especially at early stage of life [ 2].

However, we are still observing high prevalence of those youth health risk behaviours in both developed and developing countries with around 30 to 40% of young people who had drunk alcohol and around 30 to 50% taken drug in Australia and US, and around 80% of secondary school students have been found to be physically active in Hong Kong, Macao, Taipei and US [ 3, 4, 5].

Rationale for Core indicators of health promoting school

The concept of Health Promoting School (HPS) initiated by WHO aims to move beyond individual behavioural change and consider organisational and structural change such as improving the school's physical and social environment, its curricula, teaching and learning methods [ 6, 7]. The WHO HPS framework is only an outline. Langford et al. (2014) conducted Cochrane Review of WHO HPS framework for improving health and well-being of students and their academic achievement based only on 67 included cluster-randomised controlled trials (RCTs) taken place at the level of school, district or other geographical area [ 8]. The RCT design does not necessary lend itself to outcomes involving organizational or structural change as the statistical assumptions underpinning RCT are not valid to reflect organisational or structural change so limited conclusion could be drawn [ 9]. Would HPS initiatives lead to immediate change at individual level? One would argue that potential markers of success are associated with the process [ 10]. Therefore, indicators of HPS should highlight the ways in which schools would be able to adopt HPS principles successfully and the conditions to be in place to flourish [ 10]. A boarder perspective on evidence is needed in dealing with the complexity of school system [ 11, 12]. The English Wessex Healthy School Award Scheme (WHSA) [ 13] and the Hong Kong Healthy School Awards Scheme (HKHSA) [ 14] have developed detailed system to analyse whether each individual school has reached the standard to be a model HPS, reflecting a more holistic appreciation and understanding of all the effects of school-based health promotion. Both schemes have shown positive award-related changes [ 15, 16].

Patton et al. (2010) called for global agenda of adolescent health to include data beyond mortality to include information about adolescent health in the social, cultural, and economic contexts in which young people grow [ 17]. A study on health-related Sustainable Development Goal (SDG) targets has highlighted the need for boarder public health programmes and policies on behavioural risk factors with multi-sectoral commitments and investments [ 18]. An ecological model of health promotion is needed to address the complex interaction of environmental, organisational, and personal factors such as healthy setting approach, recognising the contextual issue as well as investment in social systems in which people spend their daily lives. [ 19, 20]. HPS framework is enabling school to become an appropriate setting for health promotion so it needs a clearer translation for action to create a new era for school health [ 21]. The schemes of WHSA and HKHSA have provided the structured framework for development as well as system of monitoring and evaluation, and also recognition of achievements [ 22, 23]. Some core indicators are needed for a wider implementation of HPS especially in developing countries as starting point because not many of their schools are able to implement HPS in its entirety [ 24, 25]. Paper by Joyce et al. (2017) asserts the importance of data monitoring, such as audits adopted in HKHSA to motivate changes [ 25]. Hong Kong has scaled up and sustained the HPS movement over the last two decades to enable study to be conducted in identification of the key indicators for successful HPS practice based on the data collected over a period of time.

Methods

Data source and study instruments: school level data

The structured framework of HKHSA is used for evaluation of efficacy incorporating the four types of indicators, inputs, process, impact and outcomes suggested by Nutbeam [ 26] to measure the success of health promotion (Table 1) [ 14, 23]. It reflects a more holistic appreciation and understanding of all the effects of school based health promotion [ 27]. The HKHSA covers six key areas (healthy school policies, school's physical environment, school's social environment, community links, action competencies for healthy living, and school health care and promotion services) suggested by WHO Guidelines [ 6, 14, 28]. The indicators of student health profile describe the health status of students including life satisfaction and emotional health, and health behaviours. The school health profile describes the school environment (physical and social), healthy policies, pedagogy on health training, and organisational practices. One would then analyse the indicators reflecting school health profile correlating with better health related outcomes based on student health profile.

Table 1 Indicators and measuring instruments for the different types of outcomes for health promotion [14, 23]

There is a strong body of evidence and theoretical framework in identifying the indicators that are relevant, adaptable and achievable reflecting school-based initiatives as well as involvement of parents, school managers and community, and also teacher training according to past and recent international practices [ 12, 13, 14, 30, 31, 32, 33, 34]. The system of accreditation of HKHSA had undergone process of validation by:

Face validation: Pilot testing was done with principals and teachers from 18 primary and 19 secondary schools who had basic understanding of HPS [ 23]

Content validation: Local and international HPS experts (6 international experts) provided valuable comments on the contents [ 23, 35]. There were two individual expertise teams: one was combined with veteran members (second and third authors of reference 35) who had been involved in the development of the HPS Performance Indicators, and was responsible for content validation. The other team was combined with the personal experience of the experts in Healthy School Award schemes, who were responsible for observing the process of accreditation and benchmarking.

Criterion validation: HPS experts experienced in Healthy School Award schemes with publications on HPS evaluation [ 12, 32], examined the process of accreditation and benchmarking with international standards taken into account of the local context [ 23]

Construct validation was conducted by analysis of the correlation of school performance in and between elements, components and the HPS key areas, and overall performance, measured by the different levels of indicators, among schools that implemented the HKHSA. Positive correlation between the element and the component level performance, the component and the key area performance, and the overall school performance in HPS was observed and published [ 23].

The schools were categorised into different levels of achievement (gold, silver and bronze award) based on their school profiles, and analysed the areas of strength and weakness according to the different components of guidelines of HKHSA [ 29, 36].

Student surveys

A system of surveillance of student health status based on the Hong Kong Student Health Survey Questionnaire (HKSHQ) incorporating the US Centre for Disease Control and Prevention (CDC) Youth Risk Behavioural Surveillance [ 3, 37, 38, 39] and WHSA [ 13] adapted by Centre for Health Education and Health Promotion of the Chinese University of Hong Kong (CHEP) [ 35, 39] with continuous refinement as a tool for assessing student health status/health related outcomes [ 40, 41]. K6 scale by Kessler and colleagues [ 42] has been used to assess emotional disturbance [ 40] as well as Life Satisfaction scale by Huebner and colleagues [ 42] as part of HKSHQ building up the student health profile. Primary 4 (aged 9 to 10 years) and Secondary 3 (aged 14 to 15 years) students were recruited for the survey in each primary and secondary school respectively.

Data collection at school level

In 2010, the Quality Education Fund commissioned CHEP to establish the Quality Education Fund Thematic Network of Healthy School (QTN Healthy School) aiming to establish a school network for sustaining the Healthy School movement territory wide. Making use of the school health profile developed by CHEP as described in previous section [ 29, 33, 34], the performance of schools achieving HPS standard was assessed by their performance among the six key areas at baseline and re-evaluated again for Healthy School Award (Award). Data were collected on performance of different components of six key areas among the 104 schools when they first joined the network as baseline assessment and the performance of those schools with Award (54 schools).

Data collection at student level

Primary four students and secondary three students were selected among those schools to analyse the changes in student health behaviours, self-reported health status and emotional health for consistency and to understand the cumulative impact of HPS at this mid-point of schooling making use of HKSHQ [ 35, 40, 41]. A previous study had shown improvement of student health, and also the school culture and organisation after 1 year [ 39]. Activities taken place in schools during the interim period included student leadership training, teachers training on HPS, and sharing of HPS good practice among teachers provided by CHEP.

Survey and Behaviour Research Committee of the Chinese University of Hong Kong approved the QTN Healthy School Study on tracing student health on 28 March 2011.

Data analysis at school level

T-test statistics was utilised to analyse for significant improvement of school health profile measured at baseline and among those schools with Award with level of statistical significance at 0.05. The full performance profile consists of over 90 indicators, and among those, there are still many indicators with significant change in mean scores measured at baseline and at time of award. Therefore, those indicators with significant mean score difference more than 0.25 were chosen to be part of the core indicators reflecting effective HPS as they would represent certain unique features of achievement in accomplishing overall healthy school environment.

The creation of school health profile enables categorisation of schools into different levels of achievement using the cut-off for different levels of Award, gold, silver and bronze [ 34]. The difference of scores among schools with different levels of Award for each component of respective key area was then analysed by ANOVA with level of statistical significance at 0.05. Those indicators with statistical significance were also chosen to be part of the core indicators.

Data analysis of correlation between indicators of school health profile and health related outcomes of students

In order to streamline the core indicators, each of those selected core indicators was correlated with related student health status measured by HKSHQ, i.e., indicators reflecting school social environment were correlated with emotional health and life satisfaction, indicators reflecting healthy eating policy and healthy eating environment were correlated with eating behaviours. The correlation was analysed by Pearson correlation coefficient, and analysis of primary and secondary schools was conducted separately.

Results

As described in data analysis section, the basic requirements for HPS were identified by t-test are illustrated in Table 2, i.e., those elements/indicators showing significant mean score difference more than 0.25. Under the key area, School's Physical Environment, the indicator 'School has a system in place to ensure that all food sold or served in school promote healthy eating (PE 4.1)' was also chosen even though the difference of mean between Baseline and Award was found to be less than 0.25. No indicators under school physical environment were found with the difference of at least 0.25 and only PE 4.1 was found to have the largest difference between Baseline and Award.

Table 2 Basic Requirements for HPS identified by t-test

After identification of the basic requirements for HPS by t-test, ANOVA was conducted to analyse the difference of scores among schools with different levels of Award for each indicator of respective key area with level of statistical significance at 0.05. Table 3 provides the summary results of those indicators under different key areas showing statistical significance at level of 0.05 among schools with different level of awards by different level of analysis by ANOVA (please refer to Additional file 2: Appendix 2 for results of analysis). Correlation of those indicators with significant improvement as shown in Tables 2 and 3 was analysed for correlation with health-related outcome of students. Additional file 3: Appendix 3 provides all the results of correlation between those selected indicators under each key area with health-related outcomes. Table 4 shows results of correlation analysis of those selected indicators under each key area with health-related outcomes. Table 5 lists the key indicators for motivating change under each respective key area showing significant impact on health behaviours.

Table 3 The elements/indicators under different key areas showing statistical significance at level of 0.05 among schools with different levels of Award analysed by ANOVA

Table 4 Pearson correlation coefficients between student health related outcomes using measures by Hong Kong Student Health Survey Questionnaire (HKSHQ) and core indicators of the six key areas (** p-value < 0.01, * p-value< 0.05)

Table 5 Key indicators for motivating change under each respective key area showing significant impact on health behaviours is listed below(*Primary Schools only, **Secondary Schools only)

Discussion

The core indicators under Action Competencies for Healthy Living (Table 4a) shown to have significant correlation with student health reflect the importance of curriculum design for health education, student engagement, staff professional development and school as resource centre for health information. Literature has highlighted the importance of comprehensive integrated approach via negotiated and systematic planning, leadership and management for effective implementation of HPS [ 12, 43, 44]. The Austrian study has argued for more systematic and co-ordinated approach with real commitment and understanding among the principals and teachers to integrate health and well-being more deeply into school system rather than many isolated activities notwithstanding enthusiastic support by health promotion service providers [ 24]. HPS needs to adopt the Critical Health Education (CHE) approach which requires empowerment of students in capacity building developing to act upon the wider social determinants of health [ 45, 46]. An Ecuadorian study also highlighted the possibility of developing CHE perspective to reaffirm the holistic understanding of health rather than just focusing on biomedical and behavioural modification [ 46]. Those core indicators reflecting AC analysed by this study (Table 4 a) are in line with CHE approach.

With regard to community link, the core indicators reflecting school in consultation with community bodies and parents, and working with them to promote community health education activities, and/or discussion on healthy school policies, have shown significant correlation with self-reported good health and better health as well as better life satisfaction (Table 4b). As school consults community members or professional groups, this would substantiate their understanding of HPS and offer advice and/or support for the holistic approach. Inter-sectoral collaboration would enable the education stakeholders to understand more evidence-based school health promotion, and linking to teaching and learning, and the health stakeholders would also be more upfront with school curriculum development and put health on school agenda with better perception of health status [ 51]. The same individual, family, school, and community factors predict both positive (e.g., success in schools) and negative (e.g., delinquency) outcomes in school [ 52]. Therefore, consultation with community and family on health promotion would lead to better health related outcomes.

For school social environment, school having a system in place to look after students and staff with emotional needs and/or unexpected traumatic life events (SE 3.2) has shown significant correlation with better mental health for both primary and secondary school students (Table 4c). SE 2.2 (school has a system for the prevention, and management of unacceptable behaviour in school among students by school teachers responsible for guidance counselling and/or school social workers, and encourages staff to set personal examples for cultivating students' positive actions) has also been found to correlate significantly with self-reported academic performance, physical active and better mental health (Table 4c). Interventions aiming at reduction of problem behaviours have been shown to enhance emotional and social development of children and adolescents [ 49]. Preventive work for early identification of students with difficulties and ensuring all parts of the school organization working coherently has found to be effective in promoting emotional and mental health in school [ 53].

Provision of basic health care services and management (HS 2.3) has shown significant correlation with better self-reported health in both primary and secondary schools and also better mental health for primary schools (Table 4e). Schools would follow the relevant guidelines to establish school health services by their respective authorities. The Austrian study has highlighted the importance of whole school approach with commitment by key stakeholders within the school not just gaining support from health promotion service providers [ 24]. It is more important to build up a comprehensive, integrative and co-ordinated school health programme [ 21].

HPS model utilises a socio-ecological approach for school-based intervention [ 33] but schools have found difficulty to implement HPS in entirety [ 24]. International Union for Health Promotion and Education (IUHPE) produced a document for monitoring and assessing HPS, and recommended schools to use accreditation to measure and track changes [ 56]. The IUHPE report referenced the HKHSA but did not include evidence whether accreditation type of programme could be effective in motivating changes. Similarly, the design of School Health Index (SHI) by US CDC [ 58], evaluation framework of National Healthy School Programmes (NHSP) in England [ 59] and "What is Healthy Together Victoria" Programme in Australia [ 60] share the auditing type of process in developing action teams, identifying areas of action and progress monitoring. However, they resemble continuous quality improvement but might not inspire change process. Sufficient information is needed to tell why programmes work in some schools and not others [ 61]. Realistic evaluation using mixed method incorporating both qualitative and quantitative methods involving systematic collection and analysis of data, iterative theory development, strong reflection processes should be adopted [ 62]. The data collected should also reflect capacity building for schools to understand and making use of the data to integrate health promotion within school setting [ 63]. The data collection process of HKHSA [ 14, 23, 34, 39] and further analysis conducted by this study has generated a common set of indicators that would assist evaluation of impact of HPS as discussed in recent paper on HPS [ 23].

Limitations

There are limitations in this study. This study only includes school joining the QTN project and those schools would be more committed to implement HPS. The data were collected from the schools participated in HKHSA and they underwent the assessments on voluntary basis. There is always argument that interventions other than HPS would improve health. However, the aim of this study is to identify indicators for success, and it is useful to investigate those schools with diversity of their performance on HPS when they first joined in. There have already been number of studies locally and overseas showing the effectiveness of HPS [ 9, 13, 14, 15, 16, 27, 31, 37, 39, 40]. One should focus on which aspects of HPS are critical for health improvement. Student-centred approach in health education teaching and learning has shown correlation with better health. Therefore, one should explore further how student involvement in other key areas of HPS would have impact on student health. Multivariate linear regression can also be conducted using data to identify correlation between students' health profile and indicators from the school health profiles, and sociodemographic variables.

This analysis is only cross-sectional. It would be interesting to observe how the school health profile correlates with student health profile in longitudinal study. If longitudinal study can be performed, longitudinal correlation between students' health related outcomes, and a number of independent variables (indicators from the school health profiles that are significant from the linear regression, location, school, and other socio-demographic variables) can be analysed using Generalized Estimating Equations (GEE).

Conclusion

There is wide debate what type of data would assist to evaluate impact of HPS, and whether schools should monitor health behaviour outcomes or relying more on process outcomes such as school policies and school environment. For wider implementation of HPS in its entirety, a common set of indicators is needed to identify issues requiring attention that would motivate changes within the school environment as well as health status and behaviours of students. This study has identified the indicators with most significant impact on wide range of health-related outcomes which would serve as key indicators for motivating change. Those indicators could serve as actions for implementation of change at organisational levels for the health and well-being of students. They could also be used as school performance indicators to help schools in monitoring and evaluation of their HPS efforts.

Availability of data and materials

Written request could be sent to the corresponding author.

Abbreviations

AC:

Action Competency for Healthy Living

Award:

Healthy School Award

CDC:

US Center for Disease Control and Prevention

CHE:

Critical Health Education

CHEP:

Centre for Health Education and Health Promotion

CL:

Community Links

HKHSA:

Hong Kong Healthy School Awards Scheme

HKSHQ:

Hong Kong Health Survey Questionnaire

HPS:

Health Promoting School

HS:

School Health Care and Promotion Services

IUHPE:

International Union for Health Promotion and Education

NCD:

Non-communicable Diseases

NHSP:

National Healthy School Programmes

PE:

School's Physical Environment

PO:

Healthy School Policies

QTN Healthy School:

Quality Education Fund Thematic Network of Healthy School

RCT:

Randomised Controlled Trial

SDG:

Sustainable Development Goal

SE:

School's Social Environment

SHI:

Student Health Index

WHO:

World Health Organisation

WHSA:

The English Wessex Healthy School Award Scheme

References

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Acknowledgements

The authors would like to acknowledge the Hong Kong Healthy School Team of the Centre for Health Education and Health Promotion, The Chinese University of Hong Kong for their contributions to the projects.

Funding

This work was supported by the funding from Quality Education Fund of Hong Kong Special Administrative Region Government (Grant number: EDB/QEF22/17/7). Quality Education Fund dose not control the design of study and collection, analysis and interpretation of data and writing of manuscript.

Author information

Affiliations

Centre for Health Education and Health Promotion, The Chinese University of Hong Kong, 4th Floor, Lek Yuen Health Centre, 9 Lek Yuen Street, Shatin, New Territories, Hong Kong

Albert Lee, Amelia Siu Chee Lo, Mei Wan Keung, Chi Ming Amy Kwong & Kwok Keung Wong

Contributions

AL designed the study and drafted the manuscript; ASCL designed the study and drafted the manuscript; MWK and CMAK provided advice on the study design; KKW was responsible for the data analysis and preparation of the tables. All authors have read and approved the final manuscript.

Corresponding author

Correspondence to Albert Lee.

Ethics declarations

Ethics approval and consent to participate

Ethical approval was granted by the Survey and Behavioural Research Committee of The Chinese University of Hong Kong. Information about HKSHQ and HKHSA was provided to the participating school, teachers, parents and students. Prior written consent was obtained from the involved schools and parents of the involved students before collecting the data for HKSHQ and HKHSA. All identifiable information was recorded confidentially and will not be disclosed to any party other than the research team.

Consent for publication

Not applicable as consent has been obtained for data collection and no identities will be disclosed.

Competing interests

The authors declare that they have no competing interests. Albert Lee is an associate editor for BMC Public Health and he had no role in the editorial process of this manuscript.

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Lee, A., Lo, A.S.C., Keung, M.W. et al. Effective health promoting school for better health of children and adolescents: indicators for success. BMC Public Health 19, 1088 (2019). https://doi.org/10.1186/s12889-019-7425-6
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Keywords

Health promoting school

Indicators

Evaluation

Adolescent and children

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Effective health promoting school for better health of children and adolescents: indicators for success - BMC Public Health

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Background Improvement of health literacy, health behavioural change, creating a supportive physical and social environment to be more conducive to health should be the focus of child and adolescent public health. The concept of Health Promoting School initiated by World Health Organization aims to move beyond individual behavioural change and to consider organisational structure change such as improvement of the school's physical and social environment.

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A health promoting school is one that constantly strengthens its capacity as a healthy setting for living, learning and working.

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Promoting Mental Health in Schools | Tips for Teachers

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Promoting Mental Health in Schools | Tips for Teachers

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Promoting Mental Health in Schools | Tips for Teachers

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For #ChildrensMentalHealthWeek, we’re looking at promoting positive mental health in schools. Find ideas you can easily add to the school routine, here.

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Student wellbeing programs improve academic outcomes

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Student wellbeing programs improve academic outcomes

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Australian Council for Educational Research - ACER

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Schools play a vital role in promoting student wellbeing. However, evidence about the impact of school-based wellbeing programs on both students' wellbeing and on academic outcomes is not always clear. To address this, the Evidence for Learning (E4L) and VicHealth commissioned the Australian Council for Educational Research (ACER) to conduct a systematic review and meta-analysis of the existing evidence around the impact of wellbeing interventions on student outcomes.

ACER examined 78 studies of wellbeing interventions delivered in primary or secondary schools. 'Wellbeing' was defined in its broadest terms. More than three-quarters of the studies examined interventions to improve mental wellbeing, 18 per cent focused on physical wellbeing and five per cent focused on preventing harm from substance use.

The systematic review provides the most robust evidence to date that attempts to broadly quantify the positive impact that wellbeing interventions have on not only student wellbeing outcomes but also student academic achievement, testing the widely-held belief that 'happy kids are better learners'.

Student outcomes

ACER constructed an impact map of the estimated effects of the interventions on student academic and wellbeing outcomes. While all interventions types examined in the meta-analysis had positive impacts on academic and wellbeing outcomes, the most effective were those that:

foster school belonging and engagement

provide mentoring

build social‑emotional skills.

Compared to similar students in control groups engaged in their usual activities, students in school-based wellbeing programs had small to moderate positive impacts on wellbeing-related measures, such as social-emotional adjustment, behavioural adjustment and cognitive adjustment.

Participation in a school-based wellbeing program, on average, had a small to moderate positive effect on general academic performance equivalent to three months of additional learning. Numeracy achievement gains were equivalent to two months of additional learning, while literacy achievement gains were equivalent to one month.

Belonging and engagement interventions were more effective for promoting academic achievement than wellbeing outcomes, delivering a learning gain equivalent to four months' additional learning. Programs that supported social-emotional skills were more effective for promoting student wellbeing and were associated with better literacy outcomes, while those that encouraged physical activity, exercise and relaxation were associated with better numeracy outcomes.

Success factors

The review found a number of success factors for effective wellbeing interventions, beyond the importance of a systemic whole-school approach. Programs with the best evidence of their impact on student outcomes tend to be:

shorter programs of up to one school term (fits in a crowded curriculum)

delivered over a number of regular sessions (builds student capacity)

explicitly taught by a trained classroom teacher (builds teacher capacity)

universal interventions that raise awareness (builds the whole community)

delivered to groups of students ranging from 11 to classroom size

differentiated for the developmental stage of the student.

The findings highlight the importance of teacher professional learning and emphasise teachers' essential role and capacity to influence student wellbeing outcomes.

Limitations

The systematic review presents the best evidence but not necessarily the best school-based wellbeing programs.

While more than 200 wellbeing programs and interventions are available for Australian schools to implement, only one Australian program had sufficient evidence of its impact on both academic and non-academic outcomes to be included in this systematic review. The majority of the studies included in ACER's review were conducted in the United States (51 studies), with the remaining 27 studies coming from 16 different countries.

More high-quality program evaluations are needed across Australia in order to identify programs that show promise or validate those that are widely used. Demonstrating evidence of impact is important not only for improving program quality, but also to ensure that the limited funding available is invested in ways that deliver the best outcomes for students. ■

Read the full article:
Student health & wellbeing. A systematic review of intervention research examining effective student wellbeing in schools and their academic outcomes by Katherine Dix, Syeda Kashfee Ahmed, Toby Carslake, Shani Sniedze-Gregory, Elizabeth O'Grady and Jennifer Trevitt (ACER) for Evidence for Learning, Social Ventures Australia 2020.

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Student wellbeing programs improve academic outcomes

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Schools play a vital role in promoting student wellbeing. However, evidence about the impact of school-based wellbeing programs on both students' wellbeing and on academic outcomes is not always clear. To address this, the Evidence for Learning (E4L) and VicHealth commissioned the Australian Council for Educational Research (ACER) to conduct a systematic review and meta-analysis of the existing evidence around the impact of wellbeing interventions on student outcomes.

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Evidence-based mental health and wellbeing programs for schools

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Evidence-based mental health and wellbeing programs for schools

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Student Well-Being | Greater Good In Education

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Student Well-Being | Greater Good In Education

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Practices for cultivating the social, emotional, and ethical well-being of students

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TFA COVID-19 Education Resource Hub

-

For Self-Work, Insight, or to Ground and Unwind

Onward and Onwardthebook.com

Onward:: Cultivating Emotional Resilience in Educators

Why Recharging Matters

Gratitude Journal Prompts & PDF

For Anxiety and Processing loss Amid COVID-19

Care for your Coronavirus Anxiety

Grieving the Losses of Coronavirus

Maybe You Should Talk to Someone, New York Times

That Discomfort You're Feeling is Grief

For Listening, Joy, and Comfort

Poetry and Reflections

Meditations with Lizzo

Songs of Comfort

Isle of Calm

For Teaching in the Time of Coronavirus

Self-Care for Educators and Students

The Child Mind Institute

For Supporting Social-Emotional Learning and Student Wellness

Mindfulness Activities for the Classroom

Phrases to Calm an Anxious Child

Emotional Development Videos

Coping Skills

Secondary Student Help

Find Resources & Support for Teaching Online
TFA Slack Network How Educators Can Address Trauma During the Pandemic How Teachers Can Stay Balanced During the Pandemic
Note: This resource list includes articles, organizations, apps, and program artifacts to support staff, teachers, and student wellness. Users are responsible for researching resources and professionals to find the best supports to meet their needs. Teach For America does not endorse these services in any way.

Find guidance on how to support students and communities on TFA's COVID-19 Education Resource Hub.

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Mental Health Resources for Educators | Teach For America

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Explore mental health and wellness in the time of COVID-19 with health and wellness resources for teachers.

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This guide provides an overview of student wellbeing - what it is, why it matters and how to nurture it in your students.

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Promoting mental health and wellbeing in your school

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Promoting mental health and wellbeing in your school

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Schools also play a role in creating a positive community that enhances a sense of connection and belonging in students. Using a whole school approach, schools can develop a safe and inclusive school environment and promote student mental health and wellbeing. This is best achieved by working in partnership with all members of the school community.

Schools can support students to develop:

social and emotional skills and capabilities that promote life-long mental health and wellbeing

skills to problem-solve and manage the normal stressors of life

healthy relationships and the ability to work cooperatively with others

a sense of autonomy and purpose.

The Schools Mental Health Menu is a list of endorsed programs, staff and resources across 3 tiers of support.

Tier 1 activities form a foundation for Tier 2 and Tier 3. Together, the tiers form layers of support for students. Tier 1 supports remain in place, and schools can add extra supports from Tier 2 and Tier 3 when greater needs are identified.

Tier 1: Universal interventions

Tier 1 Universal interventions help schools to create a positive, inclusive and supportive school climate, building the preconditions for optimal student learning, development and wellbeing. They are the initiatives and programs schools adopt that are good for all students.

Activities can be implemented at a school, year, or classroom level. They are usually delivered by school staff. Community organisations or agencies may be employed to deliver some activities.

Programs include:

adopting a whole school approach to mental health

social and emotional learning

wellbeing animal programs

eating disorders supports

alcohol and drug education

mental health literacy

bullying prevention

local community lead mental health intervention

peer support.

The Schools Mental Health Menu provides a comprehensive information about tier 1 activities (as well as tiers 2 and 3) available to schools.

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School's role in Tier 1 promoting mental health and wellbeing | Victorian Government

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Schools also play a role in creating a positive community that enhances a sense of connection and belonging in students. Using a whole school approach, schools can develop a safe and inclusive school environment and promote student mental health and wellbeing. This is best achieved by working in partnership with all members of the school community.

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https://www.mentalhealth.gov/basics/what-is-mental-health

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Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act, and helps determine how we handle stress, relate to others, and make choices.

Mental health is important at every stage of life, from childhood and adolescence through adulthood. Over the course of your life, if you experience mental health problems, your thinking, mood, and behavior could be affected.

Mental Health Conditions

Mental illnesses are disorders, ranging from mild to severe, that affect a person's thinking, mood, and/or behavior. According to the National Institute of Mental Health, nearly one-in-five adults live with a mental illness.

Many factors contribute to mental health conditions, including:

Biological factors, such as genes or brain chemistry

Life experiences, such as trauma or abuse

Family history of mental health problems

Some mental health topics include:

A Serious Mental Illness (SMI) is a mental illness that interferes with a person's life and ability to function. Despite common misperceptions, having an SMI is not a choice, a weakness, or a character flaw. It is not something that just "passes" or can be "snapped out of" with willpower.

View SAMHSA's Public Message about Serious Mental Illnesses.

Early Warning Signs & Symptoms

Not sure if you or someone you know is living with mental health problems? Experiencing one or more of the following feelings or behaviors can be an early warning sign of a problem:

Eating or sleeping too much or too little

Pulling away from people and usual activities

Having low or no energy

Feeling numb or like nothing matters

Having unexplained aches and pains

Feeling helpless or hopeless

Smoking, drinking, or using drugs more than usual

Feeling unusually confused, forgetful, on edge, angry, upset, worried, or scared

Yelling or fighting with family and friends

Experiencing severe mood swings that cause problems in relationships

Having persistent thoughts and memories you can't get out of your head

Hearing voices or believing things that are not true

Thinking of harming yourself or others

Inability to perform daily tasks like taking care of your kids or getting to work or school

Do you think someone you know may have a mental health problem? Talking about mental health can be difficult. Learn about common mental health myths and facts and read about ways to help you get the conversation started.

Tips for Living Well with a Mental Health Condition

Having a mental health condition can make it a struggle to work, keep up with school, stick to a regular schedule, have healthy relationships, socialize, maintain hygiene, and more.

However, with early and consistent treatment-often a combination of medication and psychotherapy-it is possible to manage these conditions, overcome challenges, and lead a meaningful, productive life.

Today, there are new tools, evidence-based treatments, and social support systems that help people feel better and pursue their goals. Some of these tips, tools and strategies include:

Stick to a treatment plan. Even if you feel better, don't stop going to therapy or taking medication without a doctor's guidance. Work with a doctor to safely adjust doses or medication if needed to continue a treatment plan.

Keep your primary care physician updated. Primary care physicians are an important part of long-term management, even if you also see a psychiatrist.

Learn about the condition. Being educated can help you stick to your treatment plan. Education can also help your loved ones be more supportive and compassionate.

Practice good self-care. Control stress with activities such as meditation or tai-chi; eat healthy and exercise; and get enough sleep.

Reach out to family and friends. Maintaining relationships with others is important. In times of crisis or rough spells, reach out to them for support and help.

Develop coping skills. Establishing healthy coping skills can help people deal with stress easier.

Get enough sleep. Good sleep improves your brain performance, mood and overall health. Consistently poor sleep is associated with anxiety, depression, and other mental health conditions.

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Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act, and helps determine how we handle stress, relate to others, and make choices.

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POSITIVE EDUCATION & Student Wellbeing

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Looking for mental health help? There are several ways to start your search.

Get Connected to Support

Pennsylvania's Support & Referral Helpline connects Pennsylvanians with mental and emotional support and to local resources. Call 855-284-2494 (TTY: 724-631-5600).

Call 211 to reach the United Way and get connected to help in your area. Search crisis services, hotlines, and warmlines near you on the United Way of Pennsylvania website .

Find a Facility/Specialist

For Medicaid Patients

If you have Medicaid coverage in Pennsylvania, you can find an in-network provider by clicking on the Behavioral Health Managed Care Organization (BH-MCO) listed for your county.

You're Entitled to Treatment

The Pennsylvania Department of Insurance is here to help you if you are having trouble with the mental health benefits covered by your insurance. Call them at 877-881-6388 for assistance.

Please call 911 if danger for self-harm seems imminent.

If you are having thoughts of suicide, you are not alone - no matter how much pain you are experiencing.

Remember that emotions aren't fixed, and how you feel today might not be the same as how you feel tomorrow.
Take these immediate actions suggested by HelpGuide :

1. Promise not to do anything right now. Your thoughts do not have to become a reality.

2. Avoid alcohol and drugs.

3. Make your home safe by removing things you could use to hurt yourself.

4. Don't keep these thoughts to yourself. Reach out to someone you trust, and/or reach the Suicide Prevention Lifeline at 988.

5. Remember that people do get through this. (Want to meet some survivors? Watch their stories here. )

You are valued and there are people who care about you and resources here to help.

Helping A Loved One

Suicide prevention is all of our business. Oftentimes, if a person in crisis gets the professional help they need, they will never be suicidal again.

If someone says they are thinking about suicide, they need professional help. Don't play it down or ignore the situation.

Encourage the person to call a suicide hotline number, such as 988

Encourage the person to seek treatment

Offer to help the person take steps to get support

Encourage them to communicate with you

Never promise to keep suicidal feelings a secret

Remove potentially dangerous items from the person's home, if possible

More tips on supporting a person who is suicidal from Mayo Clinic .

Warning Signs

Talking about suicide/wanting to die

Looking for a way to die by suicide (such as searching online or buying a gun)

Talking about feeling worthless

Talking about being a burden to others

Suddenly happier and calmer, especially after a period of depression

Giving away prized possessions

Getting affairs in order/making arrangements

Increased alcohol/drug use

Preoccupation with death

Risk Factors

Depression diagnosis

Previous suicide attempt

Family history of suicide

Loss of job/home/money

Death/terminal illness of a loved one

Divorce or loss major relationship

See more warning signs and risk factors for suicide from Prevent Suicide PA.

Worried About someone? Here's What To Do

1. Ask if they are OK, and listen to them like a true friend

2. Tell them you are worried about them and they are not alone

3. Talk to a mental health professional about your concerns

Not sure who to reach out to for help? You can call the Suicide Prevention Lifeline ( 1-800-273-8255) and text the Crisis Text Line (741741) to talk about your concerns for someone else.

Coping with loss is overwhelming. It's normal to experience a wide range of emotions.

Any loss can cause grief, including;

Please go easy on yourself if you are experiencing grief. It is normal to feel grief from even subtle losses in life.

How To Cope

Mental Health America shares these tips for living with grief:

Seek out caring people. Find friends and family who can understand your feelings of loss. Join support groups with others who are experiencing similar losses.

Express your feelings. Tell others what is going on with you.

Take care of your health. Eat well, get plenty of rest, and reach out to your family physician.

Postpone major life changes. You deserve time to adjust to your loss.

Be patient. There is no timeline for coping with grief. Please be gentle with yourself.

Seek professional help. If your grief is too much to bear, please reach out for help. Search for a grief therapist near you .

One day the pain will lessen. Until then, if you need extra support, that's completely normal. Get connected to help and resources in your area through Pennsylvania's Support and Referral Helpline: 855-284-2494 (TTY: 724-631-5600).

We all experience stress from time to time, but if you are feeling more stressed out than usual or your stress won't go away, you might want to take action to protect your health.

Here are some tips for managing stress from the National Institute of Mental Health :

Know your body's response to stress, such as:

Difficulty sleeping

Increased alcohol/substance use

Being easily angered

Feeling depressed

Having low energy

Talk to your health care provider

Get regular exercise

Try a relaxing activity

Decide what must get done now and what can wait

Say "No" to tasks that make it feel like you're taking on too much

Stay connected with people who can provide emotional support and practical help

If you are feeling overwhelmed, please seek out help. Use Psychology Today's search engine and/or SAMHSA's search tool to find therapists, treatment facilities, health care centers, support groups, and more.

You deserve to feel fully heard and understood when seeking support and resources. There are professionals/organizations that understand the unique experiences that come with being LGBTQ.

Crisis Help

If you are in need of immediate support, please call the TrevorLifeline at 1-866-488-7386, chat online with TrevorChat , or text START to 678-678 to have a text conversation.

Resources

Transgender-Specific Resources

Your struggles are real and valid, and there is so much help available to you.

Whatever you are going through, you are absolutely not alone. Even though people your age might not be talking about feeling down, experiencing anxiety, or having other mental health struggles, these issues are common and it's not your fault that you are experiencing them.

If you are having thoughts of suicide or are thinking about harming yourself, please reach out to a trusted adult and/or consider texting the Crisis Text Line: Just text PA to 741741 to get the conversation started.

You deserve to feel mentally well. Here are some common signs that you might want to reach out for help so you can start feeling better:

Often feel angry or worried

Have difficulty sleeping or eating

Lost interest in activities you used to enjoy

Isolating yourself and avoiding social interactions

Feeling grief for a long time after a loss or death

Using alcohol, tobacco, or other drugs

Obsessively exercising, dieting, and/or binge eating

Hurting other people or destroying property

Having low or no energy

Feeling like you can't control your emotions

Having thoughts of suicide

Harming yourself (for example: burning or cutting skin)

Thinking your mind is being controlled or is out of control

Hearing voices

Resources

Helping A Friend

If a friend confides in you that they are considering harming themselves, do not keep it a secret. Reach out to a trusted adult and/or call The Lifeline at 1-800-273-8255.

The best thing you can do for your friend is intervene, and quickly.

Here are tips on what to do from the National Alliance on Mental Illness (NAMI) :

Share your concerns with your friend. Focus on being nonjudgmental, compassionate, and understanding.

Reach out to someone you trust. You don't need to go at this alone.

Offer support. Ask questions like:

How can I best support you right now?

Can I help you find mental health services and supports?

Can I help you with stuff you need to get done?

Would you like me to go with you to your appointments? Do you need a ride?

Continue being there for your friend. Ways to do that:

Regularly check-in with them.

Include them in your plans.

Learn more about what your friend is going through.

Avoid judgmental/dismissive language (such as "snap out of it")

Keep Your School Safe

Safe2Say Something is a youth violence prevention program run by the Pennsylvania Office of Attorney General.

Do you think someone is going to harm themselves? Did you see something scary that concerns you online?

If it makes you uncomfortable, submit a tip. It will be up to your school to determine what the next steps are.

If you are in immediate danger, please call 911.

If you have experienced violence, it is not your fault. The sooner you get help, the sooner you can begin to feel better.

Coping With Trauma

Trauma can have long-term effects on mental health. You are not alone.

It is normal to:

Feel anxious, sad, or angry

Have trouble concentrating and sleeping

Continually think about what happened

If these reactions are interfering with daily activities, you may want to seek some help. Some signs from the National Institute of Mental Health that you might need help:

Worrying a lot or feeling very anxious, sad, or fearful

Crying often

Having trouble thinking clearly

Feeling angry, resentful, or irritable

Having frightening thoughts or flashbacks

Having nightmares/difficulty sleeping

Avoiding places or people that bring back disturbing memories

Becoming isolated

Children might:

Wet the bed after having learned to use the toilet

Forget how to or be unable to talk

Act out the scary event during playtime

Become unusually clingy

In addition to reaching out for help if you need it, try to avoid alcohol and other drugs, spend time with supportive loved ones, and maintain normal routines as much as possible.

If you suspect child abuse, report it. Call ChildLine at 800-932-0313. Find other resources on the Keep Kids Safe website.

Domestic Violence

If you witness or hear a violent incident, do not ignore it and don't intervene on your own. Call 911 immediately.

Pennsylvania has more than 50 domestic violence programs to help victims find safety. Find your closest domestic violence program and/or call the National Helpline at 800-799-7233.

It's not always easy to identify domestic violence. Here are some warning signs to watch for from the Pennsylvania Coalition Against Domestic Violence (PCADV):

Name calling/demeaning comments

Seeming "too good to be true" early in the relationship

Relationship advances quickly

Threatens to harm/kill you, your pets, or family members

Blames you for the abusive behavior

Prevents you from spending time with loved ones

Restricts access to financial resources

Worried you might be in an abusive relationship? Take the "Is this abuse?" quiz from PCADV.

Sexual Violence

If someone comes to you to say they have experienced sexual violence, the most important thing you can do is remain calm. Believe them and remind them that it is not their fault.

Pennsylvania's rape crisis centers provide 24/7 confidential services for those who have experienced sexual assault. Find your local rape crisis center with this map from the Pennsylvania Coalition Against Rape or call 888-772-7227 for support and services, including:

Crisis counseling

Services for family, friends, and partners

Information

Referrals to other services in your area

Prevention education programs

Find more resources through the National Sexual Violence Resource Center - located right here in Pennsylvania.

Are you a veteran in crisis or are you concerned about a veteran in crisis? Here's how to connect with the Veterans Crisis Line:

Here are three common mental health concerns for military members, according to the National Alliance on Mental Illness (NAMI):

1. Post-Traumatic Stress Disorder (PTSD)
Signs you might be struggling with PTSD include: trouble sleeping, anger, nightmares, being jumpy, and alcohol and drug abuse.

2. Depression
Depression symptoms include: Sleep and appetite changes, lack of concentration, loss of energy, loss of interest in activities, hopelessness, guilty thoughts, physical aches and pains, and suicidal thoughts. If you are thinking about harming yourself, please call the Crisis Line at 1-800-273-8255, then press 1.

3. Traumatic Brain Injury
Signs of a traumatic brain injury include: Difficulty thinking, headaches, fuzzy or blurry vision, irritability, sleep changes, sadness, difficulty remembering new information, and difficulty concentrating.

If you are struggling with any of these concerns, please seek out help. Find a health care provider in the TriCare network by searching online.

Learn more about common military mental health concerns and how to help a fellow warrior on the NAMI website .

Find more mental health resources for veterans on the federal Department of Veterans Affairs website.
Military Sexual Assault
The Department of Defense's Safe Helpline is here to help survivors of sexual assault. Use the Safe Helpline website for live chats, reporting retaliation, and more. Get help by phone at 877-995-5247.

Substance Use Disorder is a disease, and you deserve to get help for your illness.

Signs that you might need help include:

Lack of control/inability to stay away from a substance

Decreased socialization

Ignoring risk factors

Physical effects, such as withdrawal symptoms

Recovery starts with a call. Call 1-800-662-HELP (4357) for information about treatment resources. Your call is confidential. The hotline is staffed by trained professionals 24 hours a day, seven days a week, and is available in both English and Spanish.

The Department of Drug and Alcohol Programs has a search engine for finding treatment, as well. Search by ZIP code, county, or statewide for programs that could help you.

What to ask treatment providers to determine if they are right for you.

Online Resources

Starting a conversation about getting help isn't easy. These tips from the National Institute on Alcohol Abuse and Alcoholism are helpful for talking with your loved one about getting treatment:

Think about what you are going to say before you say it. Consider a role-playing practice with someone else.

Choose the right time to talk. Your loved one should be sober for this. Avoid having this chat at celebrations and on holidays.

Try to be calm and supportive. Your loved one's life may be in chaos right now. You can be a calming influence.

Don't gang up on the person. It's important that they feel supported, not threatened.

Stick with the facts. A person with substance use disorder has a medical problem. Treatment works, and recovery is possible. Let them know you're here to help them find a good plan of action.

Supporting Kids

The National Association of Children of Addiction educates and supports children and family members to lead healthy lives despite being hurt by substance use disorder. The organization teaches the "seven Cs" for helping kids cope with parental substance use:

I didn't cause it. I can't control it, and I can't cure it.

I can help take care of myself by communicating my feelings, making healthy choices, and celebrating me.

Alateen has chats for young people, ages 13 to 18, who have been affected by someone else's substance use. Register for an Alateen Chat .

For Parents

Whether you've just discovered your child's substance use or you need a new approach, Partnership for Drug-Free Kids' Parent Helpline is here to help you:

Knowing the facts can help your child get on the road to recovery:

Substance use changes the brain, which can make drug use compulsive.

Expecting your child to quit cold turkey is unrealistic.

Intervening early is better than waiting for "rock bottom."

Your child can have mixed feelings about treatment, and it still can be effective.

Resumed use is common and often occurs before achieving long-term recovery.

Positive behavior and communication skills are more effective than punishment.

It's crucial to find the best treatment for your child's unique needs.

Medication-assisted treatment is the gold standard of care for opioid use disorder.

Using person-first language is proven to reduce stigma and improve treatment.

This crisis toolkit has resources for parents of loved ones with substance use disorder.

Support on Social Media

Get helpful, up-to-date resources by following the Department of Drug and Alcohol Programs on Facebook and Twitter .

If you are in crisis and need immediate help, please call the National Suicide Prevention Lifeline at 1-800-273-8255.

Pennsylvania's Commission on African American Affairs recommends the following resources:

Healing in the Face of Cultural Trauma

The Association of Black Psychologists suggests these tips for self care when experiencing racial stress or trauma:

Self-monitor for signs of stress

Restore the well that is you

Take a break from social media and the news

Fill the depleted well with positive, comforting thoughts and experiences

Rest and relax

Be intentionally kind and gentle with yourself and those around you

Let others replenish the well

Ask for help

Seek out comfort and conversation with those who love and understand you

Stay spiritually grounded with prayer and/or mindfulness

Remember your body

Practice relaxation techniques (such as deep breathing)

Release energy, tension, and strain to the body that comes from carrying stress and trauma

Walk, exercise, dance, stretch - whatever suits you!

Remember to breathe deeply

Stay informed, but monitor how often you're checking in
Periodically turn of the news and tune into self-care

Be intentionally kind and gentle with yourself and those around you

Download the full self-care toolkit developed for and by people of African ancestry .

Black Mental Health Alliance

The Black Mental Health Alliance supports the health and well-being of Black people and other vulnerable communities.

Looking for a therapist? Fill out a short questionnaire and someone will follow up with you within 24 hours.

Therapy for Black Girls

This national effort by Dr. Joy presents mental health topics in a way that feels more accessible and relevant to Black girls and women.

Find a culturally competent therapist by using the Therapy for Black Girls search tool .

Vietnamese Outpatient Clinic

WES Health System has a specialized outpatient program to meet the needs of Philadelphia's growing Asian population.

The program provides medication evaluation and consultation, individual and group therapy, and family and couples therapy in a patient's native language.

The clinic is located at 2514 N. Broad St., Philadelphia. Contact the office at 215-599-2845.

Reach Out PA

In January 2020, Governor Wolf announced an initiative called Reach Out PA: Your Mental Health Matters. This initiative is aimed at expanding health care access and ending the stigma that comes with reaching out for help.

Tell the governor's administration what would help you better your mental health by filling out the Reach Out PA feedback form.

Suicide Prevention Task Force

Governor Wolf started a first-of-its-kind statewide Suicide Prevention Task Force in 2019. The task force is focused on reducing the rate of suicide in Pennsylvania.

If you or someone you love is in crisis or you are considering harming yourself, free help is available 24/7 through the National Suicide Prevention Lifeline at 1-800-273-8255.

Training for First Responders

Pennsylvania recently rolled out mental health trainings for fire, emergency, and rescue personnel.

Trauma-Informed Pennsylvania

Governor Wolf released a "Trauma-Informed PA" plan to guide Pennsylvania on what it means to be trauma-informed and healing centered. The goal is to break the cycle of trauma by setting people on the path to true healing.

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Mental Health Resources for Pennsylvanians

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Your mental health matters. Use this guide to find resources in Pennsylvania. If you or someone you know is experiencing a mental health crisis, call 911.

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7 Ways to Promote Mental Health Awareness in Schools - Netsweeper

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7 Ways to Promote Mental Health Awareness in Schools - Netsweeper

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It may be daunting to broach the subject of mental health and students, but there's reason to be optimistic: 70% of mental health cases that appear in children can be addressed through early intervention. Getting ahead of mental health disorders and offering support to those who need it helps at-risk students before their mental health issues become more serious. The good news? There are a multitude of ways to do just that.

While there are technological tools such as web filtering and monitoring that are essential for safeguarding students and can help identify mental health issues early, we believe it's even more important to learn how to identify students struggling with mental health issues and focus on helping students become resilient. In this blog post, we have put together a list of resources you can use to help promote mental health awareness in your school and create a positive mental health culture.

Why mental health awareness in schools is important

The World Health Organization estimates that close to 20%, or one in five students, are actively dealing with a mental health issue. For students, suicide is the second leading cause of death. The number of students today experiencing mental health problems is also on the rise.

For help identifying students at risk of suicide and how to help, download our Suicide Awareness and Prevention in Students Whitepaper.

Identifying the signs that something is wrong

There are many signs and circumstances that may identify a student suffering from mental health issues. Small changes in behavior (such as being withdrawn or outraged after texting or using the internet) can be an indication of a much bigger problem (bullying). It's important that we all become aware of the signs associated with mental illness, so we can provide support for those that need it. The earlier an issue is picked up, the better it is for the student.

For help identifying the students struggling with a mental health issues, plus tips on how to help them, download our Children and Mental Health Whitepaper.

What can I do to increase awareness?

It is essential that teachers provide students with the opportunities, resources, and support they need. Here are seven ways you can promote mental health awareness in your school:

1. Promote positive self-esteem. Provide students with the tools and skills necessary to resolve conflict and the inevitable setbacks they'll face. Boost their self-confidence by supporting good decision making, assertiveness, perseverance, and self-determination

2. Encourage students to eat healthy and provide healthy eating options

3. Provide outlets to relieve anxiety and stress. Physical activity, meditation and the arts are super for self-expression, growth, and work wonders on a student's overall mental health and ability to handle stress.

4. Promote school policies that support mental health such as bullying prevention

5. Display relevant material to students and families, such as the materials found on the websites for the National Alliance on Mental Illness and the World Health Organization

6. Have an open-door policy - communicate to your students that you are available to listen to their concerns and issues. Communicate openly, honestly and often. Notice the little conversational openers students may offer up and ask non-judgmental questions. Be sure to pause and listen to what they have to say

7. Provide places where students can relax, such as quiet areas and lounge chairs

Mental health disorders in students is a complex issue that requires a coordinated effort and multilevel approach from parents, schools, health care organizations, digital media outlets, and community outreach. Early detection and intervention are crucial factors in the goal towards reaching at-risk students before conditions manifest into more serious issues.

For help identifying the students struggling with a mental health issues, talk to a safeguarding expert

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7 Ways to Promote Mental Health Awareness in Schools - Netsweeper

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It may be daunting to broach the subject of mental health and students, but there's reason to be optimistic: 70% of mental health cases that appear in children can be addressed through early intervention. Getting ahead of mental health disorders and offering support to those who need it helps at-risk students before their mental health issues become more serious.

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Student wellbeing encompasses the overall health of a student, including their social, mental, physical, and emotional health. Enjoyment and satisfaction

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Importance of Mental Health Awareness in Schools

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Importance of Mental Health Awareness in Schools

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Mental health awareness is an important issue for all educators, who are often the first line of defense for their students. Education professionals have recognized the impact that a student's mental health has on learning and achievement, and they realize that there's a great deal that can be done to help students with mental health issues. As a high school teacher with more than 23 years of experience, I welcome the fact that mental health awareness is finally becoming an important part of a school's function and curriculum.

Seeing the Signs in My Student

A few years ago, a student in my senior class changed drastically in a short period of time. I noticed that Melina no longer did her homework, and she didn't even try on her essays. Previously meticulous in her appearance, Melina would come to school disheveled, wearing the same clothes. When I tried to speak to her, she was uncharacteristically distant and withdrawn. Because I had some training in mental health awareness, I knew Melina was in some sort of trouble.

Luckily, my school had social workers on staff who could speak to Melina and assess her issues. They discovered that Melina was depressed and suicidal, and she needed an immediate psychiatric intervention. Melina was hospitalized for a period of time, but she was able to return to my classroom a few months later. With the help of medication and therapy, she managed to graduate with her class.

Understanding the Impact

The National Alliance on Mental Illness estimates that one in five people live with some sort of mental disorder or disease. Despite the fact that the average age of early signs of mental illness is 14, most individuals don't seek help until adulthood. Underlining the seriousness is the fact that 60 percent of high school students with mental illness don't graduate.
Further reading: Ease Student Anxiety in the Classroom
New York mental health experts recognized that earlier intervention could result in more positive outcomes for these students. Beginning in July 2018, New York will be the first state in the nation to require mental health education for all students. The overall mission of New York's School Mental Health (SMH) program is to promote healthy social, emotional, and behavioral development of students, and "break down barriers to learning so the general well-being of students, families, and school staff can be enhanced in collaboration with other comprehensive student support and services."

The SMH program supports the emotional health and academic growth of all students with the following:

Integrating comprehensive services and support throughout every grade level

Assessing mental health needs through universal, selective, and targeted interventions

Providing access to behavioral and mental health services and programs

Leveraging higher-level personnel, such as those working with the Department of Education, for necessary support and services

Building collaborative relationships between the school and students' families and communities

Spreading Awareness Across the Nation

Until mental health education is a mandatory aspect of all schools, teachers and administrators can work to promote awareness with their students. Key elements to shine a light on include the concept of self-care and responsibility for one's own mental health and wellness, with an emphasis on the fact that mental health is an integral part of health, and the concept of recovery from mental illness.

Teachers and students should be provided with ways to recognize signs of developing mental health problems, and there should be opportunities around the awareness and management of mental health crises, including the risk of suicide or self-harm. Further, instruction should address the relationship between mental health, substance abuse, and other negative coping behaviors, as well as the negative impact of stigma and cultural attitudes toward mental illness.
Further reading: Social-Emotional Learning
Because teens spend most of their day at school, it just makes sense to have mental health awareness and education become part of the curriculum. When we empower students with knowledge, and encourage dialogue, students will be able to get the help they need.

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The Importance of Mental Health Awareness in Schools

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Mental health awareness is an important conversation few schools have with their students. Introducing the right resources can make a huge difference.

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Mental Health and Well-Being Resources for Students

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Mental Health and Well-Being Resources for Students

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Note: CSU Health Network is partially funded by CSU student fees, and most services are available for fee-paying CSU-Fort Collins students only. For more information, visit our eligibility, fees, and service charges page.

If you are a CSU student experiencing a mental health crisis, please call (970) 491-6053 to speak with a crisis counselor.

Online 24/7 Tools

YOU@CSU - Explore campus resources, and find personalized tips and tools for everything from your mental and physical health, to friendships and finding balance. Login at you.colostate.edu or through RAMweb.

SilverCloud Health- Self-guided online programs based on Cognitive Behavioral Therapy to help you enhance well-being, manage anxiety and depression, improve your sleep, boost your body image, and more.

Nod app - Strengthen your connections -A free app that offers ideas for strengthening social ties. Using evidence-based practices, the app reminds us of the small things we can do to create positive moments for ourselves and the people we care about.

Mindfulness Apps- Unwinding Anxiety, Insight Timer, Headspace, StopBreatheThink, Smiling Mind, The Shine App, Liberate Meditation, and Calm are apps that offer many ways to practice and learn about mindfulness to enhance well-being.

Financial Wellness Education - The Achieve Financial Wellness online modules will boost your financial know-how and help you learn to manage your money in college and beyond. Topics include understanding student loan debt, using credit cards responsibly, sticking to a budget, and more.

Groups and Workshops

Skill-Building Group Workshops - Available for students only, at no additional charge. See full line-up of workshops including descriptions, dates and times on the Groups and Workshops page. Spring 2022 group workshops include:

Mindfully Managing Stress

Alcohol and Other Drugs: The Mind Body Connection

Anger Management

CannaBiz 101

Gender Workshop (male-identified students only)

Life Safe 101

Risk Management

Stages of Change

Values Clarification

Who Am I?

Theme Groups- Theme therapy groups help students connect with others who share common experiences, identities and concerns. Spring 2022 theme groups include:

BIPoC Support Group

International Student Support Group

Trauma Skills Group

Coming Out, Being Out and Questioning Support Group

Transgender and Gender Fluid Support Group

Womxn of Color Support Group

Alcohol and Other Drugs Support Group

DBT Tools for Success

Body Positive

Depression Skills Group

Taming the Anxious Mind

Mindful Yoga

See full line-up, including descriptions, dates and times, on the Groups and Workshops page. Call (970) 491-6053 to register. Pre-session screenings are required.

Interpersonal Process Groups- a safe, supportive space to explore your feelings, connect with others, and practice new behaviors that can ultimately lead to more fulfilling relationships

Multicultural Resources

Multicultural Counseling Services - Designed for students who have been historically underrepresented and aims to reduce barriers for you to access and navigate Counseling Services. The webpage features a list of identity-specific services and resources that can support your emotional health and overall wellness, including Multicultural Counseling Drop-In Hours, Identity Based Group Counseling, Peer Support Identity Groups and information about the Multicultural Counseling Team and Student Office Liaisons. Visit Multicultural Counseling Services for more information.

Transgender Care- The Transgender Health Team at CSU Health Network is a multidisciplinary team committed to providing comprehensive gender-affirming care for transgender, gender non-conforming, and gender-questioning students at Colorado State University.

Mental Health Musings Podcast- Mental health can be a complex and daunting topic for folx. From navigating what resources are available to what will work best for oneself, it's not easy. Join CSU Health Network staff Stephanie Zee and Adam-Jon Aparicio as they share their own personal mental health journey, discuss different mental health topics and explain what's available at CSU to help you with your mental health and well-being. If you're someone who doesn't know what's available on CSU's campus for mental health and well-being or unsure with how to begin your own self-help journey, this show is for you.

One-on-One Services

Counseling Services - A portion of your student fees (approximately $53 per student per semester) helps pay for a wide range of mental health support resources, including crisis services, groups, workshops, and brief individual therapy.

If you would like to meet with a counselor, your first step is to come to Counseling Services on the 3rd floor of the CSU Health and Medical Center during drop-in hours:

Mondays: 9 a.m. - 3:30 p.m.

Tuesdays: 10 a.m. - 3:30 p.m.

Wednesdays: 9 a.m. - 3:30 p.m.

Thursdays: 9 a.m. - 3:30 p.m.

Fridays: 9 a.m. - 3:30 p.m.

Visit About Counseling Services for more information and learn more about what to expect at a Counseling Services appointment

Important note: Staffing shortages may impact appointment availability.

Consider using your health insurance benefits to seek individual therapy in the local community. Most health insurance carriers have a phone number (usually found on the back of your insurance card) or online portal to help you find a local provider that works with your insurance plan.

Connections is a free local service that can help you connect to mental health services in the community, including services that work with your health insurance plan. Call 970-221-5551 to get started.

Wellness and Behavioral Health Consultation- Our Wellness & Behavioral Health Consultation program embeds mental health clinicians within the CSU Health Network medical teams, following a model of integrated health care which allows immediate access to wellness, behavioral health and mental health consultation and support for both patients and medical providers. The Wellness Consultants (BHCs) function as members of the medical care team and collaborate with medical staff in their daily provision of health care to CSU students. This integrative, "no wrong door" approach means that students have access to the support they need within the context of their medical care team, as an alternative to (or alongside) support from Counseling Services.

Medical Services- Your physical health is a major factor in your overall well-being. Students can access primary care, dental, optometry, physical therapy services and more through CSU Health Network.

Nutrition Services - Services available to support a variety student health conditions and needs, as well as resources for those experiencing food insecurity.

Tobacco Cessation - Students who are thinking about or are ready to quit vaping, smoking or using tobacco can meet one-on-one with a professional health coach who specializes in tobacco cessation. Call (970) 491-7121 to make an appointment.

Drugs and Alcohol Support

Substance Use Self-Assessment Tools - Concerned about your substance use during these stressful times? These free self-assessment tools are available to help you check-in.

Online Alcohol and Other Drug Screening - Assess your use, find out how your alcohol and/or drug use compares to other college students and discover resources for more information.

Marijuana eCHECKUP TO GO - This personalized, evidence-based program provides individual feedback about behavior and risk factors, and campus and community resources.

Tobacco Cessation -Students who are thinking about or are ready to quit vaping, smoking or using tobacco can meet one-on-one with a professional health coach who specializes in tobacco cessation. Call (970) 491-7121 to make an appointment.

Opioid Use Disorder Treatment - Medication-Assisted Treatment (MAT) is available for students who suffer from abuse of heroin, pain pills or any other opioid use.

Ram Recovery Community - An inclusive student-run community designed to support students on all paths and in all phases of recovery, including substance use disorders, eating disorders, and other mental health disorders.

Education and Self-care

Ram Recovery Community - An inclusive student-run community designed to support students on all paths and in all phases of recovery, including substance use disorders, eating disorders, and other mental health disorders.

Financial Wellness Education - The Achieve Financial Wellness online modules will boost your financial know-how and help you learn to manage your money in college and beyond. Topics include understanding student loan debt, using credit cards responsibly, sticking to a budget, and more.

Mental Health Resources for CSU Faculty and Staff

Learn more about additional mental health resources for CSU faculty and staff:

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Mental Health and Well-Being Resources for Students

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Note: CSU Health Network is partially funded by CSU student fees, and most services are available for fee-paying CSU-Fort Collins students only. For more information, visit our eligibility, fees, and service charges page. If you are a CSU student experiencing a mental health crisis, please call (970) 491-6053 to speak with a crisis counselor.

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Building Better Mental Health

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Mental health has become the subject of open, honest discussion in higher education and beyond. Fallout from the pandemic thrust mental health into an even broader, brighter spotlight, exposing long-standing sources of stress, anxiety, and depression and creating new ones. Mental health is integral to one's ability to succeed academically, and colleges and universities must work to expose the sources and consequences of mental health disorders and find ways to address them.

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Mental health has become the subject of open, honest discussion in higher education and beyond. Fallout from the pandemic thrust mental health into an even broader, brighter spotlight, exposing long-standing sources of stress, anxiety, and depression and creating new ones.

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Mental health is a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community. It has intrinsic and instrumental value and is integral to our well-being.

At any one time, a diverse set of individual, family, community and structural factors may combine to protect or undermine mental health. Although most people are resilient, people who are exposed to adverse circumstances - including poverty, violence, disability and inequality - are at higher risk of developing a mental health condition.

Many mental health conditions can be effectively treated at relatively low cost, yet health systems remain significantly under-resourced and treatment gaps are wide all over the world. Mental health care is often poor in quality when delivered. People with mental health conditions often also experience stigma, discrimination and human rights violations.

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10 Mental Health Tips for Online Students

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10 Mental Health Tips for Online Students

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1. Learn to meditate

At the core of many relaxation routines is meditation, but where should you start? Most involve focusing on a single point, such as the sensation of breathing. Follow this meditation guide for helpful tips.

2. Get mindful

Mindfulness, or a state of active attention on the present, has come to the forefront in recent years as a core component in mental health. It can help you focus on the here and now, form memories, and slow down your thought processes. According to Psychology Today, mindfulness can help even during your busiest moments. Consider enrolling for the next start date of our new online course, The Mindful Semester to explore techniques for managing stress and cultivating self-awareness.

3. Eat right and exercise

We know this one's easier said than done, but the basic components of healthy living have a significant impact on physical and mental health. Meal planning and setting scheduled time to exercise can be great ways to get into a routine.

4. Rest

Getting enough sleep has serious benefits, from reduced stress levels to a healthier body. But when you're juggling work, school and family, how can you reliably get the recommended 7-9 hours a night? Follow these tips for getting a good night's sleep.

5. Socialize

It may be hard to remember with so much to do, but it's important to set aside time to spend responsibly with friends.

6. Set realistic goals

Don't stress if you can't achieve everything all at once. The best way to ensure you're hitting your goals is to make them challenging but reasonable - things you can accomplish without sacrificing the other items on this list!

7. Make time for fun

Have a favorite activity that helps you unwind? Make time for your hobby. Mental health experts agree that penciling yourself in for some "me time" is an important part of anyone's life.

8. Get out of the house

If you're able, go outside for some of the items on this list. According to Business Insider, taking a walk in the wilderness or doing a yoga routine in the sunshine can offer surprising health benefits.

9. Go easy on yourself

It's often easy to forgive loved ones for forgetting to finish a task or misremembering an appointment. But why are we often so hard on ourselves? It's important to hold ourselves accountable, but studies have also shown that self-compassion is an important part of good mental health.

10. Ask for help

Whether it's calling your academic advisor, talking to a loved one, or seeking assistance from a therapist, there is nothing wrong with asking for help. Arizona Online students have access to comprehensive counseling and support services through Launchpad. Whether it's watching a quick video to de-stress or seeking long-term solutions for issues like stress, anxiety or depression, university resources can help.

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10 Mental Health Tips for Online Students

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Being a student is hard, even for those who enjoy the flexibility of a fully online education. Here are a few tips for finding balance in your life.

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Wellbeing and resilience are important in preventing the onset of mental health problems as well as potentially lessening the severity of existing mental health problems. Wellbeing and resilience are vital to developing efficient problem-solving skills, building and maintaining interpersonal relationships and realistic goal setting, all of which greatly enhance an individual's ability to perform and contribute meaningfully in daily life.

What is wellbeing and resilience?

Good health is about more than just the absence of sickness. Focusing on wellbeing and building resiliency is important in establishing a holistic approach to health, addressing both physical and psychological states.

The World Health Organisation defines wellbeing as "the state in which an individual realises his or her own abilities, can cope with normal stresses of life, can work productively, and is able to make a contribution to his or her own community". Wellbeing involves having positive self image and esteem.

Resilience, which is directly related to wellbeing, is about having the ability to cope with and adapt to new situations. Having a sense of resilience and positive wellbeing enables a person to approach other people and situations with confidence and optimism, which is especially important for young people given the enormous changes that occur with the transition into adolescence and adulthood.
Signs of resilience and wellbeing:

confidence to approach new situations and approach new people

realistic optimism

avoiding constant self-blame

ability to set goals

positive self image and self esteem.

How can students focus on wellbeing and resilience?

In a practical sense developing and improving on setting realistic and achievable goals, problem solving and social skills all contribute to wellbeing and resiliency. Other important skills include identifying and becoming aware of one's own strengths and weaknesses.

1. Setting realistic, achievable and measurable goals is a great way to promote self-efficacy. Setting goals should be motivating. One way to increase motivation (and minimise feeling pressure or 'failure') is to set sub-goals, smaller and achievable related targets.

2. Understanding and avoiding negative self-talk as well as actively practicing positive self-talk, is an important tool for building self-esteem. Self-talk, which is essentially internal reflections on personal ability and/or image, can greatly influence self esteem and perceptions about personal ability.

3. Developing and focusing on interpersonal skills, especially learning how to engage with people from different backgrounds, is a valuable tool for young people that will enhance self esteem and ability to maintain personal and fulfilling relationships.

What can teachers do?

create safe and supportive learning environments

provide consistent guidelines for behaviour

model appropriate responses and behaviours

provide opportunities for goal setting, success, failure and reflection.

ReachOut.com resources on wellbeing and resilience

How to help

Talk to young people about their mental health in terms of building strength and resilience.

Suggest self-awareness and resilience strategies, such as mindfulness meditation. Try the Smiling Mind app.

Recommend ReachOut.com content on resilience and wellbeing.

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Wellbeing and resilience are important in potentially preventing the onset of and lessening the severity of existing mental health problems.

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Resources for Mental Health Awareness Week

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Resources for Mental Health Awareness Week

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Resources for Mental Health Awareness Week

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Download free graphics for social media and posters for your Mental Health Awareness Week event.

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Promoting mental health and wellbeing in your school

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Promoting mental health and wellbeing in your school

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Schools also play a role in creating a positive community that enhances a sense of connection and belonging in students. Using a whole school approach, schools can develop a safe and inclusive school environment and promote student mental health and wellbeing. This is best achieved by working in partnership with all members of the school community.

Schools can support students to develop:

social and emotional skills and capabilities that promote life-long mental health and wellbeing

skills to problem-solve and manage the normal stressors of life

healthy relationships and the ability to work cooperatively with others

a sense of autonomy and purpose.

The Schools Mental Health Menu is a list of endorsed programs, staff and resources across 3 tiers of support.

Tier 1 activities form a foundation for Tier 2 and Tier 3. Together, the tiers form layers of support for students. Tier 1 supports remain in place, and schools can add extra supports from Tier 2 and Tier 3 when greater needs are identified.

Tier 1: Universal interventions

Tier 1 Universal interventions help schools to create a positive, inclusive and supportive school climate, building the preconditions for optimal student learning, development and wellbeing. They are the initiatives and programs schools adopt that are good for all students.

Activities can be implemented at a school, year, or classroom level. They are usually delivered by school staff. Community organisations or agencies may be employed to deliver some activities.

Programs include:

adopting a whole school approach to mental health

social and emotional learning

wellbeing animal programs

eating disorders supports

alcohol and drug education

mental health literacy

bullying prevention

local community lead mental health intervention

peer support.

The Schools Mental Health Menu provides a comprehensive information about tier 1 activities (as well as tiers 2 and 3) available to schools.

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School's role in Tier 1 promoting mental health and wellbeing | Victorian Government

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Schools also play a role in creating a positive community that enhances a sense of connection and belonging in students. Using a whole school approach, schools can develop a safe and inclusive school environment and promote student mental health and wellbeing. This is best achieved by working in partnership with all members of the school community.

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04_Internet_Resources

Internet Resources

Resources for everyone

Emily Underwood is research and instruction librarian at the Hobart and William Smith Colleges Warren Hunting Smith Library, email: underwood@hws.edu

Approximately one in five adults (19.1%) experienced mental illness in 2018.1 In my opinion, one of the reasons that only 43.3% of those individuals received any kind of treatment or services is the stigma surrounding mental illness.2 As information professionals, we are uniquely positioned to assist patrons with finding the information and resources they need in order to learn what mental illness is, what it is not, discover that they are not alone, and find the best treatment for their situation. Everyone suffering from mental illness needs to know that there is hope for them and that they don't need to suffer alone. When people feel that there is no hope of relief, their mental illness can become fatal through suicide.

According to the Centers for Disease Control and Prevention (CDC)'s web-based Injury Statistics Query and Reporting System (WISQARS) Leading Causes of Death Reports, in 2017 suicide was the second leading cause of death in people ages 10 to 34, and it claimed the lives of more than 6,000 people ages 15 to 24.3 According to the Spring 2019 Report from the American College Health Association National College Health Assessment, 13.3% of students surveyed "seriously considered suicide" sometime in the last 12 months.4 Suicide is preventable. But it's only preventable if those who are struggling feel like it is acceptable and safe to share how they are feeling.

There are many organizations that aim to provide support and relief for mental illness. The organizations included here (which is far from being an exhaustive list) are doing what they can to promote awareness of mental illness and to improve the mental health of people in the United States and throughout the world.

Government organizations

National Institute of Health (NIH). NIH is composed of 27 institutes and centers that each have specific research specialties. While there are several institutes that focus on mental health specifically, NIH also produces resources to assist people suffering from mental health issues. They publish a monthly newsletter, NIH News in Health, that frequently contains mental health-related articles, and they also produce wellness toolkits that provide practical, concrete strategies for improving one's well-being. Access: nih.gov.

Nonprofit organizations, general

Nonprofit organizations, specialized

Professional organizations

International organizations

Notes

1. Substance Abuse and Mental Health Services Administration, "Results from the 2018 National Survey on Drug Use and Health: Detailed Tables," https://www.samhsa.gov/data/nsduh/reports-detailed-tables-2018-NSDUH, table 8.1B.

2. Ibid, table 8.17B.

3. Centers for Disease Control and Prevention WISQARS, "Leading Causes of Death Reports, 1981 - 2017," January 18, 2019, https://webappa.cdc.gov/sasweb/ncipc/leadcause.html.

4. American College Health Association-National College Health Assessment, "Reference Group Executive Summary, Spring 2019", https://www.acha.org/documents/ncha/NCHA-II_SPRING_2019_US_REFERENCE_GROUP_EXECUTIVE_SUMMARY.pdf, 13.

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04_Internet_Resources Internet Resources Resources for everyone Emily Underwood is research and instruction librarian at the Hobart and William Smith Colleges Warren Hunting Smith Library, email: underwood@hws.edu Approximately one in five adults (19.1%) experienced mental illness in 2018.1 In my opinion, one of the reasons that only 43.3% of those individuals

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Improving wellbeing and resilience is vital for students to stay mentally healthy. Use ReachOut Schools' resources to support your students wellbeing.

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BRAVE Online | Online help for worried kids

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5 T's for mental health education in Schools

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5 T's for mental health education in Schools

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Understanding Students' Mental Well-Being Challenges on a University Campus: Interview Study

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Understanding Students' Mental Well-Being Challenges on a University Campus: Interview Study

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JMIR Form Res. 2020 Mar; 4(3): e15962.

Guest Editor (s): Gunther Eysenbach

Reviewed by Christo El Morr and Qi Yuan

Sun Young Park, BA, MS, PhD, #¹ Nazanin Andalibi, BS, PhD, ¹ Yikai Zou, BS, MS, ¹ Siddhant Ambulkar, BS, ² and Jina Huh-Yoo, BA, MS, PhD ³

Abstract

Background

Research shows that emerging adults face numerous stressors as they transition from adolescence to adulthood. This paper investigates university students' lived experiences of maintaining mental well-being during major life events and challenges associated with this transitional period. As we continue to design health technology to support students' mental health needs, it is imperative to understand the fundamental needs and issues particular to this phase of their life to effectively engage and lower the barriers to seeking help.

Objective

This study first aimed to understand how university students currently seek and receive support to maintain their mental well-being while going through frequent life events during this period of emerging adulthood. The study then aimed to provide design requirements for how social and technical systems should support the students' mental well-being maintenance practice.

Methods

Semistructured interviews with 19 students, including graduate and undergraduate students, were conducted at a large university in the Midwest in the United States.

Results

This study's findings identified three key needs: students (1) need to receive help that aligns with the perceived severity of the problem caused by a life event, (2) have to continuously rebuild relationships with support givers because of frequent life events, and (3) negotiate tensions between the need to disclose and the stigma associated with disclosure. The study also identified three key factors related to maintaining mental well-being: time, audience, and disclosure.

Conclusions

On the basis of this study's empirical findings, we discuss how and when help should be delivered through technology to better address university students' needs for maintaining their mental well-being, and we argue for reconceptualizing seeking and receiving help as a colearning process.

Keywords: emerging adults, university students, life events, mental wellbeing, mental wellness, mental health, social support

Introduction

Background

During this transitional phase of emerging adulthood, university students experience various life events at different scales, ranging from entering college, leaving home and moving to a new city, and making new networks, to taking finals and looking for a job [ 4]. These life events become potential stressors as students are expected to increase their personal responsibility and independence and make constant adjustments, including personal, emotional, and social adjustments [ 5]. Research shows that support from peers, family, and health care resources aids their life satisfaction, self-esteem, perceived social acceptance, and well-being [ 6, 7].

We build upon recent work in human-computer interaction (HCI) and Health Informatics [ 13- 17], which approaches university students' struggles and challenges as a mental well-being problem rather than as a clinical, mental illness problem. This approach helps address the problems that students need to engage but often ignore because they consider those problems not to be mental health concerns but "normal" problems that occur during emerging adulthood [ 12]. Focusing on mental well-being helps us understand students' everyday lived experiences of muddling through major life events during their emerging adulthood.

With this perspective, this study first aimed to understand how university students currently seek and receive support to maintain their mental well-being while going through frequent life events during their emerging adulthood. The study then aimed to provide design requirements for how social and technical systems should support the students' mental well-being maintenance practice. In this paper, we report findings from semistructured interviews with 19 students on a university campus. We identified three key needs: (1) the need to receive help that matches the perceived severity of a problem caused by life events, (2) the need to constantly draw on new support givers because of frequent life events, and (3) the need to negotiate the tension between the benefits of self-disclosure and the stigma associated with such disclosure. On the basis of this study's findings and analysis, we make the following contributions:

We extend our knowledge about university students' understandings and perceptions of mental health and coping strategies.

We discuss how students strive to maintain their mental well-being and perceive the boundary between what counts as mental "illness" vs "wellness" in assessing whether to get help.

We present design implications for sociotechnical systems to support the needs of students to better maneuver through this important transitional life phase.

Related Work

The American Psychological Association defines emerging adulthood as the "in-between age," referring to the phase of development between adolescence and adulthood [ 18]. Regardless of socioeconomic prospects, those between the ages of 18 and 29 years commonly struggle with "feeling in between" [ 19]. Emerging adults, particularly those who attend universities, go through a great amount of stress. According to the US Department of Education (2011), student enrollment in college increased to 38% since 1999, reaching its peak. However, the majority of those who drop out of college do so in their first year [ 20], indicating that the transition process is crucial to students' success. In addition to dealing with academic pressure, they are expected to make a series of adjustments, ranging from academic assimilation to personal (eg, changed interests), emotional (eg, home sickness), and social (eg, finding new friends) adjustments [ 5].

What makes emerging adulthood more uniquely challenging than other periods is the intensity of multiple life events mounting up together in a short period. The danger of multiple life events occurring in a short period has been noted in life events research-critical life events (eg, moving, starting a new job, leaving family, and paying new rent or mortgage) and their accumulation can predict long-term medical and psychiatric illness problems [ 21, 22]. The major life events of emerging adults often begin with entering college and leaving home and their old, existing networks. To help such students with the struggles brought by the transitional phase of emerging adulthood, the American College Health Association has identified coping with stress as a high priority issue in the Healthy Campus initiative [ 23]. This initiative takes a multifaceted approach to mental well-being, which includes environmental (eg, managing air quality), physical (eg, eating well), and social (eg, student clubs) health. Universities offer Counseling and Psychological Services (CAPS) with mental health professionals. CAPS further provide campus-wide programs for first-generation college students and underserved students to reduce attrition (eg, drop out) [ 24- 26]. Despite the benefit of these initiatives, the literature still notes the problems of students not utilizing CAPS until emergency situations occur, if they ever do [ 27]. Nearly 80% of the students who die by suicide never participate in counseling services [ 28- 30]. The reasons for this underutilization include lack of awareness [ 31], stigma [ 32], long waiting list times [ 33], and preference for self-management [ 34].

Besides the institutional and national effort to support students, many studies showed that students mostly seek and receive social support from their existing networks in dealing with their struggles. Peer and family support plays a critical role in offering students a sense of belonging [ 7], affirmation of their concerns [ 35], encouragement and empathy [ 36], and facilitation of mental health maintenance as a compensatory measure when other support is unavailable [ 37, 38]. Social support enabled by technology, such as social network sites and Web-based and virtual social communities, has shown the potential benefits to supporting students, such as facilitating students' identity transitions [ 39], offering access to help when lacking in-person support [ 40], addressing unpleasant experiences with negative content on the Web [ 41], and resolving stigmatized concerns [ 42, 43]. However, research indicates that barriers related to seeking and getting social support, including stigma of mental illness [ 44, 45], a sense of autonomy (eg, "I don't need a doctor to solve this problem"), a fear of losing one's positive image (ie, "face") [ 46], and secrecy and negative cultural attitudes toward mental illness [ 47], often suppress help-seeking behaviors [ 48], which hampers students from getting timely and proactive support. These previous studies on emerging adulthood highlight both the critical need for proper support for university students during their stressful life transitional period and the associated barriers that hinder students from seeking and receiving such support.

Researchers developed and evaluated technological interventions for mental health issues such as anxiety and depression. Some examples include Harmony (a mobile health app that assists patients, caregivers, and clinicians in managing serious illnesses) [ 49], DStress (a mobile app that coaches users in balancing compliance and achievement toward daily goals of stress reduction) [ 9], the UPRIGHT project (in which researchers designed and validated resilience-based interventions for promoting early adolescents' mental health) [ 6], and Intellicare (a suite of skill-focused apps that successfully provide users with more flexibility in choosing a suitable treatment) [ 15]. Furthermore, technology-mediated therapies have been implemented (a conversational mobile app, Pocket Skills, that provides Dialectical Behavioral Therapy [ 8] and Web-based cognitive behavioral therapy) [ 50]. Although these interventions have shown their effectiveness and usefulness for treating mental illness, they mainly focus on those who are clinically diagnosed and actively seeking treatment, not those who do not consider their problems as serious mental health conditions but approach them by attempting to maintain their mental well-being.

Upon reviewing the literature on emerging adults' mental health on college campuses, we find examining how students engage everyday life challenges and the everyday maintenance aspect of their mental well-being to be a critical, emerging, and underinvestigated research topic in HCI and Health Informatics communities. As we continue to design health technology to support students' mental health needs, it is imperative to understand the fundamental needs and issues particular to this phase of their life to effectively engage and lower the barriers to seeking help. Building on the previous work summarized here, this study includes the following research questions (RQs):

RQ1: How do university students perceive their problems and maintain their mental well-being while going through various, frequent life events?

RQ2: What are the implications for designing sociotechnical systems that are tailored to meeting university students' unique needs around life events?

Methods

We conducted interviews with 19 university students (6 undergraduate and 13 graduate) from a large US Midwest university for a semistructured interview study. The inclusion criteria were as follows: (1) English speaking, (2) interested in speaking about their mental health or well-being, and (3) enrolled either as an undergraduate or a graduate student of the university. We recruited the participants through school-wide departmental email lists and word of mouth, and we stopped data collection when saturation was reached.

The study was approved by the Institutional Review Board (IRB) of the first author's university, and all coauthors who had access to the transcripts were registered as study team members. Our interview sessions were conducted in private rooms on the university campus. A member of the research team began the interview by informing the participants about the study's goals and interview procedures and assuring them that they could skip any questions they did not feel comfortable answering or stop the interview at any point. The participants were told that confidentiality would be maintained and that they could withdraw their participation at any time without any consequence. This study followed IRB guidelines, which state that if any crisis situation was observed (eg, threats and suicidal posts), the participant would be immediately referred to the staff at the University CAPS. Each participant received US $15 for study participation.

The duration of each interview session ranged from approximately 1 to 1.5 hours. The questions were designed to help us gain further insights that might not be uncovered in public reports on overall campus climate, where we see increases in student struggles with stress, anxiety, depression, and requests for on-campus counseling services. The interview questions probed the students' process of identifying their stressors, their experiences of seeking and receiving support or help, their development and adaptation of coping strategies to maintain mental health or well-being, and the tools and technologies they used in this process. At the end of the interview, the researchers offered information about college counseling services and other mental health support resources available on campus to those who were in need or had no previous experience of them.

All of the interviews were audio recorded and transcribed for the analysis. This study followed all of our institution's confidentiality, privacy, and security policies for handling and storing all the participants' data. Three researchers analyzed the data using the open coding method [ 51], using the Atlas.ti 7 (ATLAS.ti Scientific Software Development GmbH) qualitative coding software program. We conducted axial coding to explore and develop the key attributes and dimensions of each theme particular to the RQs. Working collaboratively, we explored, compared, and revised the themes as the analysis progressed. We revised the themes through a series of discussions and iterations until consensus was reached. We also conducted affinity diagramming [ 52] to generate common themes and identified any breakdowns and design implications during the analysis process. We followed the Contextual Inquiry Design process [ 52] to identify common themes from the affinity diagram to generate design requirements.

Results

Overview

In this section, we first provide demographic information on this study's participants and then present the three needs that were identified in this study. These three needs are critical to understanding how students maneuver through various life events, seek help, and maintain their mental health and well-being.

Study Participants

Table 1 shows the overall participant demographics. The students ranged in age between 20 and 29 years (mean 25 years, SD 4 years), and 13 students were female, and 6 students were male. In all, 7 students were international students. Reported ethnicities were as follows: East Asian (6), non-Hispanic white (6), Indian (5), and African American (2). A total of 14 out of the 19 students had had experiences with professional counseling services. Two (P7 and P19) students were clinically diagnosed with a psychological disorder.

The Need to Receive Help That Aligns With the Severity of the Problem

The participants emphasized the importance of how and when they receive help for their problems based on how they perceived the severity and duration of the problem they were struggling with. We found that knowing or not knowing when a problem would end and having multiple stressful events accumulate at once mainly affected students' perception about the severity of their problems. This perceived severity then affected the students' expectations about help seeking. Below, we describe how life events affected perceived problem severity and what students considered "good help" to be as a result.

The Severity of the Problem Is Perceived Differently Based on Life Events

The problems students struggled with in maintaining their mental well-being included adjusting to new cities and life on new campuses, meeting new people, paying for tuition, examinations, and job searches. Some of these problems involved more certainty in terms of how long they would last, such as final exams; others, on the other hand, seemed to last forever, such as job search-related stress. Accordingly, uncertainty regarding how long their problem would last affected how students perceived the severity of the problem and how they approached it. For instance, until receiving her recent job offer, P3, who was an international graduate student, had been "really, really stressed." She explained the following:

The past year, when I was first year [of the graduate school], I was really stressed... I would never go back to my home [in China] during the time because I can only come back with a job offer.

Here, P3 described the stressful event as having lasted for a year, which significantly affected her mental well-being during that year. She did not previously know, nor could she have predicted, how long the job search would take while it was happening. The job search was stressful, and the fact that it occurred over an indefinite period of time added a considerably increased amount stress. P3 was expressing the severity of the problem in relation to the event duration because she was unable to start or plan other things until her job status was secured, directly affecting her legal status to live in the United States after graduation.

In perceiving the severity of their problem, we found that a few students even put a predefined time boundary on the problem (how long it would last) and remarked that their current problems would pass and there would eventually be closure. This perception helped them get through the problem. For instance, when P3 was having a problem with her boyfriend during her job search period, she mentioned that she had given herself 3 months (a limited amount of time) to deal with the stress and move on when she would start a new job:

I told myself just three months to get over it. I was eating snacks, watching TV shows, and doing exercises.

Starting college as an independent young adult brought multiple problems in school, work, and relationships at the same time. These multiple problems occurring in the same period exacerbated the perceived severity of each individual problem. For instance, P5 experienced a high level of stress when she had a serious problem with her boyfriend while also applying for summer internships and working on her final exams. P8, similarly, shared an extreme, distressing moment because of the stress brought on by multiple, urgent work responsibilities:

There was this one time when I had a very large amount of work to do. I had a part-time job, had one big [class] assignment, and had one [class] project due, all within the next 48 hours. Even if I stayed up the entire 48 hours, there was no way I was going to finish everything. I knew that because of the amount of work involved, and that was really causing me stress because either the assignment, the project or the part-time job had to suffer, and I wasn't sure which. I was being paid for the part-time job, the project was a group project and if I don't do the work then nobody gets a grade, and the assignment was an individual assignment for me, but it was a large part of the grade, so I had to leave at least one.

P8 further explained that he had to seek emotional support from family members and friends and go to his academic advisor for useful advice. As in the case of P8, multiple problems could occur during the same transitional period, thus requiring the student to navigate the different types of support resources available to receive the proper help. This indicates that merely having one therapist may not work well for students.

Seeking Help That Is Accessible and Available at an Appropriate Time

The urgency and timing of seeking help varied together with whether the students framed the problem as having ended or as ongoing. All students in the study commented on the importance of receiving support during the particular period when the struggles were still happening to effectively deal with their struggles. However, ensuring timely support was challenging because seeking support required a great amount of effort in their hectic daily lives. For instance, students mentioned that they often found resource constraints in their existing support environments on campus. Several participants mentioned that existing support resources such as CAPS and other professional services sometimes failed to address their need to receive help at the right time, especially for time-pressured and serious concerns. This was because of tedious nature of scheduling phone calls, long wait times for in-person appointments, inflexible working hours, and an inefficient screening process, all of which made it difficult to access care in a timely manner:

There was a pretty long waiting time. The initial session was I think after a week and a half, and then the next appointment was after a couple of weeks. Time is the only problem [with CAPS], and I realize that the timing is not in their control because of the number of people here.

Another student described his experience:

I decided to go to CAPS, and was kind of disappointed because at first I filled out that whole questionnaire and the first meeting wasn't even an actual meeting it was just going over the questionnaire with a counseling student.

These factors that delayed the timing of receiving help frequently made the students uninterested in reaching out to CAPS for help.

As their perception of the problem severity was time bound, when students were unable to find proper help in a timely fashion, they tried to manage it on their own or consider that the problem might go away some time after they endured that particular stressful event. We found that after a certain amount of time passed, the students did not necessarily want to be reminded of an issue, nor did they feel the need for professional help anymore. Rather, they wanted to put their problems behind them, letting them resolve on their own over time or trying to ignore them. Ensuring help at the appropriate time was particularly tricky for students who were required to change their locations periodically:

I came back home for the summer so I couldn't see them [therapists at CAPS] again. I could have come in the fall but it wouldn't have been the same. It would a long break and I would have thought through some things on my own and stuff like that. I didn't go to them afterwards.

As the participants, including P9, left the campus for summer and winter breaks for various reasons such as internships, vacations, or other duties, many had to leave in the middle of getting help without fulfilling their needs, and they felt that the help that came later was meaningless.

In addition, we found that when seeking and receiving help, some students experienced a discrepancy between what they expected and how the help was actually delivered. Types of problems they had might be similar to those of their peers, as emerging adults on campus were going through similar life events. Although the perceived severity might differ, students felt that their struggles might not look as serious to others as they perceived them to be. In fact, they experienced difficulty in getting proper recognition or serious consideration from others. Consequently, students quickly lost interest or motivation to actively seek help when they did not feel they were getting enough recognition or empathy from others upon initial sharing. P3 mentioned how her problem was not appropriately acknowledged or addressed by the therapists' consultation:

The therapist said, 'Ok it's been one hour, I think we are going to wrap up.' Then I was so surprised, what!? Are we finished? I thought you were going to give me some suggestions. At least some homework for what I am going to do... Then, she [therapist] said, 'no, no you have so many stress to relieve, so this time you just relieve all your tension, you just let your sore come out. And next time we will talk about others.'

In this quote, P3 showed her frustration about how her severe problem was mostly treated as one of the many other stresses without the proper understanding she expected. In this study, this kind of experience, not getting sufficient recognition of the severity of their problems, made even those students who initially sought help consider that their problems might not be serious enough for professional treatment and that they might need to be manage the problem themselves.

Many of the students in the study wanted to receive help in a more casual way through frequent and informal conversations, instead of fixed (regular but limited) and formal conversations. As most students saw their problems as issues that could come and go and get better or worse, and as similar to what their peers were all dealing with, rather than as mental health issues requiring formal diagnoses, they preferred casual and frequent interactions, which allowed them easy access when needed. P15 expressed the need to see mental health practitioners more frequently and informally as a preventative approach, rather than seeing them only when "something was going wrong," such as "when feeling depressed, when feeling anxious, when having maniac episodes whatever it might be."

Similarly, a couple of students proactively managed their stress through frequent hangouts with friends. P14 shared her experience of using her regular get together as an outlet for her distress:

It makes me feel good about how things are. I get to offload my emotional stress. I do that [talk about things in mind/head] once a week when we all get together. But on a daily basis we don't talk as much about anything emotional or anything about our job, just like, have you had food, where are you going, things like that.

P14 designated a weekly time to "talk about things" with a small group of friends who she hung out with on a daily basis as a way to focus on sharing stressful issues, as they might go through similar stressful life events and share similar struggles. Having weekly gatherings with close friends made sharing problems comfortable instead of awkward or uncomfortable.

In sum, students struggled with various problems brought by life events, especially multiple problems concurrently happening during a transitional period, and they tried to look for help that could effectively address the problems. Despite the seriousness of a problem and the critical need for help, the problems students struggled with were mostly considered to be part of normal emerging adulthood-related issues, not "serious" ones, by the students themselves and even by others whom they tried to ask for help. Students thus preferred casual help, or they took a preventative approach so that those "normal" problems would not develop into "serious" ones.

The Need to Build, Rebuild, and Maintain Support Givers for Frequent Life Events

All students participating in the study had recently gone through major life events and changes: they had left their hometowns or relocated, sought or made new friends in college or at work, or made changes in their career-for example, switching majors, changing schools, delaying their degree, and coming back to school from industry. These transitions caused changes in social support structures, exacerbating stress and problems in maintaining their mental well-being. The following quote from P8 illustrates the highly stressful period of transitions and the loss and regaining of social support:

The transition time was very rough because I was used to a place with a lot of people and a lot of activities. When I first came here... I don't know, I found a lot of simple things to be very difficult. I didn't have my own mode of transportation, so had to rely on the bus services. Small experiences like that really added to my stress levels and I found the fact I lived away from the main campus, [which] meant that I had to spend a lot of time on my own, which I didn't like because I like hanging around people. When I was staying alone it was quite difficult for me.

Relationship Building Is Constantly Needed to Have Access to Potential Support Givers

The various life events the participants experienced not only forced them to quickly adjust to new life contexts and rebuild their social connections but also made it difficult to maintain their existing social connections. For this reason, students often felt that the support they wanted was not readily available or workable, but inconsistent; supportive social groups or support givers were likely to come and go. For instance, P18 described her premed group members with whom she initially developed deep relationships, and she described how these relationships were enhanced by their common struggles and active support for each other. Later, she felt helpless and discouraged when all the members of the group transferred to other universities or decided to pursue something else:

I think with pre-med courses, it's nice to have a community where you can be stressed out together and fall on each other for advice and study together and help each other. But then when everybody dropped, and it was just me, I think that's when it got to be very stressful because I was doing everything on my own.

The short-term and inconsistent social support received from their existing support givers was somewhat detrimental to the students' mental health, often resulting in sudden feelings of being lost or alone. Although some relationships were strong and long lasting, the students needed to be prepared to lose connections and relationships they often put a large amount of time and effort into building and rebuilding.

Most of the students in this study experienced the diminishment, disappearance, or replacement of intimate friends they previously relied on to receive support, such as the replacement of high school friends with a small group of close friends from the freshman cohort, or they experienced the quality of relationships with old friends changing over time. P9 explained how the friendships he had with close friends growing up and their support for each other became rather unstable and shifted after 3 years of college as they experienced conflict and disagreement:

These were probably the two people I would go to if I had trouble with school and things, but after I had a disagreement with them, I felt very alone and isolated. Now, I'm a better friend to them but I think because we had that break we're not as close as we used to be. It's always in the back of my mind that we had this fight so I'm not that close to them as much anymore.

This shows that even with existing support givers (eg, intimate friends), effort was still needed to maintain relationships as all parties went through different stages and events of their own lives during emerging adulthood, affecting their current or future situations, viewpoints, and needs.

While going through different life events and needing to seek appropriate help, the students encountered situations where they needed to determine how to disclose and share their problems with the new social connections they had just built or developed. The new social connections were usually people they had recently met in classes, at work, at various events, or where they lived. For instance, P10 shared her experience of sharing her concerns with a new friend she had started to get close with recently:

I talk a lot this semester with Olivia [her classmate], but like until the end of the semester, not really earlier. I feel like this semester, the early part of this semester I'm always alone because I am mostly in Fishbowl to finish 520 assignment or something. (...) She also shares her concern as well. I think for the academic part, we are very similar. In the same situation, I guess. And we haven't got internship yet and we're also worried about finding a project, final exams, so it's hard. Our schedules are more similar. We sometimes work together on weekends.

Having similar situations, interests, or struggles as other individuals helped students quickly build new relationships and potentially share their problems, although the sharing might initially be limited to their common interests.

While sharing problems with newly developed social connections, students did not share their real, deep problems upfront, unless those were the commonly shared issues they already knew about each other (eg, met at a counseling session). They wanted to share problems in a friendship after building a relationship and worried that sharing such issues in the beginning of the relationship could lead to making some "unattractive" or "undesirable" impressions:

I wouldn't necessarily want people to know that to be the first thing they know about me. I want them to know me as a person. I feel like, yes, that's an important thing to know about me in a friendship and stuff, but I don't want that to be the first thing.

Seeking Alternatives to Support Givers on the Web

Owing to the challenges of having a constant change of support givers while going through frequent life events, the students often sought alternative forms of support, such as making new Web-based social connections and asking for help (eg, Facebook groups, mental health-related web forums, and anonymous others on Reddit or Instagram). As Web-based support is always accessible, students found that this served as a support baseline that they could contact regularly or whenever they wanted to check in as a casual (not as structured and serious as a CAPS or professional service) but also steady (with minimum effort to set up) way of maintaining their mental well-being. However, despite the benefits of having Web-based help, students reported issues with the sustainability and the consistency of support based on their experiences. They believed that the size of the group, the qualities of the anonymous members, and whether there was guidance and a moderator within the Web-based communities often affected the quality of the support they received. Many, including P19, mentioned the double-edged sword aspect of anonymity in Web-based groups and communities regarding the anonymous members and expected behaviors:

I don't like Reddit, not at all! 'Cause Reddit is totally about anonymity. And I don't enjoy that. I think anonymity is to some degree dehumanizing. It's really unaccountable. And people allow their worst selves out because they don't understand impact when they're anonymous.

According to the participants, the size of the group mattered for the perceived quality of group dynamics and conversation. When the Web-based support group was too large, the conversation among the group members would become disorganized and derailed by new information, which often made participants feel less valued. In contrast, with small groups, the students often felt they did not get enough diverse opinions, which could lead to a lack of effective solutions or ideas to address their problems. Nearly all of the participants advocated 7 to 10 members as an ideal group size for sharing their concerns and having effective group discussions:

Less than 10 participants [would be good] in order to have sufficient dialogue and participation among everyone.

The personal qualities of the web members were also seen as an important consideration to ensure that the support was sustainable. Students considered being faithful, committed, and respectful of others' privacy the most needed qualities of support members as potential support givers, especially given the relative anonymity of many support spaces. The students also commented on their desire to engage both intimate friends and strangers in their envisioned Web-based support group to receive the most useful help, as each provided different types of support on different subjects. In addition, moderated interactions within support groups were seen as critical for students to better receive quality social support. They remarked that careful moderating and monitoring helped maintain the support environment as a healthy and useful place for everyone to get consistent support for the long term. A few students (P8, P12, P14, and P16) who had never used any Web-based support group expressed their interest in joining a small group conversation moderated by professionals who could understand the members, properly react to what was said in the group, and maintain group positivity:

You have a different mental state when you're talking to a therapist compared to talking to just anonymous people. I might not be able to respond if one [a person] was sad or depressed. In a sense, a therapist response would be much nicer and much more understanding compared to what I can provide.

Similarly, some who already had experience with moderated Web-based support groups also preferred to have a more structured support environment where a moderator provided group therapy or assigned particular goal-oriented tasks to help members achieve their goals. Several advocated for having more than one moderator or professional monitor to track the conversations to ensure that the members would interact appropriately, particularly in anonymous environments.

The Need to Negotiate Tensions Between the Benefit of Disclosure and the Stigma Associated With Disclosure

The last challenge that students mentioned was balancing self-disclosure to seek help and the stigma that prevents such disclosure. To express a need for help, the students attempted to find ways that allowed them to avoid the stigma associated with the disclosure while also maintaining their mental well-being.

Students Hold Tension in Maintaining Desirable Presentations of Self

One common concern related to transitions across frequent life events, particular to emerging adulthood, was maintaining and developing a desirable presentation of self in social interactions. Although wanting to maintain a "positive" image or reputation is a well-known phenomenon in social science research [ 53], it becomes particularly challenging when one's network keeps changing, as was the case for the students participating in this study. Students commented that the stigma associated with sharing personal problems could hinder the development of positive social relationships, often discouraging them from openly sharing their concerns with their social connections, such as friends, family, and the people with whom they had recently developed relationships. Particularly, as many students considered their problems might be trivial and common, they considered that what they were going through should not be overestimated as a serious problem. This thinking process aggravated their stressful situations.

The transitions during emerging adulthood made it difficult to keep up with their original support givers (ie, old and intimate friends), and it forced them to build new connections (ie, new friends). The new social connections students built were the ones with whom they wanted to further develop intimacy. These new connections were critical to their emerging adulthood in that they were the students' most preferred source of support. Thus, to further develop these new relationships in the ways they desired, students did not want to disclose their problems too much, but they preferred to maintain a positive self-presentation toward their new connections. For example, some students wanted to maintain an image of being fun and outgoing. They worried that if they disclosed too much about their depression, sadness, or struggles, their new friends would view them differently and categorize them as "not a fun friend to be around" or "problematic." P2 described hiding his concerns from friends in an effort to maintain the character of being fun and happy:

You have five friends and they expect you to be very fun and outgoing, you can't help but stay in that character. It's very difficult or you feel uncertain that if you were to reveal a little bit [of your] personal self, would they still be the same towards you know, [the] friendship or not.

As in the case of P2 above, many students worried that the negative, long-term impact of sharing their concerns with their social connections, particularly with newer ones, would outweigh the potential benefits, which ultimately prevented them from getting effective help.

Owing to the tension between their need to share with friends and the associated stigma, many students put a lot of effort into sharing their problems in ways they perceived to be less risky. They would slowly and carefully bring their concerns into the conversation or look for the right time to bring up an issue. For example, we saw that some students waited to share their concerns until a friend approached them first, instead of asking for help directly; others tended to hide their true feelings, pretending to live and act in a way that conformed to how their friends viewed them, until they felt more comfortable talking about their problems. P6 explained how long it took him to feel comfortable sharing his struggles with others, explaining that there was a certain time at which such disclosure would be allowed normatively:

At the end of April when everyone is getting ready to [graduate] and started to pull out their hearts and essentially had a very close talk. That was with everyone else, and I was just sitting there and said I'm not graduating, they are, so I should at least tell them something that has been on my mind for the past few years. There was that instance where I felt should tell them.

Here, the fact that his friends were all graduating and would not be around anymore made it easier for P6 to disclose the issues that he was holding onto. His friends' transitions also made it less burdensome to deal with their reactions, which was why he chose to disclose at that time.

Disclosure was difficult when students experienced pressure to follow and meet societal expectations or standards, such as being independent financially, accomplished educationally or professionally, or settled at a culturally expected age. This finding was more apparent among the Asian students, who felt pressured to be "good" or "mature" for their families in their particular culture. For instance, P10 who started her graduate study in her late 20s explained her struggle with feeling stigmatized by her age and financial situation:

I actually borrowed money from my parents. At my age I shouldn't do that, and especially, my parents used their retire money to support me. That's a big issue. After graduation I will definitely have to find a good job and pay back. My family invested [in] me to go abroad, so that means I will have the responsibility to support my family back as well. I think that's a concern I have. (...) The other thing is my age, I would say. I think relationship and marriage is also very...not super stressful, but when I think about it, I will kind of worried about that. Because I've never had a relationship before and right now I'm almost 30. Especially my parents worry about that. I feel everything is related to my family. If my family worry about this then I will worry about that too. I know they want me to have a family in close future, but so far in my situation I don't think I have enough time to do that, seeking one and building a relationship..."

Like P10, even though students talked to their parents every day to share their thoughts, we found that many of them tried not to reveal struggles related to their schoolwork because they wanted to present themselves as a smart, hardworking daughter or son.

Exploring a Casual, Nuanced Way of Sharing Problems

As a way to deal with the stigma associated with sharing problems, students favored communicating with their social connections (potential support givers) through images. Image-based communication included any images, such as the students' own drawings, famous paintings, landscapes, body parts, any artifacts from their daily lives, funny or abstract pictures, and funny memes, shared through mobile or Web-based messages or social network sites. This was popular among the participants, especially for when they just wanted a small amount of casual support that could cheer them up in their daily lives or for when they wanted to provide support for someone else, without anyone explicitly seeking help:

I use Facebook and Instagram basically just to see what people are up to and for funny videos and photos of dogs and videos of dogs. I like memes a lot, so if I see a funny meme I just like it. (...) so like funny pictures and funny comments, internet memes. If I see one, I'll just click like so that my friends will see it, and my friends will start laughing about it. I use that as a stress buster really.

Similarly, sharing dog and cat photos on the Web was also a popular form of support during less energized moods.

Image-based communication allowed the students to indirectly express their nuanced feelings, as they could use some of the affordance images offer to express and share their feelings in a very subtle and subjective way, without directly revealing their true feelings or intentions. It also enabled students to adjust their own moods while sharing or posting images as a way to overcome negative feelings or curate their own feelings. Students (P11 and P16) used their social media as a digital diary, using images to share and record their moods:

I think this semester I post a lot less, but usually I post a lot. Facebook is almost like one kind of my diary. I post everything, [including] not good [ones]. Especially not good things on that. (...) I don't know [the motivation], but I think it's just like, letting it go, away for me to like expressing my anger or depression. Because I feel, if I cannot find a person to talk, because on Facebook it's also a way for me to let it go and let the others know that I'm not good.

Like P11, other participants expected image sharing and posting to enable them to feel more comfortable and embedded during their everyday lives, while reducing the stress and stigma related to their support-seeking behaviors. By using a platform that people use to communicate about everyday situations, the shared problems are portrayed as mundane and normal problems of daily life rather than as serious mental health problems.

Discussion

Overview

University students go through a critical transitional life phase of emerging adulthood between adolescence and young adulthood. This life phase requires increased responsibility, maturity, and independence, causing more stress and problems with maintaining mental well-being. For this reason, there have been increased mental health incidents on college campuses [ 13, 54], and more researchers have been exploring technological interventions for emerging adults on university campuses [ 50]. Below, we describe the maintenance work required for students' mental well-being using the literature on self-disclosure [ 55]. We also discuss the boundary students perceive between mental well-being and illness, which played a critical role in students seeking help. We then discuss implications for potential sociotechnical systems that can support the needs of students in better maneuvering through this important transitional phase of life.

Negotiating Time, Audience, and Disclosure for Mental Well-Being Maintenance Work Across Life Events

This study revealed that students' mental well-being needs constantly shift and evolve as they go through the life events associated with emerging adulthood. These transitions, shaped by life events, critically impact their mental well-being. This study's findings draw attention to how students negotiate the three needs in their lived experiences related to time, audience, and disclosure. The severity and duration of the life events ( time) defined the expectations of how help should be delivered. Students encountered new social relationships, which they had to constantly rebuild and maintain as sources of support. These relationships at the same time served as the audience for whom the students had to balance the tension between the stigma and disclosure of problems and seeking help. As such, these three needs are closely interconnected and constantly negotiated to maintain their mental well-being. This interconnected relationship has been identified in the studies about disclosure in HCI and Communication fields.

For instance, "time" has been found to be a critical component in when, how, and whether disclosures occur, exploring the facilitation and hindrance of disclosures [ 55, 56]. Reasons for delayed disclosure [ 56, 57], a delay between a significant, stressful event and the time of disclosure, include fear that the disclosure will be poorly received and not supported by others as well as moving on from the event and not feeling the need to share or reopen wounds [ 56]. Although delayed disclosures have primarily been studied in the context of abusive and traumatic situations (eg, sexual abuse) [ 58], this study shows that delayed disclosure also happens when students wait for the right "timing" to disclose their problems and seek help. An example from this study's findings showed that one student (P5) waited until his friends' graduation to reveal his issue to reduce the burden of having to manage friends' reactions to his disclosure. Moreover, this was during a moment when the friends had mutually agreed to share intimate experiences as a way to reflect on their college years. The reciprocity norm of mutual self-disclosure in dyadic relationships [ 59] explains this observation of mutual sharing at the right time.

"Audience" is another important factor in explaining why people disclose or do not disclose stigmatizing experiences (eg, depression) in the Disclosure Decision-Making Frameworks [ 55, 56]. The concept of audience connects with our findings on rebuilding relationships, such as the new social connections students need to build. According to Goffman, "audience" refers to the individuals for whom one performs and who might be the recipients of one's direct or indirect disclosures as part of a help request [ 53]. The disclosing person assesses how these individuals, that is, the audience, might react and respond to the disclosure or lack thereof and makes a (non)disclosure decision accordingly. In this study, such an assessment includes balancing the potential benefits of disclosure with the risk of losing the status of being a fun friend to be around, especially when the goal is to rebuild and maintain new relationships with the audience. This negotiation is fraught as these new relationships entail potential disclosure to audiences who can be a source of support.

Furthermore, this study also showed that as a result of the risk of stigma associated with disclosing problems, students used fun and positively valued social media sharing to release stress for themselves and others. Previous work has argued that social media design should facilitate the disclosure of stressful situations directly or indirectly [ 56]. This study added to this conversation by arguing that sharing positive content is not necessarily shallow or "just for fun"; it can, in fact, be part of an activity that releases tension and stress among individuals.

Understanding the Perceived Boundary Between Mental Wellness and Illness as a Collective Effort

In this study's findings, students perceived most of their problems to be either normal or on a continuum between normal and serious. The latter would imply the need for seeking immediate help from a professional source, compared with the former, where the problem may resolve on its own as time passes. Students view the problem as fluctuating day to day, or even hour by hour, and as being influenced by many things in their daily lives, just like physical health. They think normal problems can progress to become serious and serious problems can revert to being normal as time passes (after a certain stressful life event is over). Coupled with stigma and barriers to self-disclosure [ 55], students attempted to avoid as much as possible the need to label their problems as illness problems.

The students in this study tended to consider their problems within the realm of wellness-a state where they think they have abilities to cope with the normal stresses of life and manage on their own. However, students also worried that their wellness problems could potentially develop into more serious ones and become illness problems. To prevent this progression, students actively and proactively tried to seek effective, workable resolutions. This study's findings showed that students set a maximum time (eg, three months and two weeks) in which to resolve problems (eg, relationship breakup and being stressed about grades or job search) to prevent the problems from overwhelming their overall well-being. Having a social network to share their problems with, whereby students could set up regular weekly hangouts with close friends to prevent the problems from progressing into more serious ones helped.

In this study, we reported different perspectives between the mental health literature and findings in terms of when a problem is considered as part of "wellness" vs "illness." This difference makes it difficult to determine when and how we should intervene to support students' help-seeking behaviors effectively. The traditional mental health literature on emerging adulthood problematizes the students' perceived, self-endorsed boundaries between wellness and illness, defining it as a barrier to mental health care and support [ 60]. The literature legitimizes self-management activities for mental health but only to a certain extent. Self-management activities, referring to seeking help from family and friends and going to meditation groups, are largely described as barriers to mental health care access. Rickwood et al [ 61, 62] found that participants preferred to talk to friends and family rather than health care professionals, which might prevent access to health care when added to participants' lack of emotional competence and negative attitudes toward seeking professional help. Biddle et al [ 63] showed that participants continuously self-assessed whether they could accommodate high levels of distress and avoid seeking help.

Where the boundary between wellness (ie, whether a problem is a normal part of emerging adulthood) and illness (ie, a symptom of a serious mental health disorder) lies or whether the boundary should even exist remains an open question. This might be an applicable question for the general population, such as those with mental health issues in the workplace [ 69], but it is the salient case for students as they are especially close to their peers who go through similar types of problems and life events during their emerging adulthood, which can make the students more ignorant or blunt about their problems. The question about the boundary has often been unclear even for health professionals because of individualized, situational factors [ 70]. Health care workers need to individually assess how much the unstable, uncertain experiences of a student should be treated as a healthy part of self-development and how much should be treated as a symptom of a serious mental health disorder [ 70]. This nuanced boundary as well as the differing viewpoints between health care professionals and students can add to maintaining student mental well-being negatively. This problem forces students on college campuses to be tolerant of severe problems and to ignore the need to get help.

We argue that this boundary between wellness and illness needs to be carefully negotiated, evaluated, and coordinated for each individual student through collective efforts among the social systems made up of responsible stakeholders: university students themselves, health care professionals, family, friends, educators, designers, institutions, and the public health sector.

Reconceptualizing a Support Group as a Place for Colearning

In examining the ways in which students received support, including from their groups of intimate friends, Web-based groups, and social media, we noticed that being part of a "support group" had a negative connotation for our students. Many students avoided labeling the wanted help as a "support group," as the term problematizes what should be a normal process of being supportive of each other in a seamless way throughout everyday contexts. The negative connotation associated with support groups served as a barrier to students accessing helpful resources, such as CAPS or related peer groups, on campus. It is worth investigating how to engage and assist students with various stressors in their emerging adulthood more effectively.

Accordingly, this study calls for an urgent need to reconceptualize the existing notion of support as a colearning space where individuals learn to maintain their own mental wellness: how to be aware of it, how to keep it healthy, and how to prevent potential risks. This knowledge is not something normally gained from formal education, although it should be. Importantly, in this reconceptualization, each individual can be a help giver as well as a receiver. This sort of mutual exchange has been discussed in the literature as the helper therapy principle [ 71], which is the central concept for building support groups. In this study, a few of those who wrote blogs or made images related to mental wellness awareness expressed their interest in working with counseling services to help their peers, based on their own experiences. At any given time, one can be a helper for multiple people on different issues, while seeking help for one's own mental well-being maintenance work. This multiparticipatory nature of a support exchange can facilitate accountability among the helpers and the individuals receiving help.

Design Implications

We discussed university students' challenges and efforts to maintain their mental well-being around time, disclosure related to stigma, and the right audience. This study indicated that it is important to facilitate the negotiation of students' own perceived boundaries of where illness begins through self-reflection and evaluation so that they can receive appropriate help. To that end, ideal sociotechnical systems should be designed in more inclusive ways that allow self-reflection to support students in managing their mental health in a casual, informal, and positive manner, rather than approaching the challenge from a mental illness perspective.

This study's findings show value in integrating functionality from such systems to support students' mental well-being maintenance work. They call for investigating how existing systems and applications for the general population can be extended and designed to offer self-reflective and self-evaluative mechanisms for students' mental well-being. For instance, existing practices, such as Expressive Art Therapy (EAT), which offers individuals the opportunity to use any expressive and creative art form (eg, singing, poetry, art, dance, or performance) to reflect on and identify what the root of a problem is, increase self-awareness, enhance social relationships, and foster emotional growth and development [ 73- 75]. EAT can then be integrated into existing everyday systems and applications to provide nonclinical solutions. Specifically, existing media applications for self-expression, such as video blogs, amateur music sharing, sharing creative artwork or images, drawing, or poetry sharing forums, can be used to support these varieties of forms of expression as a form of EAT. Similarly, doodling can be used to benefit the process of mindfulness training with some guidance (eg, "Choose whether to document a current happy moment or think back to a happy time and doodle your memory") [ 76]. Integrating such expressive capabilities into existing applications could enable students to be mindful and aware of their mental health status. In addition, integrating such an approach with Positive Psychology [ 6, 77, 78] can help students release their stress and discover positive moments and strengths, instead of focusing on the problems and the negativities. Examples include enabling the platform to suggest recording a thankful moment from the day through a photo, writing, or drawing and sharing it with friends on Instagram or in a group chat or cocreating humorous internet memes with friends on Sketch as a positive mood booster. These activities can foster emotional growth, enhance social relationships, and improve self-awareness [ 22, 35]. These outcomes will eventually help young adults define their own perceived boundary of mental health and receive proper help when needed.

Upon developing the platform, we argue that it should be designed to facilitate the involvement of a community of all relevant stakeholders in supporting the mental well-being maintenance work of an emerging adult on campus (eg, students, health care providers, practitioners, institutions, designers, and app developers). This platform will not only help students to self-reflect and evaluate their mental well-being maintenance activities but also help stakeholders to easily analyze functionalities, use cases, and user populations of existing applications. It will also help them analyze new applications as they are developed and suggest potential connections to existing therapeutic practices of mental well-being. The platform could show usage trends of user populations, along with new features that these applications might be able to provide. It could also offer a database of EAT curated by health care professionals. The stakeholders could then exchange feedback regarding how these existing and newer applications could work together to support therapeutic mechanisms according to the life events of an individual.

The findings also indicate that it is critical to support the process of navigating and renegotiating time, audience, and disclosure. The aforementioned platform could provide a variety of approaches to requesting as well as receiving situated help, ranging from the immediate and direct to the more casual and abstract. On the basis of the mood or level of activity of a user or a particular life event, a platform could directly intervene by matching or suggesting appropriate helpers or by nudging and casually connecting with family and friends to encourage students to share their struggle with others. This could help with providing support within the appropriate time window when the impact of that event is still active. For instance, the findings showed students did not want to be reminded of their problem after a certain amount of time had passed after the issue occurred. Such a platform could also pick up on and identify potential emotional breakdowns or challenges that might come up, based on their behavioral and emotional patterns. In addition, in terms of suggesting an audience, selecting helpers from social group contacts or outsourcing highly customized help based on the topic or similar interests and needs (eg, nearby peer groups, mentors, and professional consultants) could be done for the user. Matching with others based on similar needs or interests was found to be helpful in previous work using others' life transition trajectories as a form of social support among peer patients [ 79]. The incentive for anyone to become a helper could be established by keeping them informed of both the short-term and long-term positive outcomes of addressing a problem through feedback, thus alleviating tension related to stigma and facilitating the rebuilding and maintenance of relationships between users and new and potential helpers.

Conclusions

We investigated the mental well-being maintenance practices of emerging adults on a university campus: how students perceive problems, set expectations for help, and go through the work of from whom, when, and how to seek help. We identified three needs that are required for students to maintain their mental well-being: (1) getting help at an appropriate time and in an appropriate form that aligns with the severity of the problem, (2) building relationships with potential support givers, and (3) negotiating tension between disclosure and the associated stigma. This formative study informed how sociotechnical system support for this population should be sensitive to how help is framed and offered to make it easier to embrace. We also discussed how and when help should be delivered through technology and argued for reconceptualizing help as a colearning process. This research was conducted with a subsample of emerging adults, focusing on those at a large university in the Midwest. Although the participants do not represent the broader population of emerging adults nor all university students, this study's findings demonstrate a unique set of needs and challenges that should be acknowledged and supported in the population to which these findings theoretically generalize. This study contributes to helping mental health practitioners, researchers, and system designers understand and support students' mental well-being maintenance practices as part of the normal course of life beyond the clinical context.

Abbreviations

CAPS

Counseling and Psychological Services

EAT

Expressive Art Therapy

HCI

human-computer interaction

IRB

Institutional Review Board

RQ

research question

Footnotes

Conflicts of Interest: None declared.

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Understanding Students' Mental Well-Being Challenges on a University Campus: Interview Study

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Research shows that emerging adults face numerous stressors as they transition from adolescence to adulthood. This paper investigates university students' lived experiences of maintaining mental well-being during major life events and challenges ...