School professionals committed to student well-being

ABSTRACT

The northern provinces of Finland are mostly not densely populated, with long distances to healthcare services. This creates a challenge for how to reach all children and adolescents with mental health services. In order to assess the effectiveness of school-based mental health promotion interventions, it is essential to understand the views of school professionals on student well-being and mental health promotion activity in schools. This study was carried out in urban area comprehensive schools where psychiatric nurses delivered additional mental health promotion interventions. The data were collected using a questionnaire, and a mixed-methods approach was utilised in the analysis. School professionals perceived that students are more unwell than before; they exhibit a general disregard for their well-being and more mental health problems. The respondents regarded the promotion of students’ mental health as a basic function of schools. Teachers need adequate support with this work.

KEYWORDS:

• Child health
• adolescent health
• health promotion
• mental health
• school nursing

Introduction

Half of all psychiatric disorders begin in school age [1], and therefore prevention of problems and promoting healthy behaviour in this age group are of the utmost importance [2]. In northern Finland, the number of child protection notifications doubled from 2010 to 2018. The number of outpatient contacts in psychiatry for adolescents aged 13–17 increased from 162 in 2010 to 635 in 2017 [3]. This is not completely in line with one self-reported school health promotion study, which indicated that most adolescents are doing well [4]. The challenge is how to stop the increase in psychiatric referrals and child welfare and how to reach the adolescents in need of mental health support.

In the Scandinavian countries, almost all children attend public domain schools, which in Finland are obliged to provide health education as a part of their curriculum. This practice is based on the assumption that education and other information received in adolescence affect decisions and choices made even in adulthood [2]. In upper comprehensive schools, health education includes mental health as a specific theme. Comprehensive schools also have student welfare services that include counsellors, psychologists and nurses [5]. School nurses provide general health promotion, disease prevention and statutory health check-ups. In Finland, some schools employ psychiatric nurses to accomplish preventive and promotive work, particularly on mental health issues. Although increasing, this is still not a common practice in Finland [5].

Although school welfare services have an important role in schools, teachers spend most of their time with students in the school environment, and therefore have a front seat view of student well-being. Teachers have long reported an increase in school-related problems in children and adolescents, such as behavioural and emotional problems that affect school work. For example, a study including 112 teachers in northern Finland reported an increase in behavioural and emotional problems of comprehensive and senior secondary school students between 1998 and 2000 [6]. The transfer of students with behavioural and social difficulties to special education increased significantly between 2002 (3967 students transferred) and 2010 (5894 transfers) [7]. Special education in Finland can be realised in a special education school, a small group within a comprehensive school, or integrated into a mainstream education class depending on the special needs of the student. A personal education plan is made for each student. According to one recent study in Finland, teachers felt that mental health problems of students have become more severe. Behavioural symptoms are recognised well by teachers, but internalising problems such as depression are poorly recognised [8].

Furthermore, a closer look at the symptoms of young people does not unambiguously support the view of increased problems in school-aged adolescents. An epidemiological study of self-reports of seventh- and ninth-grade students in Finland showed that depressive symptoms and behavioural problems did not in all respects increase from 1998 to 2008 [9]. Other studies reported an increase only in self-reported depressive symptoms in marginal groups of adolescents from 2000 to 2011 [10], and in eight-year-old girls at three time points from 1989 to 2005 [11]. A study in The Netherlands of 10-year trends in self-reported emotional and behavioural problems among 11- to 16-year-old adolescents also indicated that emotional and behavioural problem levels of Dutch adolescents were rather stable during the decade from 2003 to 2013 [12]. On the other hand, a cohort study in Finland showed an increase in the use of services for psychiatric or neurodevelopmental disorders of adolescents between 12 and 18 years old [13]. Increase in the use of these services may also be explained by an increase in awareness and diagnosing of mental health problems, improvement in the services or attitudes towards treatments [14]. Although psychiatric services have increased together with the number of service users, the problems have not eased. On the contrary, severe symptoms among young people have increased [15].

Family-related issues play an important role in child and adolescent well-being. Although most inhabitants in Finland live in socioeconomic prosperity, some families face increasing social disadvantage, changes in family structure and mental health problems of parents [16]. The number of child protection notifications increased from 4.7% in 2010 to 7.1% in 2018 as a percentage of the total same-age population in the northern area, and, respectively, support by child welfare family services from 1.5% in 2010 to 2.6% in 2018 among children and adolescents aged 0–17, as a percentage of the total same-age population in the northern area [4]. Schools make a large proportion of all child protection notifications.

Students’ mental health, social and family-related problems increase strain for teachers. A report of the Finnish national agency of education regarding teacher occupational health stated that an increase in students’ family-related issues is a stressor in their work (Onnismaa, [17]). A recent survey indicated that in Finland over 50% of the teachers report their workload to have increased to an intolerable level [18]. Some children and adolescents with mental health problems demonstrate increased violent behaviour towards teachers [19]. Although most children and adolescents do well, it is those students exhibiting violent and severe behaviour who cause strain on teachers. Mental health problems of pupils and inadequate student support systems were reported as the main causes of stress in school professionals [20].

Teachers’ coping and knowledge of student support can be increased with school-based collaborative and multi-professional interventions. In a survey of 318 New Zealand schools reporting teachers’ perceptions of mental health issues and school strategies, collaboration with families, counselling services and participation in referral processes were valued highly by the teachers [21]. The Mind Matters programme in Australia emphasised that promoting mental health is a basic activity of teachers and that they need support in order to be confident and comfortable in the promotion and education of mental health [22]. In a Finnish study of 786 educators, school professionals regarded mental health issues as relevant to their work but felt that they did not have adequate training in these issues [23].

Aims

Based on previous literature, there is some discrepancy between teachers’ views and epidemiological study findings on student well-being. In addition, there is a lack of knowledge about how teachers and other school professionals appreciate mental health promotion interventions outside the curriculum. Our aims were to clarify school professionals’ perceptions of 1) the well-being of students, and 2) mental health promotion activity in schools. The school professionals included both teachers and student welfare professionals.

Methods

Participants and procedure

In 2011 the city of Oulu in Finland established a mental health promotion project in comprehensive schools and hired four psychiatric nurses to plan and deliver interventions in pilot schools in 2011–2012. Nine pilot schools were chosen for interventions out of 58 comprehensive schools in Oulu. The pilot schools were chosen together with school professionals and Oulu Education Board, and the choice was directed towards schools with a recognised need for mental health promotion. The mental health promotion interventions were developed using a participatory action research model. The interventions included training of school professionals in how to recognise and support students with mental health problems, classroom lessons for students on mental health issues such as anxiety, stress and alcohol and drug use, directed groups for students to learn social and emotional skills, as well as individual solution-focused therapeutic conversations [24]. Permission to carry out the interventions was given by the school principals in accordance with Oulu Education Board ethical guidelines.

The present study was conducted in August 2013 in all 58 comprehensive schools with students aged 7 to 15 years. Nine of the schools (the pilot schools) with 180 professionals (teachers, counsellors, psychologists, nurses) received mental health promotion interventions provided by the psychiatric nurses, whereas 49 schools with 500 professionals received only conventional health support from the student welfare services. The schools included primary schools with grades 0–6, secondary schools with grades 7–9 and combined schools with grades 0–9. The population density varied in the different school areas. The 49 non-pilot schools also included specialised schools with e.g. art-, music- or sport-based curriculum emphases. The number of professionals working in the schools is an approximation due to changes in staffing, such as frequently used substitutions. All professionals were collectively e-mailed a link to a Webropol® questionnaire, an online survey tool [25] in which they were asked to comment on the well-being of students and mental health promotion activities in their school. We did not enquire the employment position of the professional, in order to guarantee anonymity, since most schools have only one nurse, counsellor and psychologist. We delivered a survey in order to collect information from school professionals on mental health promotion, for which there were no existing surveys. The majority of school professionals are teaching staff. In accordance with the personal data act, no data were collected from the respondents with which s/he might be identified. The data were handled only by the authors, and all data are to be kept for a minimum of 3 years after completion of the study and all data files are stored securely in a locked file. The questionnaire included the following demographic items: gender (male, female), age (under 30, 30–40, 41–50, 51–60, over 60 years), and experience in the current profession (under 1 year, 1–5 years, 6–10 years, over 10 years).

Measures

The mixed-method approach uses and integrates both qualitative and quantitative methods. We aimed to reach an in-depth understanding of a phenomenon through qualitative approach and statistical evaluation through quantitative methods. We analysed quantitative and qualitative data separately and integrated both approaches in the discussion.

The quantitative questions included statements on a continuous Osgood scale, which are rated on a line with no other exact points than disagree = 1 and agree = 5 [26]. The first statement was rated by both the intervention school and non-intervention school professionals: 1) Promoting mental health should be a school’s basic function. It was followed by an open-ended item 1: Mental health promotion is a basic function of schools because … (the respondents had a possibility to comment on their answer to the previous statement). Professionals in the intervention schools also rated the following Osgood scale statements: 2) Recent mental health promotion interventions have improved aid for students, 3) Recent mental health promotion interventions have increased my knowledge of mental health issues, 4) A psychiatric nurse has supported me in student mental health promotion, 5) Support from a psychiatric nurse has been sufficient in mental health promotion, 6) Collaboration with a psychiatric nurse has been profitable.

The qualitative questions included two other open items for professionals in the total sample: 2) What kinds of changes have you perceived in the well-being of students? and 3) What kind of collaboration do you wish to have with a psychiatric nurse?

Data analysis

We used inductive content analysis to analyse the open items in this research. The analysis process includes the classification of words and sentences of the data into categories. The categories are gathered from the specific words and sentences that were condensed and grouped into categories and then crystallised into a general concept [27]. We used abstraction to create a general description of the phenomenon through the grouping of the sub-categories under main categories that were named using content-characteristic themes [28]. In this study the data were organised using open coding, categorising and abstraction. The first step was an open coding process, in which notes and headings were marked in the text. The headings were then abstracted from the text and categorised freely. In the next stage the different categories were grouped under headings. Grouping the data under higher-order headings by similarities reduced the number of categories. We enhanced the reliability by the two co-authors using replication of the analysis process. During the process, we discussed the key findings and themes to form a consensus between all the authors.

We used SPSS software version 23 for the statistical examination of the data with frequency counts and chi-square testing. We analysed the Osgood scale statements by examining the scale mean values, and by comparing the mean values for the first statement using Student’s T-test.

Results

We received questionnaire data from 43 professionals in the intervention schools and from 103 professionals in the non-intervention schools; thus, the total sample included 146 responses. The overall response rate was 21.5%, with 23.8% for the intervention schools and 20.6% for the non-intervention schools. Demographic information for the respondents showed no statistically significant differences between the two school groups. Respondents were females in 83% of the intervention and 85% of non-intervention schools. Of the respondents in the intervention schools, 71% were under 50 years old, as were 75% in the non-intervention schools. More than 5 years of work experience was reported by 79% in the intervention and by 75% in the non-intervention schools.

What kinds of changes have you perceived in the well-being of students?

School professionals in the overall sample considered that students were doing less well than before. The original responses were categorised under the following five sub-categories: 1) reduced family well-being, 2) lack of basic care, 3) difficulties in social relations, 4) disregard for school, and 5) excess computer gaming, and further grouped under the heading A general disregard for well-being (Table 1).

1. Reduced family well-being was composed of problems in the family environment, broken homes and disregard for the care of children. The respondents regarded these items as having an effect on student well-being. We included family-related adversities, such as economic difficulties, health problems and social difficulties in this sub-category. Family-related problems also affected the students’ academic work.

“Mental health problems of parents are reflected in their children, including material needs, lack of dental hygiene, broken families and divorces. Problems accumulate in the same families.” (Quotations in italics are examples of responses from school personnel. More examples of responses regarding the open items 1-4 are available in Table 1).

Table 1. Inductive content analysis based on the opinions of school professionals

1. What kind of changes have you perceived in well-being of students?
Heading	Sub-categories	Examples
A general disregard	1) reduced family well-being	“(there are) A lot of problems in the families, loose family ties, fighting, violence etc. that are reflected in school life.” “A lot of family related ill-being. Neglect has increased.” “Parents are busy, nobody spends time with the children.”
	2) lack of basic care	’(there are) Students in classrooms, that are not taken care of properly. They might be hungry, not dressed properly etc. Basic needs are not taken care of.’ Irregular sleeping hours, no routine in life … ’ “Poor nutritional habits, students don’t eat breakfast, which leads to tiredness in school.” “Obesity has increased.”
	3) difficulties in social relations	“In addition, some children clearly have a weakened understanding of what is funny, nice and correct behaviour towards other children.” “More social conflicts due to the student’s own problems.”
	4) disregard for school	“More students with attention deficit, learning difficulties or difficulties in study strategies.” ’Weakened sense of responsibility. Homework is not taken care of, pens and pencils are missing and exams not prepared for.’
	5) excess computer gaming	“Attention deficit caused by gaming is visible especially in young boys, it’s like they live in a pawn world.”
Increase of mental health problems	anxiety	“Anxiety has increased.” “Elementary students are showing depressive and anxiety behaviour.”
	depression	’Striking is the lack of dreams.’ “Depression has become more common. Disregarded ‘numb’ adolescents → nothing matters attitude.”
	restlessness	“(they) Demand action all the time, have difficulties waiting for their turn and have difficulties sitting still.” “Restless and aggressive behaviour have increased.”
2. Mental health promotion is a basic function of schools because …
	Sub-categories	Examples
	1) a comprehensive part of the everyday activity in school	“Good mental health is the foundation for learning.” “A school’s mission is to raise healthy and balanced members of society.” “It is our task to take care of student well-being and their ability to learn in schools.”
	2) covers the whole age group	“Schools accept all age groups and therefore all (children) are reached. In addition, adolescents spend an important part of their time in school, so taking care of mental health is definitely a school’s function.” “In schools, we have entire age groups in our hands.”
	3) a mean to help students to deal with problems	“ Students show symptoms (of mental health problems). A psychodynamic interventions are an important addition in schools.” “Children’s’ problems should be dealt with as early as possible.”
3. What kind of collaboration with psychiatric nurse do you wish to have?
	Sub-categories	Examples
	1) student-related collaboration	“If we are concerned about an individual student, it would be important to talk about the situation with a mental health professional as early as possible.” “ Working with education groups and on the school community level.” “ … groups for shy girls … ”
	2) consultation and guidance	“ Education for teachers.” “ It would be nice to get a chance to ventilate thoughts raised by (my) job.”
	3) multi-professional collaboration in school welfare services	“Theme days for different age groups on health related topics could be organised together with student welfare services. “ “ Join student welfare services.”

2) Respondents saw the lack of basic care as relating to disregard for well-being on the part of both the parents and the students themselves, and basic care such as eating, sleeping or hygiene was not taken care of. Adversities in families were manifested in neglect of basic care. Students showed a disregard for their own well-being, which according to the responses was related to excess gaming or lack of interest in health.

There are children in every class that are not taken care of properly. They might be hungry, in untidy clothes etc. Their basic needs are not taken care of.

Furthermore, there were 3) difficulties in the social relations of students. Some students did not have the skills to form friendships or to uphold previous ones, nor to take others into consideration. Students’ behaviour was self-centred and inconsiderate, leading to difficulties in social situations. Many students were lacking meaningful friendships due to their lack of social skills.

They don’t take others into consideration, and behaviour towards their peers is disrespectful

School professionals evaluated that the students showed 4) disregard for school. They evaluated students having A “nothing matters” attitude towards studying and school in general and that they did not show responsibility for homework, not coming to school on time and not following school rules.

Disregard for school and studying starts already in first and second grades.

The respondents considered disregard for well-being in relation to 5) excessive computer gaming. Respondents regarded violent games and excessive gaming as having effects on student behaviour. The respondents saw aggressive behaviour and anxiety as results of gaming and excessive use of the internet, including harmful internet sites. They also assessed computer as decreasing the amount of sleep and physical exercise.

Some students play too many computer games and … live in the game world

School personnel observed a change in student well-being as an increase in mental health problems, which have become more diverse. The respondents considered depression, anxiety and restlessness as having increased and reflecting on school attendance and learning. The responses also highlighted the lack of healthcare for these students. These responses were further categorised under the heading Increase of mental health problems (Table 1).

Elementary school students are showing depressive and anxiety behaviour.

There are more students in schools and classrooms with mental health problems, who should not be in school. Support by primary healthcare does not reach these children and hospital treatment is hard to get.

Only a few of the comments indicated a positive dimension in well-being or a positive change in student well-being. For example, students were seen to share their worries more easily with adults than before. School personnel evaluated that bullying has decreased due to systematic measures taken in schools, and most students do well despite the growing population of students that are not doing well.

Opinions on mental health promotion in schools

School professionals clearly considered that 1) promoting mental health is an integral part of school activity, with a mean score of 4.4 (SD 0.5) in the intervention schools and 4.2 (SD 0.6, p = NS) in the non-intervention schools on the Osgood scale (disagree = 1, agree = 5). The school professionals were also asked with an open question of why they considered mental health promotion to be a basic function of schools. School professionals considered mental health promotion as a basic function because 1) it is a comprehensive part of the everyday activity in school, 2) it covers the whole age group, and 3) it is a means to help students deal with their problems (based on sub-categorisation, Table 1, values are presented in Table 2).

Table 2. Opinions on mental health promotion in schools

Variables, mental health promotion in schools	Intervention schools	Non-intervention schools
	Mean (SD)	Mean (SD)
1. Promoting mental health is included in school activities.	4.4 (0.5)	4.2 (0.6)
2. Recent mental health promotion interventions have improved aid for students. 3. Recent mental health promotion interventions have increased my knowledge of mental health issues. 4. A psychiatric nurse has supported me in student mental health promotion. 5. Support from a psychiatric nurse has been sufficient in mental health promotion. 6. Collaboration with a psychiatric nurse has been profitable.	3.7 (0.7) 3.3 (0.9) 3.2 (0.8) 3.0 (1.0) 3.9 (0.6)

Osgood scale values range from 1 = disagree to 5 = agree

In item 1 the difference between intervention schools and non-intervention schools was not statistically significant.

More closely, the respondents regarded 1) a comprehensive part of the everyday activity in a school’s mental health promotive tasks included enhancement of learning, supporting the educational mission, and supporting the well-being of students, families and school professionals:

It is our task to take care of students’ well-being and their ability to learn in schools

A happy teacher generates well-being for everyone in the school community

Furthermore, the respondents considered 2), mental health promotion over the whole age group to be an important part of school activity, as school is a universal environment for all children and adolescents.

Respondents saw mental health promotion as 3) a means to help deal with problems and also to increase knowledge on how to seek help. Respondents regarded early involvement in students’ problems as important, and schools as a good environment in which to offer support for students and families. Respondents considered increased skills in self-care methods to be ways of helping students deal with different kinds of adversities.

It is important for students to know when and where to look for help with different mental health problems

What kind of collaboration with a psychiatric nurse do you wish to have?

The respondents wished for 1) student-related collaboration, 2) consultation and guidance, and 3) multi-professional collaboration in school welfare services (based on sub-categorisation, Table 1).

They wished for 1) student-related collaboration on individual and group levels, as well as for both promotive and caring actions. They also hoped for sufficient allocation of time from the psychiatric nurse.

“ … support for individual students”

Time to talk about self-esteem, empathy and responsibilities, in group discussion.

The respondents hoped for collaboration such as 2) consultation, training and professional guidance to support their work. They valued opportunities to increase their knowledge on how to deal with students’ problems in school, but also to receive guidance for their work.

Teachers need an opportunity to consult a psychiatric nurse

They also hoped for collaboration in 3) multi-professional teams in school welfare services, such as attending meetings with parents and working together with challenging classroom situations.

Work together with challenging families

School professional experiences of interventions

School professionals in the intervention schools considered that mental health promotion interventions have improved aid for students (mean rating 3.7, SD 0.7) and that collaborating with a psychiatric nurse has been productive (mean rating 3.9, SD 0.6). They did not agree or disagree on the issue of whether the mental health promotion interventions had increased their knowledge of mental health (mean rating 3.3, SD 0.9). They did not have a clear opinion on whether they had received support from the psychiatric nurse in mental health promotion (mean rating 3.2, SD 0.8), or whether the support provided by the psychiatric nurse was sufficient (mean rating 3.0, SD 1.0).

Discussion

Using a mixed-method approach, this study aimed to gain a better understanding of school professionals’ perceptions of student well-being. In addition, we explored how school professionals perceived mental health promotion activity in school. School professionals expressed a perception that students are doing less well than before, and that they indicate a general disregard for their well-being and show signs of mental health problems, although the frequency of these issues was not reported by the respondents. In their opinion, family-related issues affected student well-being. The respondents regarded mental health promotion of students as a basic activity of schools, but school professionals need support for mental health promotion work.

The first research question of this study aimed to identify school professionals’ perceptions of student well-being. The present data identified that student well-being, or alternatively ill-being, has a comprehensive nature, with family-related issues as a significant factor. Respondents regarded reduced family well-being, such as parents’ mental health problems and neglect as well as lack of basic care, as a factor affecting student well-being. This is in accordance with the increasing numbers of child welfare notifications and support by child welfare services in recent years in Finland [29]. A study by [30] suggested that family-related issues, such as parents’ mental illness or substance use disorder, which affect the whole family’s well-being, were related to school nurses’ concern about students’ psychosocial development, particularly internalising and externalising symptoms. The present findings also indicate that school professionals identified an increase in behaviour related to the mental health problems of students. Although the epidemiological data is not unambiguous, some existing research supports this finding, showing an increase in the use of services for psychiatric or neurodevelopmental disorders of adolescents between 12 and 18 years old in one Finnish cohort study [13]. Teachers also recognise and seek help more often for externalising problems [8], such as restlessness which was also reported as increasing in our study. At the same time, there is a significant increase in student numbers in special education [7], which indicates that there is an attempt to solve emotional and behavioural problems pedagogically. The perception of school personnel appears to be that students as doing less well than before and that teachers are left without adequate support in increasingly difficult mental and social situations. This conclusion is supported by a study by [31], on teachers’ perspectives on student well-being, stating that almost 90% of the teachers reported insufficient numbers of school-based mental health professionals and over 87% reported a lack of adequate training for staff in dealing with children’s mental illness.

In the current study, the responses concerning student well-being were almost all negative. Only a few school professionals replied that student well-being had increased or otherwise reported positive factors related to well-being. This is quite contradictory to the general situation since according to the Finnish national institute of health and welfare reports [32], most children are doing well. School health surveys show that in many ways most children are doing better than before, but the adversities accumulate in specific groups of students such as students from immigrant families, low education level of the mother and students with limitation of activity, such as a learning disability [33]. There is a polarisation of well-being and the students who are not doing well are a very distinguishable group in the classroom.

The second research question aimed to identify how the respondents viewed mental health promotion as a school activity. The respondents perceived that mental health promotion is a comprehensive part of the everyday activity in schools, which covers the whole age spectrum and offers means to help students deal with problems. School professionals in the intervention schools regarded that the interventions did not significantly increase their knowledge, or their ability to promote student mental health on a general level, but considered individual student-related supportive interventions to be significant. The perception of the respondents was that interventions delivered by psychiatric nurses improved aid for individual students. Teachers may report mental health problems of students, but they rarely recommend help [34]. According to the Finnish core curriculum, “Teachers’ main tasks are to teach and to guide students towards lifelong learning as well as to promote the well-being of students” (Finnish national agency for education, 2014). In addition to these tasks, teachers are dealing with students with a variety of emotional, social and behavioural problems, and they need the help of social and healthcare professionals in order to be able to do their work well.

Although teachers regard mental health promotion as an important part of the role of schools, they regard dealing with mental health issues of students as straining and stressful. School professionals have the desire to support the mental health of students, but they are strained by the workload as it is and are unable to take on all the duties that seem to be expected of them. Schools need more multidisciplinary resources to promote well-being together with teaching professionals, and to attend to the mental and social needs of students. In addition, teachers need training and support in mental health issues [35]. The respondents in our study regarded that collaborating with a psychiatric nurse was advantageous. Handley and McAllister [36] suggested that collaboration in mental health promotion requires cooperation between teachers and mental health workers.

Teachers need professional training on mental issues in order to meet the demands made on them. In one Canadian study, over two-thirds of teachers reported not having received any professional training in the area of student mental illnesses [31]. In their study, almost all teachers reported a significant need for additional knowledge and skills training in recognising and understanding the mental health issues of students. Almost 90% of the teachers also reported a significant need for additional knowledge and skills training for working with families. Teachers are the primary source of support for students, and therefore teachers’ competence on mental health support should be increased.

Our study reveals that collaboration with a psychiatric nurse in student-related issues and in school welfare services as well as consultation and guidance is appreciated. Adequate resources, including school welfare services, are significant in supporting school professionals in their work. School welfare services and student-related collaboration were regarded as a means to offer help and promote the well-being of students on an individual and group level. School professionals’ suggestions for methods of collaboration can be used in the future development of collaboration methods and interventions.

Although this study was carried out in an urban setting, the intervention is transferable to rural schools. The interventions included in the study are relatable to students in both rural and urban settings due to their general content. Although the interventions in the study were carried out by psychiatric nurses, they could be carried out by other school professionals, such as nurses, counsellors, psychologists or teaching staff that are already present in schools. Interventions that reach adolescents in their own environment have the possibility to answer to the mental health support needs of adolescents. Jack et al [37] found in their study with First Nations adolescents in Canada that a school-based intervention improved student behaviour and academic outcomes, and reduced suicidal thoughts and actions. Interventions carried out in adolescents’ own environments by multi-professional collaboration have the possibility to decrease the need for special services. As established by Niemelä et al. [38], The “Let’s Talk about Children Service Model”, a community-based service approach commonly used in schools in northern Finland, was associated with a significant decrease in special services. Although this does not automatically indicate a decline in problems among children and adolescents, it reflects that schools’ have better abilities to encounter pupils’ socioemotional and behavioural problems.

One strength of our study was the use of qualitative methods to illuminate the experiences of school professionals, who had the possibility to freely present their perceptions and thoughts on the matter. Another strength was that our sample represents the experiences of school professionals from different schools.

Our results present the views of school personnel on perceived student well-being and their perceptions on mental health promotion in schools. Therefore, it offers valuable information for developing mental health promotion work in school environments. A more comprehensive study on the subject is now needed. One limitation was the relatively low number of participants in relation to the target population. Furthermore, there was no detailed knowledge of the professions of the respondents, although we can assume that most of them were teachers.

In addition, the questionnaire was developed by the researchers, to specifically gather information on school professionals’ perceptions of student well-being and mental health interventions, and no standardised instruments were used. However, similar questionnaires have been used in other studies of school personnel experiences [39].

Conclusions

School professionals regarded mental health promotion in schools as important to student well-being. The school professionals cared for the well-being of students and expressed a desire to improve their well-being, but they felt that they did not have the knowledge or resources to do as much as they would like to. Regarding the families, the well-being of the students reflects the situation of the entire family. Therefore, developing means for school professionals and social- and healthcare professionals to tighten their network and work together in all child and family environments is crucial. It is important to understand the school professionals’ perceptions of the well-being of students in order to develop effective interventions in school environments and support school professionals in their work. We recommend further research on multidisciplinary and collaborative interventions to support teachers and offer supportive measures to families.

Acknowledgments

The authors gratefully acknowledge the school headmasters for their cooperation and thank the school professionals for sharing their experiences. We also thank Leena Joskitt, from the Clinic of Child Psychiatry, Oulu University Hospital, Finland for her statistical expertise.

Disclosure statement

There is no conflict of interest.