Resources and strategies young people use and need to promote mental health – a qualitative study from a salutogenic perspective

Abstract

Aim:

The aim of this study was to explore young people’s experiences of resources and strategies for promoting their mental health.

Methods:

Individual interviews with 33 people aged 16–25 years were conducted using a method inspired by cognitive interviewing, which combines think aloud techniques with probing questions. The interviews were based on the young people’s reflections of the questions in the Swedish national public health survey. Data were analysed with reflexive thematic analysis.

Results:

The resources and strategies that the young people in this study described as important for promoting mental well-being are related to societal prerequisites needed to navigate life; to their immediate surroundings, including social interactions; and to the young people themselves. These resources and strategies are presented under the following three themes: prerequisites for navigating life, social interactions on one’s own terms, and who I am and what I can do.

Conclusions:

Young people have a variety of resources and strategies of their own available for promoting mental well-being. However, they cannot promote mental health just on their own; access to social networks and the opportunity to share thoughts and feelings are central. Further, to promote mental health, young people need good social conditions, knowledge, and support from adults so that the existence they struggle to navigate feels comprehensible, manageable and meaningful.

Background

Mental health problems among young people are a public health concern, both globally [1–3] and in Sweden [4]. In Sweden, mental health problems such as anxiety are reported to the highest extent in the 16–29-year-old age group [4], although 77% of people in that same age group indicate good mental well-being [5]. Girls report mental health problems to a greater extent than boys [3,4]. However, mental well-being and mental health problems are subjective experiences, and people may have different perceptions and experiences of the concepts. Young people have pointed out the difficulties of describing the positive aspects of mental health, since it is more common to talk about mental health problems [6] and they have highlighted that mental health problems need to be understood based on how they affect everyday life and interactions [7].

Young people have mentioned good self-esteem, confidence and happiness as aspects of positive mental health, together with feeling like being a good person, having parental love and someone to talk to, and to socially fit in with the world [8]. Determinants of particular importance for young people’s mental health are relationships with family and friends, education and school environment and physical activity. Good self-esteem, resilience and self-efficacy and social aspects such as support from significant others and a sense of belonging have also been described as important determinants [9].

The theoretical underpinning of this study was the rainbow model of social determinants of health [10,11] and the salutogenic theory [12,13]: the rainbow model because it illustrates how health is not only a product of individual choices and genetics but is created in a complex interaction with and between societal and structural factors; the salutogenic theory because of its focus on individual and societal health resources. In the rainbow model, the determinants are presented as different layers that interact with each other and that require different interventions to influence. The outermost layer of the rainbow represents general structures in society and the second layer represents the material and social conditions in which people live and work. The third layer represents support from social and community networks, while the fourth layer represents the health behaviour of the individual himself. At the heart of the model is a core that represents the individual’s genetic conditions, such as age and gender [10,11]. One of the main pillars of the salutogenic theory is the general resistance resources (GRRs) [12,13]. These are the resources of a person, group or community that facilitate coping with stressful situations in life. The resources a person uses to cope with a specific stressor in particular circumstances are defined as specific resistance resources (SRRs) [14]. Identifying one’s GRRs/SRRs, and being able to use them, can strengthen the development of sense of coherence (SOC) [15]. SOC is a way of perceiving life as comprehensive, manageable and meaningful [13] and highlights confidence in one’s ability to use resources in a way that promotes health [16]. Strong SOC can be protective against negative consequences of stress [17,18] and against the risk of developing more serious mental illness among young people [19].

Mental health and well-being are subjective experiences and prone to individual interpretation. To support young people and promote their mental health, knowledge of how they view promoting factors is needed.

Aim

The aim was to explore young people’s experiences of resources and strategies for promoting their mental health.

Methods

Design

This study has a qualitative design. An interview method inspired by cognitive interview was used to collect data [20], which were analysed by reflexive thematic analysis (RTA) [21,22].

Participants

Participants were recruited through advertisements on Facebook, Instagram, LinkedIn and Snapchat. Inclusion criterion was being aged between 16 and 25 years. Information about the study was provided through a link to the project website. An extra effort to recruit more boys was made through targeted advertising. In total, 48 young people registered their interest in participating; 15 withdrew before the interview, mostly for unknown reasons, but also because of lack of time or ill-health. Finally, 33 young people participated: 22 girls, 10 boys and one non-binary person aged 16–25 years (m = 20.4). The interview was scheduled via e-mail after the participants had given their consent to participate in the study. Most of the participants studied at primary, secondary or university level [20], while 10 worked, two both studied and worked and one was on sick leave. They lived in different parts of Sweden and almost all were born in Sweden (30). Twelve participants lived in a metropolitan region, 11 in a small or medium-sized city and 10 in a rural area.

Data collection

Data was collected through individual interviews based on the young people’s reflections of the questions in the Swedish national public health survey [23] including seven items about mental well-being from the Short Warwick–Edinburgh Mental Well-being Scale (SWEMWBS) [24,25] and two items about anxiety and stress [23].

The cognitive interviews were conducted by combining ‘think aloud’ technique and probing questions [20,26]. The combination of these two techniques is suitable when the purpose is to describe perceptions and experiences related to specific questions [26] and is highlighted as particularly suitable when the informants are young [20]. An interview guide was used. Participants were asked to ‘think aloud’ when they were reading through the questions in the public health survey. Then, probing questions were asked about the participants’ resources and strategies for promoting mental well-being and managing mental health problems, and what support they needed. Examples of probing questions related to SWEMWBS: What is needed for you to be optimistic about the future? What makes you feel useful? What makes you feel relaxed? What do you think is a good way to deal with problems? What helps you to think clearly? What makes you feel close to other people? What helps you to be able to make up your own mind about things? Examples of probing questions related to items about anxiety and stress: What resources do you have yourself or in your environment to deal with anxiety or stress? What support do you need to deal with anxiety or stress? Thus, it was their reflection based on the questions in the public health survey that was in focus rather than the questions themselves. The interview guide was tested on three young people and slightly adapted accordingly. The pilot interviews were not included in the analysis.

The interviews were conducted by the authors in February and March 2022 via Zoom and lasted for 24 to 91 min (m = 56), and were recorded and transcribed verbatim by professional transcribers.

Analysis

The interviews were analysed by RTA [21,22] and NVivo was used to organize the data. RTA is a flexible interpretive method that gives the researcher an active role in developing themes and to reflect on the analysis. Theoretical assumptions are seen as a resource in data analysis which contributes to a deep interpretation of the data [21]. Thus, the data were coded inductively but were underpinned by reflection from the theoretical and conceptual assumptions of the salutogenic theory [12,13] and social determinants of health [10] for being able to understand and interpret the pattern of shared meaning and to generate themes important for the research aim [21].

The analysis was conducted according to Braun and Clarke’s analytic process [22,27]. Initially, the interviews were read through to get familiarized with the data. Codes were generated through organizing and labelling statements that met the study aim. The authors coded one interview to ensure consistent coding and then each coded an equal number of interviews. All codes were compared and discussed according to meaning, designations and relationship, and through these discussions, patterns of recurring themes were generated.

Themes were reviewed, collapsed and further developed to describe the pattern of shared meaning. The themes were defined and named in a way that responded to the research aim and to the theoretical and conceptual assumptions to ensure the themes provided a meaningful contribution. Coding and thematization were not linear processes but required reflections about how they are mirrored against each other and the theoretical and conceptual assumptions [21]. This was done through discussions between the authors and reconciliations with a fourth researcher. Codes were moved back and forth between themes and preliminary themes until a robust pattern could be constructed. The findings were illustrated with pseudonymized quotes and correct age.

Ethics

The study was conducted in accordance with the Helsinki Declaration’s ethical principles for research involving human subjects [28] and was approved by the Swedish Ethics Review Authority (dnr. 2021-06471-01). Before the participants gave their consent to participate, they received verbal and written information about the study. They were also informed that participation was voluntary, that they could withdraw at any time, that the interviews would be treated confidentially and that no unauthorized people would be allowed access to the collected material.

Results

Three themes were developed through the analysis, describing areas important for promoting mental well-being: Prerequisites for navigating life, Social interactions on one’s own terms, and Who I am and what I can do.

Prerequisites for navigating life

The participants navigated an existence filled with opportunities and expectations. The first theme captures their experiences of prerequisites needed for navigating everyday life in a way that promotes their mental well-being.

Important prerequisites were to have security in everyday life, such as stability, structure and routines. Security included having a stable economic situation and living in a neighbourhood without being afraid to go out.

Not too much trouble, not too much stuff going on around you that can weigh you down. If you live in a place that’s without rules, where people get shot in the street right where you live, then you’re not in a safe environment, you probably meet the wrong people, the wrong group of friends, and then it gets worse from there. (Linus 20)

It was considered necessary to have the power to shape one’s life to navigate in a way that promoted mental well-being. This meant having the opportunity and freedom to make independent decisions about both everyday life and the future. It was found important to have the possibility to change one’s mind because it could be difficult to know exactly what was needed in the future.

One might need to know that there are many more choices and many more possibilities than what we have sort of learned, [. . .] you might be studying to be a doctor, but you want to be a carpenter [. . .] there are a lot more paths in life than you thought. (Victoria 23)

Another prerequisite was a context of reasonable demands and expectations, including reasonable external demands and expectations regarding what to achieve. The participants described how it would benefit their mental well-being if living as a young person was less demanding. An open and accepting social climate was also identified as a prerequisite. The participants desired a more positive view of the future conveyed by adults in society, to be able to have some faith in the future. To promote mental well-being, the social climate should be characterized by knowledge, openness and tolerance of mental health issues, and the image of a successful and friction-free life conveyed in social media needs to be changed. Increased awareness and openness among adults about their own mental health problems was also identified as important.

I think adults should also talk to each other about how they feel. (Isak 22)

Social interactions on one’s own terms

The second theme shows how participants used social relations as resources and strategies for their mental well-being, depending on their needs.

The participants described the need to have company in everyday life to not feel alone. It was comforting having friends and family around, without any requirements attached to the interactions. Being close to others to chat, laugh and do everyday things together was calming and provided opportunities to let off steam when not feeling well. Household pets were also a source of calmness and relaxation.

Sometimes, just a hug can help me a lot, that I get to hug Mum or Dad or my siblings. Just being close to family. (Samira 22)

Social interaction in the form of emotional belonging was also described as important for mental well-being. This state was deeper than just having other people around; it meant being able to emotionally share things with others, belong to a social context, and to fit in. Therefore, it was important with social relations that felt genuine, in which the participants could be themselves, and where they experienced community, understanding and security. Relationships where they felt valued and where they contributed were important for the sense of belonging.

To feel that I am needed and that I contribute. . . [. . .] To be in a situation, to belong to something. Not being outside of society in any way, but being part of it, having something to do, having friends. (Rebecka 24)

It was important to have relations where one could communicate with others about one’s state of mind. In some situations, the participants felt they needed to be guided by others, such as receiving advice on everyday matters from someone they relied on and could reason with. Family, friends and classmates could help when the participants did not feel they had the answers within themselves.

Sometimes I feel that I want to ask for advice or someone else’s opinion. I think it’s part of human nature to want to be sure that you make the right choice and that someone who knows you or the situation agrees with you. (Victoria 23)

School was a demanding part of the participants’ lives but could also be an arena of opportunities to manage problems in their everyday lives. Social relations were important in managing these problems. To feel good at school, guidance and social support from teachers was necessary. For participants who had a day job it was important to feel that they could ask colleagues for help when work felt overwhelming, even though they preferred to manage tasks without anyone else’s help. Access to professional social support with their mental health was also expressed as important. Even if participants had not used professional support, it felt secure to know where to find it.

Being met by understanding and validation in their social relations made the participants feel less alone in everyday demands and challenges. It meant a lot to be treated nicely and to be shown gratefulness and appraisal after handling something well in school or at work. The participants wanted to be met with compassion when they did not feel well, primarily by family and friends, but also by managers and colleagues. They wanted to be sure not to be judged by others based on their mental health state. If they were met with understanding, it removed the pressure to put on a disguise to cover up one’s state of mind.

Who I am and what I can do

The third theme describes internal resources and own strategies that the participants have, use or feel they need to be able to promote their mental well-being. They explained these resources and strategies as coming from within themselves, expressed in their thinking, being and acting.

Having good self-esteem, a belief in oneself and courage to stand up for oneself was perceived as important internal resources. It was described as important to accept all parts of oneself and feel allowed to be who you are without trying to please anyone else.

When I know I can be who I am and they don’t see it as all I am. If I’m sad or worried or angry or frustrated, I know I can be, and they will understand that it’s just part of my day or part of what I’m going through. (Victoria 23)

The participants expressed the importance of taking responsibility for one’s situation and facing problems as something that can be solved. They described the need to not enlarge problems, take a step back and think logically about the situation. One strategy was not to postpone what needs to be done and to plan and prioritize one’s time.

It was considered important to accept that everything may not be perfect. Instead of focusing on unfilled expectations and dwelling on the past, it was important to focus on what can be done in the future, and to have faith that everything is going to be all right.

So, it’s like this. . . it’s a bit foreign to me that I didn’t start to understand until, like last year, to find calmness in the chaos, to find a kind of acceptance that not everything is exactly as I had wanted it to be and still feel like, it will be okay. (Maja 20)

The participants described reasoning with oneself as helpful for being in touch with their inner self, understanding problems and looking at situations with some distance.

But I try to take it easy and think, well what could be the reason for this or why do I feel this way, try to talk to myself, it will pass, it’s just a feeling, it’s just in my mind, nothing will happen, like trying to calm myself down. (Celine 17)

This inner dialogue was described as a strategy to explore the reasonableness of one’s thoughts and feelings and to get to know oneself and one’s needs. This included having reasonable expectations from oneself regarding how to live one’s life and setting goals that were achievable and enabled one to feel satisfied with the achievement.

The participants described that shutting out the world for a while could promote mental well-being. They expressed a need to unwind and not be available all the time. Instead, they wanted to be present with themselves, enjoy the moment and just be in a peaceful environment.

Like, what do I have around me, what can I feel, what can I see, what can I hear and, what do I need to do right now. Trying to sort of land a little in the present. (Jasmine 24)

Taking care of oneself was described as important and was about doing things in everyday life that felt good and met basic personal needs such as getting enough sleep, being physically active, eating regularly, and managing rest and recovery. Physical activities and nature were described both as a strategy for dispelling thoughts and as a source for recovery. Taking time for oneself, such as listening to music, scrolling through social media, watching cartoons, creating something with the hands, exercising or taking care of animals were described as meaningful activities for enhancing mental well-being.

Discussion

This study extends knowledge about the promotion of young people’s mental health by elucidating important resources and strategies. The resources and strategies are related to societal prerequisites needed to navigate life; to their immediate surroundings, including social interactions; and to the young people themselves. These correspond with the layers of social determinants of health as illustrated in the rainbow model [10] and underpin the understanding of health being created in an interaction between the individual and society. According to our results young people need certain societal prerequisites to navigate life in a way that promotes mental health, similarly the rainbow model highlights the importance of general structures in society, and material and social conditions for promoting health [10]. Previously, young people have described mental health as an interaction between themselves and their environment and as a shared responsibility between themselves and the adults in their life [7]. The GRRs [12,13] clarify how health is determined by the access to and the usage of resources on different levels. Further, the salutogenic theory assumes that life inevitably includes stressors of different severity, and that health is determined by how a person copes with the stressors [13]. Correspondingly, the young people in our study described an existence of opportunities, demands and expectations. Our results reveal that favourable social conditions are important resources for young people to navigate in a way that benefits their mental health, such as having the power to shape one’s own life and that demands and expectations from others are reasonable and manageable. Similarly, young people have described how pressure to live up to expectations, such as those from school, negatively influence their mental well-being and that a sense of control, meaning and structure in life enhance mental well-being [29]. Previous research has also shown how perceived inclusive school climate is associated with better mental health [30].

Further, our findings highlight social relationships as a central resource for enhancing mental well-being. Different forms of relationships met different needs in young people’s everyday life. Previous studies have described the importance of social relationships for young people’s mental health; for example, social support from family and friends and having someone trustful to talk to and share concerns with [31–33]. The third layer of the rainbow model highlights social and community networks as important determinants [10] and social support and cohesion have been proposed to be explicitly highlighted in an updated version of the model to better correspond with the needs of today [11]. Further, perceived low social support is related to more depressive symptoms among young people [34,35]. Our results show that not only receiving support but also contributing to a relationship was found to be important for the sense of belonging. Similarly, supportive and rewarding social relationships and the perception of contributing to the happiness of others have previously been found to be related to fewer symptoms of depression, anxiety and eating disorders [36]. Social and community networks are well-established GRRs [12] that are central in determining health [10]. The context of secure and healthy relationships has been proposed to be included when adolescents’ overall well-being is defined and described [9], which underpins its importance for adolescents and young people.

In our results, being able to look at situations logically and reason with oneself for managing different situations was found to be an important resource. One strategy was to accept and make the best of the situation. Previous studies have concluded that young people genuinely understand that challenges and difficulties are part of life [6,32] and that well-being is more about the ability to deal with difficulties than about feeling great all the time [29]. This acceptance of one’s situation and belief in one’s ability to deal with problems can be seen as important GRRs to cope with challenges in everyday life. According to Antonovsky [12], positive life experiences can create a strong SOC. Managing challenging situations can be a positive experience for young people, confirming that they can take responsibility for their situation and make the right decisions, which strengthens them in terms of managing further challenges. However, our results also show that young people need guidance from adults in decision-making and dealing with everyday life challenges. This corresponds to previous research showing that young people request guidance in the transition from youth to adult, such as in career choices, economy and housing [6].

Our results reveal a variety of strategies that are used to promote mental well-being, from shutting the world out for a while to doing practical things. Previous studies have highlighted the importance of having a safe place where one can gather thoughts and experiences [33] and recover in solitude [31]. Similarly, our findings and previous research [33] show that enjoyable activities such as taking a bath, watching television, listening to music or volunteering are important for relaxing and ‘recharging batteries’. Our results showed that physical activity and nature were sources of peace with which one can recover from the demands of everyday life. Physical activity is well known to enhance mental health [37] in terms of better self-esteem, more positive thinking and meaningfulness among young people with mental illness [38]. Nature has been described as a calm place where one can be oneself, feel relaxed, and rest from worries and demands [33,39]. The need for a space for oneself to gather strength can be assumed to be a general human need and not only among young people. Further, to be aware of one’s needs was found to be a resource in our results, enabling young people to create space for recovery. In the salutogenic theory, meaningful activities and contact with one’s feelings have been highlighted as important to be able to balance demands and the available resources. A good balance can promote the development of a strong SOC [12,40]. In summary, the results from our study underpin the importance of SOC for young people’s mental well-being: that the existence they struggle to navigate feels comprehensible, manageable and meaningful.

Methodological considerations

The interview was based on items about mental health in a well-recognized national survey. This can be a weakness because the participants may define mental health differently. However, these items are used in the surveillance of mental health in the general population in Sweden. Thus, the results provide increased knowledge about young people’s understandings of the surveilled conditions.

The recruitment was done via social media, which made it possible to get a varied selection of participants. However, it can be assumed that those who chose to participate had a special interest in mental health issues. This does not have to be a weakness, as commitment and interest in the subject can provide well-thought-out answers. It is generally more socially accepted for girls than boys to talk about mental health, which may explain why two-thirds of the participants were girls. However, the aim was not to search for differences between boys and girls but rather to get a wide range of different experiences.

The data material was analysed with RTA [21,22] and the themes are reflected based on theoretical assumptions. Researchers with different pre-understandings might have used other theoretical assumptions and reached different results. However, to establish trustworthiness [41], the data were coded close to the participants’ stories, and theoretical assumptions were thoughtfully used to create meaning. During the analysis researcher triangulation was done through reflections on codes and themes and by returning to raw data.

Questions about mental well-being and mental health problems can arouse uncomfortable thoughts and feelings. The interviewing authors were sensitive to how the participants felt about sharing their experiences and adapted the interviews accordingly. It was also conveyed that it was optional what and how much the participants wanted to share. The authors provided contact details for support, although this was not required. All participants chose to conduct interviews digitally. In the digital format it can be difficult to read emotional reactions and create a relaxed interview situation. However, it can be experienced as less emotionally stressful because it provides a distance that makes it easier to talk openly.

Conclusion

According to our findings, the resources and strategies that young people use to strengthen well-being can be summarized in three levels: an overall level that captures the societal conditions that young people need to navigate their existence, an intermediate level that includes the young people’s social interactions and their immediate surroundings, and an innermost level that describes individual abilities and characteristics. Our results show that young people are capable of action. They are aware that mental health can be influenced by their own actions, and they have a variety of strategies available. The results also show that young people cannot promote mental health just on their own; access to a social network and the opportunity to share thoughts and feelings is central. Further, to promote mental health, young people need good social conditions, knowledge, and support from adults in their lives to navigate a complex existence.