55808 research-article2014
onal wellbeing and mental healthEmotional wellbeing and mental health
Peer Review Emotional wellbeing and mental health: an exploration into health promotion in young people and families
Emotional wellbeing and mental health: an exploration into health promotion in young people and families Authors Gillian E Coverdale School of Healthcare, University of Leeds, Leeds, UK Andrew F Long School of Healthcare, University of Leeds, Rm 1.11 Baines Wing, Leeds LS2 9UT, UK Email: [email protected] Corresponding author: Andrew F Long, as above
Keywords emotional wellbeing; health promotion; young people; parents; family; qualitative research
Abstract Aims: Promoting mental health and emotional wellbeing (EWB) in children and young people (YP) is vitally important for their psycho-social development. Critical review of the literature reveals a dearth of research that has explored the perspective of the child, adolescent or adult in this concept, with much research being intervention focused and promoted at crisis level. The current study aims to address this gap in understanding of young persons’ and parents’ perspectives. Method: A small-scale, exploratory qualitative study was conducted with YP, and parents of YP aimed at exploring the meaning of EWB and how it could be promoted. Data were collected via focus groups with 15 YP (aged 18–24 years) and 15 interviews with parents of a different group of YP. Results: Study participants identified key constructs for good EWB as stability, coping ability, happiness, confidence, balance, empathy and being grounded. Feeling comfortable with self, managing and controlling emotions and having the confidence to persevere with challenges were all felt to contribute to a positive sense of EWB. Sources of support were overwhelmingly cited as family and friends, with schools identified as a potentially good environment for supporting and promoting the EWB of pupils. Participants stressed the need for a positive attitude change towards YP, advocating this as promoting a sense of belonging and community citizenship. A lay-informed ‘recipe’ for successful EWB promotion is drawn out, centred on the core goal of raising awareness and understanding of YP’s EWB, in the YP themselves, their parents, schools and the wider community. Conclusions: This research provides key messages for society, policy makers, education and public health and healthcare practitioners for integration into the delivery of services for YP and families that include education on supporting EWB, activities for YP and a multi-agency approach to supporting families within the community.
Introduction The last two decades have seen a growing body of seminal work exploring emotional and mental health and wellbeing, but a dearth of good quality research and evaluations on promoting emotional wellbeing (EWB) in young people (YP) in the United Kingdom.1–5 There still remains a lack of agreement over its definition.6–8 EWB is defined by the World Health Organization (WHO)9 as a state of wellbeing in which the individual realises their own abilities, can cope with the normal
stresses of life, work productively and fruitfully and is able to make a contribution to the community. The Health Development Agency further argues that EWB is ‘a holistic, subjective state which is present when a range of feelings, among them energy, confidence, openness, enjoyment, happiness, calmness and caring, are combined and balanced’.10 Policy and research literature acknowledges varying aspects of EWB. For example, the National Institute for Health and Care Excellence
Copyright © Royal Society for Public Health 2014 January 2015 Vol 135 No 1 l Perspectives in Public Health 27 SAGE Publications Downloaded from rsh.sagepub.com at NORTHERN ARIZONA UNIVERSITY on June 18, 2015 ISSN 1757-9139 DOI: 10.1177/1757913914558080
Peer Review Emotional wellbeing and mental health: an exploration into health promotion in young people and families (NICE)11,12 state in their policy guidance that promoting YP’s social and EWB encompasses: •• Psychological wellbeing/good mental health – the feeling of autonomy and control over one’s life, problemsolving skills, resilience, attentiveness and a sense of involvement with others. •• Social wellbeing – the ability to have good relationships with others and to avoid disruptive behaviour, delinquency, violence or bullying. •• EWB – happiness, confidence and not feeling depressed. Adi et al.4 argue that psychological wellbeing involves having self-efficacy, itself comprising high self-esteem, power and control, confidence and positive beliefs about the ability to change a situation and succeed. Uskul and Greenglass13 suggest that psychological wellbeing involves an absence of depression, a high life satisfaction, coping capacity and optimism; good psychological wellbeing becomes a sound indicator of how someone will cope in a stressful situation. Thus, EWB is both separate from mental (ill) health and comprises good mental health within its scope. As Rees14 argues within the context of clinical paediatric care, EWB is recognised rather than defined precisely; moreover, as in the NICE definition above, it is multi-faceted, with its interrelating elements being on a spectrum from optimum to damaging. Much of the existing research on EWB is North American or Australasia based, intervention focused and promoted at crisis level, for example, addressing low self-esteem, self-harm and attempted suicide. Moreover, the meaning of EWB is largely professionally defined, with limited insight into the views of YP or parents of YP, despite a plethora of information on the health and wellbeing needs of pre-adolescent young children, with advocacy for a concentration of resources in the early years.15–18 As Coleman et al.3 argue, it is questionable whether the constructs of emotional health and wellbeing in adults are the
same as those applied to YP. Indeed, Sir Ian Kennedy’s policy review commented that one of the biggest obstacles for YP is the lack of recognition of them as different from children, as well as adults.6 Yet in some contexts, such as protection from sexual exploitation, violence and conflict with the law, adolescents have the greatest needs.19 There is also little investment and health and welfare assistance provided to YP. Furthermore, it is important to note that existing research on YP has often equated ‘mental health’ with ‘mental ill health’ and is therefore negative.1,3 There is a similar dearth of research evidence on the views of parents of YP, despite recognition of the vital contribution parents make in developing their children’s mental health and EWB, along with the need to support parental EWB.20, 21,22 The limited parental research has focused on parenting in small children or parental management of vulnerable children and YP, with little insight provided into factors that are important in the development of EWB.1–5 Parenting is a multiplex concept, with cultural and social contextualisation23 influencing the type of parenting and the success of parenting. However, picking up the skills and knowledge on how to be a ‘good enough parent’ is extremely ad hoc. However, it is well recognised that relationships within families is a key influencing factor on good emotional health and wellbeing.24,25 This article shares the findings of a study that aimed to address the gap in the evidence base, of hearing the voices of YP and those of parents of YP and gaining insight into their perceptions about EWB and factors that may promote and protect it. This article thus explores the meaning of EWB to a sample of YP and parents of YP, comparing this to the professional perspective and discusses how this sample of participants believed EWB may be protected and promoted.
Methods A small-scale exploratory qualitative study, undertaken as part of a research
degree at the University of Leeds,26 was designed to explore the meaning of EWB and ways that it can be promoted from the perspective of YP and parents of YP. The exploratory study aimed to ‘elucidate the essence of the meaning’27 that EWB held for these two groups, an area lacking in current literature. The research required the involvement of two distinct sets of participants – parents and YP. To ensure anonymity and enhance confidentiality, participation and disclosure, recruited parents needed not to be the parents of the recruited YP. For both groups, a purposive sampling approach was used. All parents had to have experienced bringing up children through their teenage years within the last five years, leading to the selection criteria of parents of YP aged between 17 and 24 years. YP between these ages were also selected; they would still be able to reflect upon life in their teens. Involving YP between these ages is highly appropriate as it is during late adolescence that YP start to disengage from their families, beginning the gradual transition towards economic and emotional independence and also a transitional time of cognitive and social development.28 In view of the exploratory nature of the study and in line with guidelines provided in qualitative research,29 a sample of about 20 or so YP and similar numbers of parent interviews would be an appropriate and sufficient sample size providing rich and informative insights into the perceptions of EWB of a set of potentially diverse YP and parents. For reasons of practicality and resource constraints, a convenience sample was recruited from cohorts of student nurses in the researcher’s work location in a British Colony. Subsequent to a verbal introduction to the research project and an information sheet to interested students, 15 YP, aged 18– 24 years, agreed to take part. No coercion or other pressure was consciously placed on any student to participate. Three focus groups were held with an average of five students per focus group. Conducting a group interview with a small number of
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Peer Review Emotional wellbeing and mental health: an exploration into health promotion in young people and families well-informed participants can be more informative than a larger sample.30 Focus groups enable participants to share their views within a common frame of reference, challenging and influencing each other and commiserate if necessary.31 Given the size and close knit nature of the Colony’s population, parent participants, of a separate group of YPs, were recruited from the researcher’s base country, the United Kingdom, using snowball sampling. The first invitation was extended to people (via a group e-mail using the blind copy facility) who were known to the researcher to have at least one child in the chosen age range, thus ensuring experience of bringing up children through their teenage years within the last five years. These participants were asked to invite their own friends and colleagues who fitted the inclusion criteria. A total of 15 parents were recruited, and individual semistructured, Skype-based interviews were conducted. Over half of the parent participants still had YP of school age, some of whom were the siblings of their older children in the family who fell within the criteria for participation. This approach facilitated a ‘recent’ retrospective and sometimes concurrent view. The research interviews were perceived and conducted as a conversation about the real-life world of the participants, with the verbal discourse tape recorded and subsequently transcribed for later analysis and interpretation.32 To ensure reliability, a common topic guide was used for the focus groups and individual interviews, so that comparisons between the responses could be made. This explored the following areas in a flexible manner, being responsive to the flow of the conversations: •• What does EWB mean? •• What feelings are associated with EWB? •• What kinds of life events influence EWB? •• What sources of support could influence EWB in a positive way? •• What kinds of support would be useful?
In order to look for common themes within the categories explored in the interviews, the principles of Collaizzi’s33 seven-step data analysis framework were utilised, using thematic content analysis.34 Each transcript was read and re-read, key phrases noted and coded within each of the topic/interview guides and significant statements highlighted that emphasised the theme. A set of lower level themes was developed leading to the gradual emergence of a set of higher-level themes. The analysis was primarily undertaken by the lead author, emerging themes discussed with the second author and agreed refinements made. This article focuses on a sub-set of these questions, aimed at illustrating the meaning of EWB to YP and parents of YP and sources of support they would find useful, leading onto the identification of a lay-informed recipe for successful EWB promotion and support.
RESULTS The meaning of EWB to YP and parents of YP Both YP and parents of YP described feelings of EWB as being on a continuum from very poor to very good and that it was okay to feel that range of emotions (Box 1). Both groups discussed stability, happiness, ability to cope, being confident and comfortable with ‘who you are’ and ‘where you fit in’ and being empathic as being key to good EWB. Being able to enjoy life was also acknowledged as subjective and dependent upon what was happening in their lives and not a fixed state. For YP, stability was linked to coping, confidence, empathy and being able to control and manage their range of emotions. For parents, stability was perceived to be more likely in a YP who was balanced, grounded, able to cope, resilient, able to take risks, deal with challenges and manage their emotions. Both YP and parents discussed the importance of being able to rationalise and manage the fluctuation of emotions, without allowing their response to these emotions to be extreme. Achieving and being successful was important, with
both YP and parents mentioning Maslow’s35 hierarchy of needs when discussing accomplishment and selfactualisation. For both YP and parents, feeling confident and comfortable with self was perceived as a key component of good EWB. For YP, this also influenced their management of expectations, along with their perception of life’s challenges. Parents felt it helped YP to communicate their feelings and to problem solve. Empathy was seen by both YP and parents to be a positive aspect of EWB and being able to understand other people’s emotions as well as their own. Parents expressed their pride when their YP showed empathy with and for others.
Useful sources of support A large range of ideas were raised by participants for supporting EWB and areas they felt needed to change. Promoting good citizenship and support for being a good parent were important themes for parents. For YP, the family, school and the community, and a need to address perceived stigma associated with accessing support services were central. Both groups discussed the importance of giving or gaining praise and encouragement and being loved as essential, both as a defining aspect and as a supportive element of EWB that helped to promote the YP’s positivity, engagement and confidence to try new things (Box 2). YP and parents of YP discussed the importance of good citizenship and a need for a cultural change in societal attitudes towards YP. Parents recognised that the engendering of respect was something that needed addressing between YP and the older generation, citing seeking opportunities to meet together socially and undertaking voluntary work as a way forward. YP talked about society as a whole and wanting to be accepted as the person they were. Parents wanted services that would provide early and non-stigmatising help and support for YP, such as advice or drop-in sessions within the community.
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Peer Review Emotional wellbeing and mental health: an exploration into health promotion in young people and families
Box 1 The meaning of EWB to YP and parents Theme/concept
YP’s illustrative extract
Parents’ illustrative extract
Being stable and able to cope
‘If you are emotionally okay if a problem comes … it’s a challenge and you get over it and you move on’ [FG1]
‘Being centred, grounded. Knowing who you are and how and where you fit in … Resilient’[P15]
‘Being stable … we really can cope’ [FG3]
‘Being on an even keel’[P5,P6]
‘That balance of the right life event will make ‘If they have security and they feel loved and you happy but not OTT or something like that’ nurtured at home … become more emotionally [FG2] stable’[p5]
‘Doing things rationally, not being emotional, like make it bigger than it actually is … As human beings we have to manage the daily balance of life’ [FG2]
‘Not experiencing great extremes of emotion … not being emotionally sterile either’[P11]
Being comfortable with self
‘Accepting what comes – being happy with who you are’ [FG1]
‘Being at one with yourself to the point where you can deal with things that come up without it causing a dramatic trauma’[P9]
‘Feeling good with yourself, happy, confident’ [FG3]
‘How you feel about yourself how you fit with the world out there … that ability to express how you feel’[P3]
‘Feeling comfortable in your … own skin’ [FG3]
Having empathy for others
‘If you have a positive wellbeing it reflects into someone else and … you get it back’ [FG1]
‘If you behave with some grace and dignity then that is reflected back’[P15]
‘Trying to understand other people’s feelings … or understanding somebody else’s emotions’ [FG2]
‘They (his friends) find him really supportive …’[P15]
‘If you don’t understand your own emotions … you won’t be able to help or understand others’ [FG2]
Being successful
‘Doing things well, that you think you should be doing well’ [P2] [FG2]
‘He seemed to have this goal of wanting to do Grade 5 … and he’s achieved it … great’[P3]
‘Also feeling like you’ve reached your level, you feel you have accomplished things … Yeah like Maslow’s hierarchy … selfactualised’ [FG3]
On a continuum
‘It is on a continuum from very sad to very happy with all the emotions between’ [FG3]
‘Emotions run through a spectrum … a perfectly natural thing … we cannot be happy all the time’[P13]
‘It can vary from day-to-day or moment-tomoment, something that can go from being good to bad in seconds and then revert itself back’ [FG3]
EWB: emotional wellbeing; YP: young people.
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Peer Review Emotional wellbeing and mental health: an exploration into health promotion in young people and families
Box 2 Potential useful sources of support for EWB. Theme/concept
YP quotes
Parent quotes
Community and citizenship
‘To be more accepted of what we want to be instead of fitting some ideal that the older generation feel we should fit into’ [FG1]
‘I’d like to think that society can celebrate YP’[P3]
‘When you’re younger especially … interacting with kids … your own age group outside school with similar hobbies … help your sense of belonging’ [FG3]
‘Have a real sense of community … have a village hall … things going on all the time … a sense that people feel they belong to the community’[P12]
‘Getting feedback off other people … acknowledgement … Someone tells you “look you have done well here”’ [FG3]
‘Respect for other people and other people’s property … encouraging them at an early age to respect others and with that brings respect for them’[P9]
‘He has done some voluntary work, and I think that the little bit he puts in actually is appreciated … able to learn to have a rapport and respect with some older folk’[P3]
Services and activities for YP
‘Counsellors … more available … to be referred to or self-refer’ [FG3]
‘Counselling … there are just huge waiting lists so unless people can pay to go privately … there’s definitely a need for it’[P6]
‘And then from that you find good friends because they give you someone else to confide in and will support you … and other adults as well’ [FG2]
‘Access to a range of social activities and social venues … people around who know and understand YP because a lot of YP think nobody understands them’[P11]
‘“ChildLine” … a help line that is excellent’ [FG3]
‘People could do team activities, not necessarily competitive … just doing something you enjoy, without children being tested all the time’[P10]
‘Hobbies, such as sports, especially team sports and also things like the Duke of Edinburgh award, also Brownies/Girl Guides, they all give you a sense of belonging’ [FG2]
‘Other organisations like the scouts … guides for girls … some teenagers enjoy that and really stick with it’[P8]
‘They get a great opportunity to feel their place in the team … talk with their friends … they very much bond’[P3]
‘Outward Bound … team building things … away from the normal everyday stuff … being able to achieve something different and learn resilience as well’[P4]
Parenting support
‘Educating parents to identify when … their child is being bullied or … when they’re stressed … some parents don’t know what to do’ [FG3]
‘You need someone to say you are not nagging you are doing them good in the long run’[P10]
(continued)
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Box 2 (continued) Theme/concept
YP quotes
Parent quotes
‘Emotional loving … not just to give them stuff … because then people will say I love my child so I buy them this’ [P2] [FG1]
‘I’d really like to … kind of debate some of the issues that we’re having … there’s nothing there in the prevention side, it’s always when there’s a problem’[P6]
‘Parents need support and education about how to ‘Helping people make decisions in that crisis spot and deal with problems early on’ [FG3] period without having to go away and come back in six weeks … making decisions which have large impact’[P9]
Family
‘Positive reinforcement from family/carer … Grandparents … and also from school’ [FG1]
‘Nowadays … a child goes home and he gets into the ‘Families can solve their own problems if they bedroom, watches the TV, parents never talk together, are given that time and space’[P8] they don’t spend time with the child and the child doesn’t know what’s going on with the parent’ [FG3]
‘Family cohesion … doing more things together’ [FG3]
‘Supportive family and friends … raising awareness … making the child aware of all the topics’ [FG2]
Education
‘Emotional education such as being self-aware, being able to self-analyse and accept feelings can be good/bad’ [FG1]
‘Teachers having education and training on ‘Fostering a caring culture’[P14] managing children and YP’s emotional wellbeing and mental health issues such as bullying, poor self esteem … being able to identify those kids who are struggling early on’ [FG2]
‘I don’t know what is included in their education but teaching them about bullying, abuse’ [FG3]
‘Group work with YP … an understanding of what other people have to go through’[P4]
‘Start giving those tools to people from a young age in order to process how they feel’ [FG1]
‘If you have a culture of caring and being quite tough on any sort of bullying or alienation type behaviour … it keeps it under control’[P14]
Addressing perceived stigma surrounding seeking support
‘Doing things together … we go to the gym together, we go swimming together’[P15]
‘I would like teachers to have education and training in promoting and supporting confidence and self-esteem in teenagers’[P12]
‘Parenting class sounds like school and you go to school to be taught things … you’re not a good enough parent’[P7]
‘The name of the group, if the name is something like Depression Society’ [FG2]
‘I think we need to get over the fact that you are going to visit … not being ashamed … advertising not to be embarrassed, to admit there’s something wrong and they need support … It’s to do with confidence … confidentiality’ [FG2]
‘It’s not like your weakness, everyone goes through it, it’s the fact of the stigma there is to it’ [FG3]
‘Advice services that do not have a negative label … youth workers that have experience and can give advice that are not seen as stigmatising if you go to see them’[P11]
EWB: emotional wellbeing; YP: young people.
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Peer Review Emotional wellbeing and mental health: an exploration into health promotion in young people and families
Table 1 An indicative lay-informed recipe for successful promotion of EWB. Overall goal
Possible interventions/supportive actions
Raise awareness of EWB among teachers and YP
Formal training within teacher training and in continuing professional development (CPD)
To support and enable learning discussions about emotional issues
School-based activities such as discussions of EWB in PSHE (personal, social and health education), peer support (YP as mentor and mentee)
YP learning about emotional issues and their normality in teenagehood
Develop parents own understanding about YP’s EWB
Non-stigmatised initiatives to support discussions with other parents, both within the school and the community at large
Reduce stigma to discussing EWB by YP and parents
YP learning and discussing with their peers in PSHE and other school-based activities about EWB
To promote discussion of EWB issues between YP
Initiatives to enable YP peer mentoring within school and elsewhere
To promote discussion of EWB of the YP and their parents
Provision of community-based support groups, opportunity for oneto-one discussions and drop-ins
Parents providing peer support to one another and other sets of parents
Parents demonstrating ‘emotional loving’ for their YP
Parents creating more ‘family time’ and doing things together with the YP
Reduce stigma about access and raise awareness of help and Positive marketing of services, as places that provide supportive advice services for YP and parents in schools and the community services for all YP and parents (including youth clubs, school counselling services, healthcare services and parenting classes and provision of a career coach in schools) To enable its easier access
Initiatives to involve YP and parents in the design of such marketing and in the names of services (e.g. parental support classes or drop-in sessions vs parenting classes/sessions)
To enable early access to its services
Change attitudes in the community and society in general to YP
Provision of places to ‘hang-out’ in the locality
To create a more positive attitude to YP and enable and value their engagement in community activities
Provision of opportunities for inter-generational activities in community activities – such as sports clubs, pursuit of hobbies
To enhance the YP’s sense of belonging to the community
Associated challenges Expectations placed on the YP (by themselves, their parents, the school and society at large) to become financially independent, achieve educationally and adopt socially acceptable ways to behave in the community and society in general. EWB: emotional wellbeing; YP: young people.
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Peer Review Emotional wellbeing and mental health: an exploration into health promotion in young people and families Both sets of participants talked about a perceived lack of services or not knowing where services were. They argued that universal support services would be a positive way forward if these were accessible, appropriate and effective. They also discussed the importance of being able to access youth-friendly activities and hobbies, including non-competitive sports or dance activities, as well as youth clubs, which were seen to be a good resource that should be available to all. They wanted to feel a sense of belonging when in a group activity; alongside, parents recognised the importance of their YP fitting in. While parents lamented the seeming demise of youth clubs, YP perceived these to be aimed at problem kids and not a place for the average YP. Parenting was a key topic of discussion for both groups. Professional support and guidance was seen to be problematic for parents, with a stigma attached to parenting classes; these were perceived as negative and needed only for people with problem or vulnerable children. Parents, however, acknowledged how useful it would be to gain support and advice on parenting of the average child or teenager and discussed ‘parenting support’ as a more favoured term and approach, suggesting that it could come from both formal and informal sources within the community, either in groups, as a drop-in or one to one. YP, although calling for their freedom and autonomy, also argued that being loved and spending time doing things together with the family was vital. They were keen to point out that parents should tell their child they were loved as well as show them. They called for ‘emotional loving’ rather than just buying them ‘stuff’ to show they were loved. Central to YP and parents was the creation of more quality time for the family. YP expressed concern about the lack of time parents tended to spend with their children; conversely, parents lamented how much they craved to spend more time with them.
School was identified by both sets of participants as valuable for promoting, supporting and managing emotional health issues, but they felt that many teaching staff were ill-prepared for this role. Parents called for teaching/school staff to have raised awareness of the need to promote EWB, whereas YP called for teachers’ formal education about EWB within teacher-training programme.25 YP argued that education about emotions should be taught at school and to parents; learning about emotional health issues in school might reduce the perceived stigma associated with ‘problem’ mental health and help to raise community awareness generally about YP’s EWB. Overall, both sets of participants thought that support groups were a good idea, if marketed properly. However, the perceived attached stigma surrounding them and of seeking help for emotional issues needed to be overcome. YP cited issues of embarrassment, shame, lack of confidentiality and the actual names of the services themselves as barriers to seeking help. The perceived stigma became a barrier to YP or parents seeking help and support.
Discussion The voices of YP and parents of YP were the focus of this study aimed at addressing a major gap in the research literature. The findings portray a lay perspective of the meaning of EWB and give an insight into the support participants would value to promote YP’s EWB. While recognising the exploratory and small-scale nature of the study, the findings provide rich and deep insight into a lay view grounded in the views of YP and parents of YP. These both cohere with and add to existing knowledge in the area and provide pointers towards a recipe for the successful promotion of EWB in YP. Overlapping concepts between this study’s participants and previous empirical studies with YP are evident, such as being empathic, achieving, coping and being optimistic. Little
difference is apparent between the overall definitions of parents and YP and existing professional expositions.2,14,35–37 Additional aspects were however raised. The YP emphasised EWB as being subjective, changeable and dependent on day-to-day issues, and thus perceptions of success were personal. Parents talked about their own YP being able to communicate their emotions and feelings, this being seen as a sign of good EWB, along with being grounded and on an even keel, as symbols of stability in their YP. The parental findings provide new insight into the impact on parents of their own YP’s EWB. Areas mentioned included the impact of their YP’s mood, their relationships with friends and their behaviour, both at home and at school, one parent depicting these as ‘absorbing their emotions’. YP’s communication, or lack of, was also a major discussion point, with many parents despairing at the lack of desire of their YP to be involved with the rest of the family. Parents pointed to a host of strategies for re-involving their YP. As one parent stated the teenage years can be epitomised by them ‘going over to the dark side of the moon’ and returning when they desire to re-engage with family and life. Conversely, the YP emphasised the importance and need to promote family time and its being a precursor of family EWB and good parenting. A number of other areas of valued support were emphasised, all adding to knowledge in the area. First, an important role was suggested for services such as drop-ins and peer mentorship within the community or school setting. Second, schools were seen as a potential source of support, with both YP and parents calling for formal education for parents and YP on EWB. YP also suggested that education about emotional health issues should become part of teacher-training programmes;38 this, they felt, would enable the normalisation of discussions about EWB and encourage earlier helpseeking. One perhaps surprising omission in the findings was study participants’ general
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Peer Review Emotional wellbeing and mental health: an exploration into health promotion in young people and families disregard for the role and potential of health services, as currently provided. Healthcare services were seen as illness services and not a place to go for emotional support ‘when you are emotionally wobbly’. Both parents and YP reported not knowing where to go for help. They pointed to the need for effective and sensitive marketing of services, to promote awareness and reduce potential stigma about their use. This has potentially important implications for policy and practice. To draw the findings together, Table 1 presents a summary of an indicative, layperceived set of components of a recipe for the successful promotion of EWB to help inform future public health decisionmaking and practice. While this represents the views of a small set of YP and parents in one exploratory study, the recipe has potential public health policy and practice significance in its emphasis of factors perceived as significant by YP and parents of YP. Five main areas or goals to be achieved were identified, with a common core centred on initiatives to raise awareness and understanding of YP’s EWB, in the YP themselves, their parents, schools and the wider community. The aim was to promote recognition of the normality of YP experiencing and expressing stress, anxiety, unhappiness and relationship problems. The provision of places to ‘hang-out’ and promotion of intergenerational activities might also promote a sense of community citizenship, ‘fitting in’ being seen as vital for YP’s EWB.39–41 Key components of their suggestions included peer support, for YP to each other and for parents to other parents (e.g. parents sharing strategies for managing EWB
challenges); parenting support, especially for parents who might not have close friends or family, an approach currently only advocated or evaluated in younger children;42 and enhancing positive marketing of services, thus reducing the stigma associated with accessing support and advice services, including healthcare services. The study has both strengths and limitations. Areas of strength include giving voice to YP and parents of YP; the flexibility of using Skype to conduct interviews with parents located in a different country to the location of the researcher; and the chosen sampling and data collection methods enabling insight into current and retrospective reflections on YP’s EWB. There are also some study limitations. First, due to the lead researcher’s location and in order to protect the anonymity of participants, the voices of YP and parents came from two different countries; however, both shared common cultural and educational features. Second, the sample size was small, requiring care in interpretation and extending the findings to other settings; thus, the findings are indicative, not definitive. At the same time, this small sample size and data collection methods enabled the generation of rich and illuminative findings on lay perspectives of YP’s EWB and of parental views, thus beginning to address a gap in existing research literature. Third, the retrospective reflections may be reconstructions of the past or provide a more optimistic viewpoint, forgetting the dramas and traumas of teenage-hood. To overcome these weaknesses, a larger sample needs to be investigated, in particular, with participants based in the same country and a more diverse set of YP and parents of YP. In addition,
research could adopt a longitudinal perspective, following a sample of YP and parents of YP through the teenage years, examining changes and influences on their EWB.
CONCLUSION The findings of this small-scale qualitative research study have begun to identify lay perspectives on YP’s EWB and outline a lay-informed recipe for successful promotion of EWB in YP, to inform policy and practice. Participants identified a range of important factors that if acted upon in practice would provide an opportunity for younger children and YP to benefit in the future. Given the criticality of YP’s EWB, exploring the precursors to mental ill health is important and to identify ways to enhance strong EWB and thus to prevent mental and other social adjustment problems. Further research is needed on YP and parents of YP to enable the development of acceptable strategies to support the development of successful EWB.
Acknowledgements Ethical approval for the parent interviews was obtained from the School of Healthcare at the University of Leeds; for the YP focus group participants from the Directors and Chief Executive of the hospital trust, where the students studied. Grateful acknowledgement and thanks are given to those people who gave their time to help explore this topic and for support from colleagues in the School of Healthcare. This research was undertaken as part of post-graduate MPhil study with the University of Leeds. This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
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determinants of health related quality of life in childhood and adolescence: Results from a European study. Journal of Epidemiology and Community Health 2006; 60: 130–5. 22. Save the Children State of the World’s Mothers Champions for Children, 2011, Westport, CN: Save the Children. 23. Kendall S, Blookfield L. Developing and validating a tool to measure parenting selfefficacy. Journal of Advanced Nursing 2005; 51(2): 174–81. 24. The Children’s Society. Understanding Our Children’s Well-Being. London: The Children’s Society, 2010. 25. Department for Children, Schools and Families. Promoting the Emotional Health of Children and Young People. Guidance for Children’s Trust Partnerships, Including How to Deliver NI 50. London: HMSO, 2010. 26. Coverdale GE. Talking about Emotional Wellbeing: An Exploration into Its Promotion in Children, Young People and Families. MPhil Thesis, University of Leeds, Leeds, 2013. 27. Carter SM, Little M. Justifying knowledge, justifying method, taking action: Epistemologies, methodologies, and methods in qualitative research. Qualitative Health Research 2007; 17: 1316–28. 28. Department for Education. Positive for Youth: A New Approach to Cross-Government Policy for Young People Aged 13 to 19. London: HMSO, 2010. 29. Richie J, Lewis J, Elam G. Designing and selecting samples. In: Richie J, and Lewis J (eds) Qualitative Research Practice. London: Sage, 2003, pp. 77–108. 30. Denzin NK, and Lincoln YS. (eds). Collecting and Interpreting Qualitative Materials, 2nd edn. Thousand Oaks, CA: Sage, 2003. 31. Kidd PS, Parshall MB. Getting the focus and the group: Enhancing analytical rigor in focus group research. Qualitative Health Research 2000; 10(3): 293–308. 32. Kvale S. Interviews. Thousand Oaks, CA: Sage, 1996. 33. Collaizzi P. Psychological research as the phenomenologists view it. In: Valle R, and King M (eds) Existential Phenomenological
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onal wellbeing and mental healthEmotional wellbeing and mental health
Peer Review Emotional wellbeing and mental health: an exploration into health promotion in young people and families
Emotional wellbeing and mental health: an exploration into health promotion in young people and families Authors Gillian E Coverdale School of Healthcare, University of Leeds, Leeds, UK Andrew F Long School of Healthcare, University of Leeds, Rm 1.11 Baines Wing, Leeds LS2 9UT, UK Email: [email protected] Corresponding author: Andrew F Long, as above
Keywords emotional wellbeing; health promotion; young people; parents; family; qualitative research
Abstract Aims: Promoting mental health and emotional wellbeing (EWB) in children and young people (YP) is vitally important for their psycho-social development. Critical review of the literature reveals a dearth of research that has explored the perspective of the child, adolescent or adult in this concept, with much research being intervention focused and promoted at crisis level. The current study aims to address this gap in understanding of young persons’ and parents’ perspectives. Method: A small-scale, exploratory qualitative study was conducted with YP, and parents of YP aimed at exploring the meaning of EWB and how it could be promoted. Data were collected via focus groups with 15 YP (aged 18–24 years) and 15 interviews with parents of a different group of YP. Results: Study participants identified key constructs for good EWB as stability, coping ability, happiness, confidence, balance, empathy and being grounded. Feeling comfortable with self, managing and controlling emotions and having the confidence to persevere with challenges were all felt to contribute to a positive sense of EWB. Sources of support were overwhelmingly cited as family and friends, with schools identified as a potentially good environment for supporting and promoting the EWB of pupils. Participants stressed the need for a positive attitude change towards YP, advocating this as promoting a sense of belonging and community citizenship. A lay-informed ‘recipe’ for successful EWB promotion is drawn out, centred on the core goal of raising awareness and understanding of YP’s EWB, in the YP themselves, their parents, schools and the wider community. Conclusions: This research provides key messages for society, policy makers, education and public health and healthcare practitioners for integration into the delivery of services for YP and families that include education on supporting EWB, activities for YP and a multi-agency approach to supporting families within the community.
Introduction The last two decades have seen a growing body of seminal work exploring emotional and mental health and wellbeing, but a dearth of good quality research and evaluations on promoting emotional wellbeing (EWB) in young people (YP) in the United Kingdom.1–5 There still remains a lack of agreement over its definition.6–8 EWB is defined by the World Health Organization (WHO)9 as a state of wellbeing in which the individual realises their own abilities, can cope with the normal
stresses of life, work productively and fruitfully and is able to make a contribution to the community. The Health Development Agency further argues that EWB is ‘a holistic, subjective state which is present when a range of feelings, among them energy, confidence, openness, enjoyment, happiness, calmness and caring, are combined and balanced’.10 Policy and research literature acknowledges varying aspects of EWB. For example, the National Institute for Health and Care Excellence
Copyright © Royal Society for Public Health 2014 January 2015 Vol 135 No 1 l Perspectives in Public Health 27 SAGE Publications Downloaded from rsh.sagepub.com at NORTHERN ARIZONA UNIVERSITY on June 18, 2015 ISSN 1757-9139 DOI: 10.1177/1757913914558080
Peer Review Emotional wellbeing and mental health: an exploration into health promotion in young people and families (NICE)11,12 state in their policy guidance that promoting YP’s social and EWB encompasses: •• Psychological wellbeing/good mental health – the feeling of autonomy and control over one’s life, problemsolving skills, resilience, attentiveness and a sense of involvement with others. •• Social wellbeing – the ability to have good relationships with others and to avoid disruptive behaviour, delinquency, violence or bullying. •• EWB – happiness, confidence and not feeling depressed. Adi et al.4 argue that psychological wellbeing involves having self-efficacy, itself comprising high self-esteem, power and control, confidence and positive beliefs about the ability to change a situation and succeed. Uskul and Greenglass13 suggest that psychological wellbeing involves an absence of depression, a high life satisfaction, coping capacity and optimism; good psychological wellbeing becomes a sound indicator of how someone will cope in a stressful situation. Thus, EWB is both separate from mental (ill) health and comprises good mental health within its scope. As Rees14 argues within the context of clinical paediatric care, EWB is recognised rather than defined precisely; moreover, as in the NICE definition above, it is multi-faceted, with its interrelating elements being on a spectrum from optimum to damaging. Much of the existing research on EWB is North American or Australasia based, intervention focused and promoted at crisis level, for example, addressing low self-esteem, self-harm and attempted suicide. Moreover, the meaning of EWB is largely professionally defined, with limited insight into the views of YP or parents of YP, despite a plethora of information on the health and wellbeing needs of pre-adolescent young children, with advocacy for a concentration of resources in the early years.15–18 As Coleman et al.3 argue, it is questionable whether the constructs of emotional health and wellbeing in adults are the
same as those applied to YP. Indeed, Sir Ian Kennedy’s policy review commented that one of the biggest obstacles for YP is the lack of recognition of them as different from children, as well as adults.6 Yet in some contexts, such as protection from sexual exploitation, violence and conflict with the law, adolescents have the greatest needs.19 There is also little investment and health and welfare assistance provided to YP. Furthermore, it is important to note that existing research on YP has often equated ‘mental health’ with ‘mental ill health’ and is therefore negative.1,3 There is a similar dearth of research evidence on the views of parents of YP, despite recognition of the vital contribution parents make in developing their children’s mental health and EWB, along with the need to support parental EWB.20, 21,22 The limited parental research has focused on parenting in small children or parental management of vulnerable children and YP, with little insight provided into factors that are important in the development of EWB.1–5 Parenting is a multiplex concept, with cultural and social contextualisation23 influencing the type of parenting and the success of parenting. However, picking up the skills and knowledge on how to be a ‘good enough parent’ is extremely ad hoc. However, it is well recognised that relationships within families is a key influencing factor on good emotional health and wellbeing.24,25 This article shares the findings of a study that aimed to address the gap in the evidence base, of hearing the voices of YP and those of parents of YP and gaining insight into their perceptions about EWB and factors that may promote and protect it. This article thus explores the meaning of EWB to a sample of YP and parents of YP, comparing this to the professional perspective and discusses how this sample of participants believed EWB may be protected and promoted.
Methods A small-scale exploratory qualitative study, undertaken as part of a research
degree at the University of Leeds,26 was designed to explore the meaning of EWB and ways that it can be promoted from the perspective of YP and parents of YP. The exploratory study aimed to ‘elucidate the essence of the meaning’27 that EWB held for these two groups, an area lacking in current literature. The research required the involvement of two distinct sets of participants – parents and YP. To ensure anonymity and enhance confidentiality, participation and disclosure, recruited parents needed not to be the parents of the recruited YP. For both groups, a purposive sampling approach was used. All parents had to have experienced bringing up children through their teenage years within the last five years, leading to the selection criteria of parents of YP aged between 17 and 24 years. YP between these ages were also selected; they would still be able to reflect upon life in their teens. Involving YP between these ages is highly appropriate as it is during late adolescence that YP start to disengage from their families, beginning the gradual transition towards economic and emotional independence and also a transitional time of cognitive and social development.28 In view of the exploratory nature of the study and in line with guidelines provided in qualitative research,29 a sample of about 20 or so YP and similar numbers of parent interviews would be an appropriate and sufficient sample size providing rich and informative insights into the perceptions of EWB of a set of potentially diverse YP and parents. For reasons of practicality and resource constraints, a convenience sample was recruited from cohorts of student nurses in the researcher’s work location in a British Colony. Subsequent to a verbal introduction to the research project and an information sheet to interested students, 15 YP, aged 18– 24 years, agreed to take part. No coercion or other pressure was consciously placed on any student to participate. Three focus groups were held with an average of five students per focus group. Conducting a group interview with a small number of
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Peer Review Emotional wellbeing and mental health: an exploration into health promotion in young people and families well-informed participants can be more informative than a larger sample.30 Focus groups enable participants to share their views within a common frame of reference, challenging and influencing each other and commiserate if necessary.31 Given the size and close knit nature of the Colony’s population, parent participants, of a separate group of YPs, were recruited from the researcher’s base country, the United Kingdom, using snowball sampling. The first invitation was extended to people (via a group e-mail using the blind copy facility) who were known to the researcher to have at least one child in the chosen age range, thus ensuring experience of bringing up children through their teenage years within the last five years. These participants were asked to invite their own friends and colleagues who fitted the inclusion criteria. A total of 15 parents were recruited, and individual semistructured, Skype-based interviews were conducted. Over half of the parent participants still had YP of school age, some of whom were the siblings of their older children in the family who fell within the criteria for participation. This approach facilitated a ‘recent’ retrospective and sometimes concurrent view. The research interviews were perceived and conducted as a conversation about the real-life world of the participants, with the verbal discourse tape recorded and subsequently transcribed for later analysis and interpretation.32 To ensure reliability, a common topic guide was used for the focus groups and individual interviews, so that comparisons between the responses could be made. This explored the following areas in a flexible manner, being responsive to the flow of the conversations: •• What does EWB mean? •• What feelings are associated with EWB? •• What kinds of life events influence EWB? •• What sources of support could influence EWB in a positive way? •• What kinds of support would be useful?
In order to look for common themes within the categories explored in the interviews, the principles of Collaizzi’s33 seven-step data analysis framework were utilised, using thematic content analysis.34 Each transcript was read and re-read, key phrases noted and coded within each of the topic/interview guides and significant statements highlighted that emphasised the theme. A set of lower level themes was developed leading to the gradual emergence of a set of higher-level themes. The analysis was primarily undertaken by the lead author, emerging themes discussed with the second author and agreed refinements made. This article focuses on a sub-set of these questions, aimed at illustrating the meaning of EWB to YP and parents of YP and sources of support they would find useful, leading onto the identification of a lay-informed recipe for successful EWB promotion and support.
RESULTS The meaning of EWB to YP and parents of YP Both YP and parents of YP described feelings of EWB as being on a continuum from very poor to very good and that it was okay to feel that range of emotions (Box 1). Both groups discussed stability, happiness, ability to cope, being confident and comfortable with ‘who you are’ and ‘where you fit in’ and being empathic as being key to good EWB. Being able to enjoy life was also acknowledged as subjective and dependent upon what was happening in their lives and not a fixed state. For YP, stability was linked to coping, confidence, empathy and being able to control and manage their range of emotions. For parents, stability was perceived to be more likely in a YP who was balanced, grounded, able to cope, resilient, able to take risks, deal with challenges and manage their emotions. Both YP and parents discussed the importance of being able to rationalise and manage the fluctuation of emotions, without allowing their response to these emotions to be extreme. Achieving and being successful was important, with
both YP and parents mentioning Maslow’s35 hierarchy of needs when discussing accomplishment and selfactualisation. For both YP and parents, feeling confident and comfortable with self was perceived as a key component of good EWB. For YP, this also influenced their management of expectations, along with their perception of life’s challenges. Parents felt it helped YP to communicate their feelings and to problem solve. Empathy was seen by both YP and parents to be a positive aspect of EWB and being able to understand other people’s emotions as well as their own. Parents expressed their pride when their YP showed empathy with and for others.
Useful sources of support A large range of ideas were raised by participants for supporting EWB and areas they felt needed to change. Promoting good citizenship and support for being a good parent were important themes for parents. For YP, the family, school and the community, and a need to address perceived stigma associated with accessing support services were central. Both groups discussed the importance of giving or gaining praise and encouragement and being loved as essential, both as a defining aspect and as a supportive element of EWB that helped to promote the YP’s positivity, engagement and confidence to try new things (Box 2). YP and parents of YP discussed the importance of good citizenship and a need for a cultural change in societal attitudes towards YP. Parents recognised that the engendering of respect was something that needed addressing between YP and the older generation, citing seeking opportunities to meet together socially and undertaking voluntary work as a way forward. YP talked about society as a whole and wanting to be accepted as the person they were. Parents wanted services that would provide early and non-stigmatising help and support for YP, such as advice or drop-in sessions within the community.
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Box 1 The meaning of EWB to YP and parents Theme/concept
YP’s illustrative extract
Parents’ illustrative extract
Being stable and able to cope
‘If you are emotionally okay if a problem comes … it’s a challenge and you get over it and you move on’ [FG1]
‘Being centred, grounded. Knowing who you are and how and where you fit in … Resilient’[P15]
‘Being stable … we really can cope’ [FG3]
‘Being on an even keel’[P5,P6]
‘That balance of the right life event will make ‘If they have security and they feel loved and you happy but not OTT or something like that’ nurtured at home … become more emotionally [FG2] stable’[p5]
‘Doing things rationally, not being emotional, like make it bigger than it actually is … As human beings we have to manage the daily balance of life’ [FG2]
‘Not experiencing great extremes of emotion … not being emotionally sterile either’[P11]
Being comfortable with self
‘Accepting what comes – being happy with who you are’ [FG1]
‘Being at one with yourself to the point where you can deal with things that come up without it causing a dramatic trauma’[P9]
‘Feeling good with yourself, happy, confident’ [FG3]
‘How you feel about yourself how you fit with the world out there … that ability to express how you feel’[P3]
‘Feeling comfortable in your … own skin’ [FG3]
Having empathy for others
‘If you have a positive wellbeing it reflects into someone else and … you get it back’ [FG1]
‘If you behave with some grace and dignity then that is reflected back’[P15]
‘Trying to understand other people’s feelings … or understanding somebody else’s emotions’ [FG2]
‘They (his friends) find him really supportive …’[P15]
‘If you don’t understand your own emotions … you won’t be able to help or understand others’ [FG2]
Being successful
‘Doing things well, that you think you should be doing well’ [P2] [FG2]
‘He seemed to have this goal of wanting to do Grade 5 … and he’s achieved it … great’[P3]
‘Also feeling like you’ve reached your level, you feel you have accomplished things … Yeah like Maslow’s hierarchy … selfactualised’ [FG3]
On a continuum
‘It is on a continuum from very sad to very happy with all the emotions between’ [FG3]
‘Emotions run through a spectrum … a perfectly natural thing … we cannot be happy all the time’[P13]
‘It can vary from day-to-day or moment-tomoment, something that can go from being good to bad in seconds and then revert itself back’ [FG3]
EWB: emotional wellbeing; YP: young people.
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Box 2 Potential useful sources of support for EWB. Theme/concept
YP quotes
Parent quotes
Community and citizenship
‘To be more accepted of what we want to be instead of fitting some ideal that the older generation feel we should fit into’ [FG1]
‘I’d like to think that society can celebrate YP’[P3]
‘When you’re younger especially … interacting with kids … your own age group outside school with similar hobbies … help your sense of belonging’ [FG3]
‘Have a real sense of community … have a village hall … things going on all the time … a sense that people feel they belong to the community’[P12]
‘Getting feedback off other people … acknowledgement … Someone tells you “look you have done well here”’ [FG3]
‘Respect for other people and other people’s property … encouraging them at an early age to respect others and with that brings respect for them’[P9]
‘He has done some voluntary work, and I think that the little bit he puts in actually is appreciated … able to learn to have a rapport and respect with some older folk’[P3]
Services and activities for YP
‘Counsellors … more available … to be referred to or self-refer’ [FG3]
‘Counselling … there are just huge waiting lists so unless people can pay to go privately … there’s definitely a need for it’[P6]
‘And then from that you find good friends because they give you someone else to confide in and will support you … and other adults as well’ [FG2]
‘Access to a range of social activities and social venues … people around who know and understand YP because a lot of YP think nobody understands them’[P11]
‘“ChildLine” … a help line that is excellent’ [FG3]
‘People could do team activities, not necessarily competitive … just doing something you enjoy, without children being tested all the time’[P10]
‘Hobbies, such as sports, especially team sports and also things like the Duke of Edinburgh award, also Brownies/Girl Guides, they all give you a sense of belonging’ [FG2]
‘Other organisations like the scouts … guides for girls … some teenagers enjoy that and really stick with it’[P8]
‘They get a great opportunity to feel their place in the team … talk with their friends … they very much bond’[P3]
‘Outward Bound … team building things … away from the normal everyday stuff … being able to achieve something different and learn resilience as well’[P4]
Parenting support
‘Educating parents to identify when … their child is being bullied or … when they’re stressed … some parents don’t know what to do’ [FG3]
‘You need someone to say you are not nagging you are doing them good in the long run’[P10]
(continued)
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Box 2 (continued) Theme/concept
YP quotes
Parent quotes
‘Emotional loving … not just to give them stuff … because then people will say I love my child so I buy them this’ [P2] [FG1]
‘I’d really like to … kind of debate some of the issues that we’re having … there’s nothing there in the prevention side, it’s always when there’s a problem’[P6]
‘Parents need support and education about how to ‘Helping people make decisions in that crisis spot and deal with problems early on’ [FG3] period without having to go away and come back in six weeks … making decisions which have large impact’[P9]
Family
‘Positive reinforcement from family/carer … Grandparents … and also from school’ [FG1]
‘Nowadays … a child goes home and he gets into the ‘Families can solve their own problems if they bedroom, watches the TV, parents never talk together, are given that time and space’[P8] they don’t spend time with the child and the child doesn’t know what’s going on with the parent’ [FG3]
‘Family cohesion … doing more things together’ [FG3]
‘Supportive family and friends … raising awareness … making the child aware of all the topics’ [FG2]
Education
‘Emotional education such as being self-aware, being able to self-analyse and accept feelings can be good/bad’ [FG1]
‘Teachers having education and training on ‘Fostering a caring culture’[P14] managing children and YP’s emotional wellbeing and mental health issues such as bullying, poor self esteem … being able to identify those kids who are struggling early on’ [FG2]
‘I don’t know what is included in their education but teaching them about bullying, abuse’ [FG3]
‘Group work with YP … an understanding of what other people have to go through’[P4]
‘Start giving those tools to people from a young age in order to process how they feel’ [FG1]
‘If you have a culture of caring and being quite tough on any sort of bullying or alienation type behaviour … it keeps it under control’[P14]
Addressing perceived stigma surrounding seeking support
‘Doing things together … we go to the gym together, we go swimming together’[P15]
‘I would like teachers to have education and training in promoting and supporting confidence and self-esteem in teenagers’[P12]
‘Parenting class sounds like school and you go to school to be taught things … you’re not a good enough parent’[P7]
‘The name of the group, if the name is something like Depression Society’ [FG2]
‘I think we need to get over the fact that you are going to visit … not being ashamed … advertising not to be embarrassed, to admit there’s something wrong and they need support … It’s to do with confidence … confidentiality’ [FG2]
‘It’s not like your weakness, everyone goes through it, it’s the fact of the stigma there is to it’ [FG3]
‘Advice services that do not have a negative label … youth workers that have experience and can give advice that are not seen as stigmatising if you go to see them’[P11]
EWB: emotional wellbeing; YP: young people.
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Table 1 An indicative lay-informed recipe for successful promotion of EWB. Overall goal
Possible interventions/supportive actions
Raise awareness of EWB among teachers and YP
Formal training within teacher training and in continuing professional development (CPD)
To support and enable learning discussions about emotional issues
School-based activities such as discussions of EWB in PSHE (personal, social and health education), peer support (YP as mentor and mentee)
YP learning about emotional issues and their normality in teenagehood
Develop parents own understanding about YP’s EWB
Non-stigmatised initiatives to support discussions with other parents, both within the school and the community at large
Reduce stigma to discussing EWB by YP and parents
YP learning and discussing with their peers in PSHE and other school-based activities about EWB
To promote discussion of EWB issues between YP
Initiatives to enable YP peer mentoring within school and elsewhere
To promote discussion of EWB of the YP and their parents
Provision of community-based support groups, opportunity for oneto-one discussions and drop-ins
Parents providing peer support to one another and other sets of parents
Parents demonstrating ‘emotional loving’ for their YP
Parents creating more ‘family time’ and doing things together with the YP
Reduce stigma about access and raise awareness of help and Positive marketing of services, as places that provide supportive advice services for YP and parents in schools and the community services for all YP and parents (including youth clubs, school counselling services, healthcare services and parenting classes and provision of a career coach in schools) To enable its easier access
Initiatives to involve YP and parents in the design of such marketing and in the names of services (e.g. parental support classes or drop-in sessions vs parenting classes/sessions)
To enable early access to its services
Change attitudes in the community and society in general to YP
Provision of places to ‘hang-out’ in the locality
To create a more positive attitude to YP and enable and value their engagement in community activities
Provision of opportunities for inter-generational activities in community activities – such as sports clubs, pursuit of hobbies
To enhance the YP’s sense of belonging to the community
Associated challenges Expectations placed on the YP (by themselves, their parents, the school and society at large) to become financially independent, achieve educationally and adopt socially acceptable ways to behave in the community and society in general. EWB: emotional wellbeing; YP: young people.
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Peer Review Emotional wellbeing and mental health: an exploration into health promotion in young people and families Both sets of participants talked about a perceived lack of services or not knowing where services were. They argued that universal support services would be a positive way forward if these were accessible, appropriate and effective. They also discussed the importance of being able to access youth-friendly activities and hobbies, including non-competitive sports or dance activities, as well as youth clubs, which were seen to be a good resource that should be available to all. They wanted to feel a sense of belonging when in a group activity; alongside, parents recognised the importance of their YP fitting in. While parents lamented the seeming demise of youth clubs, YP perceived these to be aimed at problem kids and not a place for the average YP. Parenting was a key topic of discussion for both groups. Professional support and guidance was seen to be problematic for parents, with a stigma attached to parenting classes; these were perceived as negative and needed only for people with problem or vulnerable children. Parents, however, acknowledged how useful it would be to gain support and advice on parenting of the average child or teenager and discussed ‘parenting support’ as a more favoured term and approach, suggesting that it could come from both formal and informal sources within the community, either in groups, as a drop-in or one to one. YP, although calling for their freedom and autonomy, also argued that being loved and spending time doing things together with the family was vital. They were keen to point out that parents should tell their child they were loved as well as show them. They called for ‘emotional loving’ rather than just buying them ‘stuff’ to show they were loved. Central to YP and parents was the creation of more quality time for the family. YP expressed concern about the lack of time parents tended to spend with their children; conversely, parents lamented how much they craved to spend more time with them.
School was identified by both sets of participants as valuable for promoting, supporting and managing emotional health issues, but they felt that many teaching staff were ill-prepared for this role. Parents called for teaching/school staff to have raised awareness of the need to promote EWB, whereas YP called for teachers’ formal education about EWB within teacher-training programme.25 YP argued that education about emotions should be taught at school and to parents; learning about emotional health issues in school might reduce the perceived stigma associated with ‘problem’ mental health and help to raise community awareness generally about YP’s EWB. Overall, both sets of participants thought that support groups were a good idea, if marketed properly. However, the perceived attached stigma surrounding them and of seeking help for emotional issues needed to be overcome. YP cited issues of embarrassment, shame, lack of confidentiality and the actual names of the services themselves as barriers to seeking help. The perceived stigma became a barrier to YP or parents seeking help and support.
Discussion The voices of YP and parents of YP were the focus of this study aimed at addressing a major gap in the research literature. The findings portray a lay perspective of the meaning of EWB and give an insight into the support participants would value to promote YP’s EWB. While recognising the exploratory and small-scale nature of the study, the findings provide rich and deep insight into a lay view grounded in the views of YP and parents of YP. These both cohere with and add to existing knowledge in the area and provide pointers towards a recipe for the successful promotion of EWB in YP. Overlapping concepts between this study’s participants and previous empirical studies with YP are evident, such as being empathic, achieving, coping and being optimistic. Little
difference is apparent between the overall definitions of parents and YP and existing professional expositions.2,14,35–37 Additional aspects were however raised. The YP emphasised EWB as being subjective, changeable and dependent on day-to-day issues, and thus perceptions of success were personal. Parents talked about their own YP being able to communicate their emotions and feelings, this being seen as a sign of good EWB, along with being grounded and on an even keel, as symbols of stability in their YP. The parental findings provide new insight into the impact on parents of their own YP’s EWB. Areas mentioned included the impact of their YP’s mood, their relationships with friends and their behaviour, both at home and at school, one parent depicting these as ‘absorbing their emotions’. YP’s communication, or lack of, was also a major discussion point, with many parents despairing at the lack of desire of their YP to be involved with the rest of the family. Parents pointed to a host of strategies for re-involving their YP. As one parent stated the teenage years can be epitomised by them ‘going over to the dark side of the moon’ and returning when they desire to re-engage with family and life. Conversely, the YP emphasised the importance and need to promote family time and its being a precursor of family EWB and good parenting. A number of other areas of valued support were emphasised, all adding to knowledge in the area. First, an important role was suggested for services such as drop-ins and peer mentorship within the community or school setting. Second, schools were seen as a potential source of support, with both YP and parents calling for formal education for parents and YP on EWB. YP also suggested that education about emotional health issues should become part of teacher-training programmes;38 this, they felt, would enable the normalisation of discussions about EWB and encourage earlier helpseeking. One perhaps surprising omission in the findings was study participants’ general
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Peer Review Emotional wellbeing and mental health: an exploration into health promotion in young people and families disregard for the role and potential of health services, as currently provided. Healthcare services were seen as illness services and not a place to go for emotional support ‘when you are emotionally wobbly’. Both parents and YP reported not knowing where to go for help. They pointed to the need for effective and sensitive marketing of services, to promote awareness and reduce potential stigma about their use. This has potentially important implications for policy and practice. To draw the findings together, Table 1 presents a summary of an indicative, layperceived set of components of a recipe for the successful promotion of EWB to help inform future public health decisionmaking and practice. While this represents the views of a small set of YP and parents in one exploratory study, the recipe has potential public health policy and practice significance in its emphasis of factors perceived as significant by YP and parents of YP. Five main areas or goals to be achieved were identified, with a common core centred on initiatives to raise awareness and understanding of YP’s EWB, in the YP themselves, their parents, schools and the wider community. The aim was to promote recognition of the normality of YP experiencing and expressing stress, anxiety, unhappiness and relationship problems. The provision of places to ‘hang-out’ and promotion of intergenerational activities might also promote a sense of community citizenship, ‘fitting in’ being seen as vital for YP’s EWB.39–41 Key components of their suggestions included peer support, for YP to each other and for parents to other parents (e.g. parents sharing strategies for managing EWB
challenges); parenting support, especially for parents who might not have close friends or family, an approach currently only advocated or evaluated in younger children;42 and enhancing positive marketing of services, thus reducing the stigma associated with accessing support and advice services, including healthcare services. The study has both strengths and limitations. Areas of strength include giving voice to YP and parents of YP; the flexibility of using Skype to conduct interviews with parents located in a different country to the location of the researcher; and the chosen sampling and data collection methods enabling insight into current and retrospective reflections on YP’s EWB. There are also some study limitations. First, due to the lead researcher’s location and in order to protect the anonymity of participants, the voices of YP and parents came from two different countries; however, both shared common cultural and educational features. Second, the sample size was small, requiring care in interpretation and extending the findings to other settings; thus, the findings are indicative, not definitive. At the same time, this small sample size and data collection methods enabled the generation of rich and illuminative findings on lay perspectives of YP’s EWB and of parental views, thus beginning to address a gap in existing research literature. Third, the retrospective reflections may be reconstructions of the past or provide a more optimistic viewpoint, forgetting the dramas and traumas of teenage-hood. To overcome these weaknesses, a larger sample needs to be investigated, in particular, with participants based in the same country and a more diverse set of YP and parents of YP. In addition,
research could adopt a longitudinal perspective, following a sample of YP and parents of YP through the teenage years, examining changes and influences on their EWB.
CONCLUSION The findings of this small-scale qualitative research study have begun to identify lay perspectives on YP’s EWB and outline a lay-informed recipe for successful promotion of EWB in YP, to inform policy and practice. Participants identified a range of important factors that if acted upon in practice would provide an opportunity for younger children and YP to benefit in the future. Given the criticality of YP’s EWB, exploring the precursors to mental ill health is important and to identify ways to enhance strong EWB and thus to prevent mental and other social adjustment problems. Further research is needed on YP and parents of YP to enable the development of acceptable strategies to support the development of successful EWB.
Acknowledgements Ethical approval for the parent interviews was obtained from the School of Healthcare at the University of Leeds; for the YP focus group participants from the Directors and Chief Executive of the hospital trust, where the students studied. Grateful acknowledgement and thanks are given to those people who gave their time to help explore this topic and for support from colleagues in the School of Healthcare. This research was undertaken as part of post-graduate MPhil study with the University of Leeds. This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
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