Introduction 

There is an emerging global emphasis on more comprehensive mental health promotion and intervention for children and youth in schools (WHO, 2007). This is partly due to the increase in mental health problems in the adolescent population (Bakken, 2018; Collishaw, 2015; O´Reilly, Svirydzenka, Adams & Dogra, 2018). For example, in Norway, 15% - 20 % of adolescents experience mental difficulties such as stress, depression, and anxiety which influence their everyday functioning, coping, and learning (Mykletun, Knudsen, & Mathiesen, 2009).

The school setting provides an efficient means of improving young people’s mental health (WHO, 1997). A whole-school approach is recognized as particularly efficient for mental health promotion in this population (Stewart-Brown, 2006). However, mental health education within schools is also of significant importance (O´Higgins, Galvin, Kennedy, Gabhainn, & Barry, (2013). The focus should be on wellbeing, quality of life, and life skills among other things. Implementing personal skills development in mental health education can help young people acquire and practise life skills that enable them to deal effectively with the psychological demands and challenges of everyday life. This means enhancing their wellbeing, which in the current study is defined as “a positive and sustainable mental state that allows individuals to thrive and flourish” (Clarke et al., 2011; WHO, 2014). Mental health education can be provided as a separate subject in the curriculum, as part of other subjects, or as a combination of the two (WHO, 1997). The intent of the present study is to shed light on mental health education.

The Irish education system mandates health education for all students; accordingly, Social, Personal and Health Education (SPHE) has been a compulsory subject since 2000. Research has shown that SPHE is valuable in school; all stakeholders agree that SPHE provides students with the opportunity to develop personal and social skills, promotes their self-esteem and wellbeing, contributes to their physical, mental and emotional health, and fosters  respect for others (O´Higgins et al., 2013). Furthermore, 65% of students agreed that the subject appealed to them.

In Norway, the focus on mental health literacy as part of the curriculum on a systematic basis has traditionally been minor. However, wellbeing and mental health literacy is now to become a key element in the new Norwegian school curriculum from 2020 (The Norwegian Directorate for Education and Training, 2018). Although several school-based programs aimed at mental health promotion are available both internationally (O´Reilly et al., 2018) and nationally (Klomsten, 2017), there is a strong need to work more systematically with mental health literacy within the school setting.

In Trondheim, Norway, we have developed and implemented a wellbeing subject entitled Education in mental health (EMH) for students in secondary school. EMH has a salutogenic foundation and was implemented as a separate subject in the secondary school timetable in 2017 (Klomsten, 2018). The core emphasis of EMH is on mental health literacy and especially on the components of understanding how to obtain and maintain good mental health and practicing good decision-making; an additional aim is enhancing students’ help-seeking efficacy (Kutcher, Wei, & Coniglio, 2016). There is an explicit need for research that investigates how students themselves experience mental health literacy education within a school setting. Thus, the aim of this study is to investigate the potential outcome of students who participated in a new school subject (EMH). The research questions are 1) What are the content and reflections that are communicated by the students after having attended EMH for one year? and 2) Has one year of EMH had significant effect on mental health variables such as knowledge, social support, mental health, mastery, help seeking strategies, and self-confidence?

Methods Students in one public school were enrolled in the school subject EMH during the 2017/2018 school year. These students attended one EMH class every week (each class lasted 60 minutes) over a period of 25 weeks. EMH was designed to align with and facilitate the educational principles that underpin the new Norwegian school curriculum (The Norwegian Directorate for Education and Training, 2018). The EMH class comprised a mixture of lectures, group related work, and guidance activities. Participants and procedure During the 2017/2018 school year, EMH was implemented as a separate subject in one public secondary school; this school is the focus of the present study. The study participants were a cohort of 164 students (85 boys, 79 girls) in 9th grade in one secondary school in mid-Norway. Informed consent forms were used for all participants. Measures Data was collected by two different methods. To gain insights into the content and priorities of reflections, we interviewed selected participants after they had completed one year of the mental health education programme (EMH). Individual semi-structured interviews were held with 16 students. The interviews were audiotaped with the permission of participants and written consents was obtained from the parents of the participants. Self-completion questionnaires were administered during class time to all students in 9th grade who participated in the study. The first questionnaire was administered before EMH education (T1) and the second questionnaire was administered after EMH education (T2). The questions were primarily closed, with a limited number of open-ended questions. In order to maximize the reliability and validity of the questions, some mental health questions were drawn from other studies such as the Hopkins Symptom Checklist (Derogatis, 1982; Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974), the Depressive Mood Inventory (Kandel & Davies, 1982), and the Self-Perception Profile for Adolescents (SPPA) (Harter, 1982). Questions about EMH were included, specifically those seeking the student view of the importance, interest, relevance, and usefulness of EMH. Questions about future EMH education were also included in the questionnaire. Data management The data collected from the questionnaires were primarily quantitative and were analysed using SPSS version 25.0. The qualitative interviews were transcribed and analysed according to guidelines for content analysis from Corbin & Strauss (2015).

Results 1) What are the content and reflections that are communicated by the students after having attended one year of mental health education in school? The students expressed their thoughts and feelings for EMH in different ways. The majority of students liked EMH very much, saying, “We have learned things that are important in our lives and we have learned information that we could use in the future”, “I have learned to understand how to deal with hard feelings and thoughts ”, and “I have learned to understand other people who are struggling in their lives”. Furthermore, 82% of the students liked EMH very much. The results are almost similar for boys and girls. 84% of students agreed that EMH should be a separate subject in the curriculum. 2) Does one year of mental health education have a significant effect on mental health variables such as knowledge, social support, mental health, mastery, help seeking strategies, and self-confidence? It is useful to have mental health literacy organized as a separate subject in the curriculum. EMH showed significant effect on the variables of mental health mastery and mental health literacy. An important finding is enhanced help-seeking behavior after EMH. Furthermore, the findings show that the students would like to continue EMH. They did, however, have some important suggestions for improvement. These included, allowing for more discussion time, placing more focus on the good things in life, and working with issues that arise regularly such as, “how to deal with stress and difficult thoughts.” The knowledge gained through this study may be a relevant contribution when it comes to designing new courses that support mental health and wellbeing for students in Norway or other European countries.

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