International Journal of

Environmental Research
and Public Health

Article
Development of a Proposal for a Program to Promote Positive
Mental Health Literacy among Adolescents: A Focus
Group Study
Joana Nobre 1,2,3, * , Helena Arco 1,4 , Francisco Monteiro 1 , Ana Paula Oliveira 1,2,5 , Carme Ferré-Grau 2
and Carlos Sequeira 5,6

1 Health School, Polytechnic Institute of Portalegre, 7300-555 Portalegre, Portugal

2 Faculty of Nursing, University of Rovira i Virgili, 43003 Tarragona, Spain
3 VALORIZA—Research Centre for Endogenous Resource Valorization, Polytechnic Institute of Portalegre,
7300-555 Portalegre, Portugal
4 Comprehensive Health Research Centre (CHRC), 7000-811 Évora, Portugal
5 Group Innovation & Development in Nursing (NursID), Centro de Investigação em Tecnologias e Serviços de
Saúde (CINTESIS), 4200-450 Porto, Portugal
6 Nursing School of Porto, 4200-072 Porto, Portugal
* Correspondence: [email protected]

Abstract: Over the last years, there have been several studies that have shown insufficient levels of
adolescents’ mental health literacy (MHL). Knowledge about intervention programs that promote
positive mental health literacy (PMeHL) among adolescents is still very scarce. In this sense, we
defined as objectives to identify and describe the necessary components to design a program proposal
that promotes adolescents’ PMeHL. We conducted an exploratory, descriptive, qualitative study using
two focus groups in July and September 2022 with an intentional non-probability sample of eleven
participants (nine professional experts and two adolescents). Data were analyzed using content analy-
sis, using NVivo® 12 software (version 12, QRS International: Daresbury Cheshire, UK). We obtained
Citation: Nobre, J.; Arco, H.; a total of four categories and eighteen subcategories: structure (context; format; contents; length and
Monteiro, F.; Oliveira, A.P.; frequency; pedagogical methods; pedagogical techniques; resources; denomination), participants
Ferré-Grau, C.; Sequeira, C.
(target group; program facilitators), assessment (timing; evaluation instruments), other components
Development of a Proposal for a
(planning, articulation and adaptation; involvement; training; special situations; partnerships; refer-
Program to Promote Positive Mental
ral). The perspectives of the professional experts and of the adolescents that we obtained from this
Health Literacy among Adolescents:
A Focus Group Study. Int. J. Environ.
study contributed to the design of a proposal for a program to promote adolescents’‘PMeHL.
Res. Public Health 2023, 20, 4898.
https://doi.org/10.3390/ Keywords: adolescents; mental health literacy; positive mental health; qualitative research
ijerph20064898

Academic Editor: Paul B.

Tchounwou
1. Introduction
Received: 29 January 2023 The mental health of adolescents has been a subject of interest in recent years, not
Revised: 7 March 2023 always for the best of reasons. The high prevalence of mental disorders is a reality [1,2],
Accepted: 8 March 2023 but above all, the insufficient level of mental health and mental health literacy among
Published: 10 March 2023
adolescents is a cause for concern [3–5].
We are aware that adolescence is a turbulent transitional period in the life of a human
being, because it is full of marked and rapid changes in biological terms, which are also
Copyright: © 2023 by the authors.
reflected in mental, psychological and emotional terms, and where brain neuroplasticity is
Licensee MDPI, Basel, Switzerland. high [2,6]. This is why adolescence is considered a privileged stage of human development
This article is an open access article for investment in the implementation of interventions to promote mental health literacy
distributed under the terms and (MHL) but especially to promote PMeHL [2,7–9].
conditions of the Creative Commons These concepts of health literacy (HL) and MHL have been gaining more expression
Attribution (CC BY) license (https:// and interest in the last decades, not only by health and education professionals, but also
creativecommons.org/licenses/by/ by researchers. According to the integrated model proposed by Sørensen et al. [10], HL
4.0/). refers to the “the knowledge, motivation and competencies of accessing, understanding,

Int. J. Environ. Res. Public Health 2023, 20, 4898. https://doi.org/10.3390/ijerph20064898 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2023, 20, 4898 2 of 16

appraising and applying health-related information within the healthcare, disease pre-
vention and health promotion setting, respectively” (p. 80), and is strongly based on the
dimensions of access, understanding and application of health-related information and
health services [11]. In turn, the concept of MHL was initially defined by Jorm et al. [12] and
has been updated over the years by Jorm and by Kutcher and colleagues; MHL currently
involves four dimensions: understanding how to achieve and maintain good mental health;
understanding mental disorders and their treatments; decreasing the stigma related to
mental disorders; and increasing the effectiveness of help seeking [13,14].
The concept of positive mental health (PMH) has also clearly emerged in recent years
in the health field, due to its salutogenic dimension, and although it does not have a
universal definition, it is related to an individual’s ability to understand themself and their
environment in order to optimize daily functioning in relation to themself and others [15].
Associated with this concept is the Multifactor Model of Positive Mental Health developed
by Lluch-Canut and consisting of six interrelated factors: personal satisfaction (Factor 1),
pro-social attitude (Factor 2), self-control (Factor 3), autonomy (Factor 4), problem solving
and self-actualization (Factor 5) and interpersonal relationship skills (Factor 6) [15].
Recently, Carvalho et al. [16] published a study on the conceptual analysis of PMeHL,
in which they concluded that it is a dynamic concept, that it is one of the components of men-
tal health literacy, and that it has the following attributes: competence in problem-solving
and self-actualization; personal satisfaction; autonomy; relatedness and interpersonal rela-
tionship skills; self-control; and prosocial attitude [16]. Thus, the relationship between the
concept of PMH and PMeHL is evident.
School has been recognized by several researchers as a privileged context for the
promotion of HL and MHL in children and adolescents [2,7,9,17–20], for being the environ-
ment where adolescents spend more time [19,21], for being a place where adolescents come
into contact with a huge diversity of people with diverse characteristics and ages [2,7], and
where they are more available and more curious to develop knowledge and competen-
cies [9,17].
Therefore, we must invest in interventions that promote adolescents’ PMeHL, so
that they acquire competencies that allow them to deal with and experience all of the
normal changes in this stage of human development in a healthy way, thus making a
huge contribution to the future of having mentally healthy and resilient adults [2,6,22].
This is a wake-up call for health professionals and education professionals to implement
interventions with adolescents, but also for researchers to build those interventions.
In this sense, and continuing our research to date in this area, we gathered a group
of experts and sought to explore their perspectives on a PMeHL program for adolescents,
using the focus group technique in order to obtain information to design an interven-
tion proposal.
In order to identify and describe the components necessary to design a program pro-
posal to promote adolescents’ PMeHL, we used the new framework for developing and
evaluating complex interventions [23] from the UK Medical Research Council (MRC) in
collaboration with the National Institute of Health Research (NIHR). This framework con-
sists of four research phases that can be carried out in the context of complex interventions
(development or identification of the intervention, feasibility, evaluation, and implementa-
tion) and contemplates core elements in each phase (considering context; developing and
refining program theory; engaging stakeholders; identifying key uncertainties; refining the
intervention; and economic considerations) [23]. In our study, we are in the intervention
development phase, and we tried to take into special consideration the following core
elements: (1) “considering context”, which in our case is the school context, and (2) “engaging
stakeholders”, such that in the focus groups, besides health and education professionals,
who are the potential facilitators of the intervention, we also included adolescents, who are
the target group.
The research question that guided the present study was the following: What are the
necessary components for designing a program to promote PMeHL among adolescents?
Int. J. Environ. Res. Public Health 2023, 20, 4898 3 of 16

2. Materials and Methods

2.1. Study Design
A qualitative, descriptive and exploratory study was conducted using a focus group [24]
and content analysis techniques [25]. The Consolidated criteria for reporting qualitative research
(COREQ) checklist [25] was used as a guide for writing this paper.

2.2. Participant Selection

The participants in this study, in both focus groups (F1 and F2), were professional
experts with experience in the field of positive mental health and adolescence, and were
also included in the panel on adolescents in the early adolescent phase (10–14 years) as
one of the core elements within the new framework for developing and evaluating complex
interventions [23].
In this study, we used the non-probability sampling method to select the experts in
the field of PMH, HL, MHL and adolescence for the sample constitution, i.e., an intentional
sample was used.
One of the researchers (J.N.) sent an email to the professional experts inviting them
to participate in the study, which contained the link to the online informed consent form
and an explanation about the study. The professional experts were invited after discussion
and consensus of the research team, based on their expertise, experience and work done.
The selected professional experts met the mandatory inclusion criterion of wanting to
participate voluntarily in the study, and at least two more of the following inclusion criteria:
(a) having professional experience of at least 5 years; (b) being a health professional or a
researcher or teacher in basic education; (c) having a master’s or doctoral degree; (d) having
experience working with/researching adolescents; (e) being familiar with the concepts of
PMH, HL and MHL.
Regarding the adolescents, the research team had access to their names and contacts
by e-mail through the teachers of one of the schools in the Alentejo region of Portugal,
who had previously contacted the adolescents and their parents/legal representatives,
explained the objectives of the study and asked for their participation. An e-mail was
sent to the adolescents’ parents/legal representatives by one of the researchers of the team
(J.N.) with the formalization of the invitation to participate in the study and with the
link to fill out the online informed consent form. The adolescents who were selected for
participation in this study cumulatively met the following inclusion criteria: (a) being
between 10 and 14 years of age; (b) being representative of their class at school; (c) not
knowing any of the selected professional experts; (d) having informed consent authorized
by their parents/legal representatives; (e) wanting to participate voluntarily in the study.
Given that the literature indicates that the panel of participants in a focus group can
range from four to twelve members [24], and in order to ensure a sufficient number of
experts in our sample, fifteen potential experts were invited (twelve professional experts
and three adolescents), of which three declined (two professional experts and one ado-
lescent), twelve accepted, and eleven actually participated in the study. Participants who
refused or dropped out cited personal reasons as justification. Participation by experts and
adolescents was voluntary, and there were no monetary compensations or other offers as
incentives for participation.

2.3. Setting
Two focus groups were conducted by videoconference, through the Zoom platform,
in order to facilitate the presence of participants, since they came from different regions of
Portugal. In the first focus group, 11 participants were present, and in the second focus
group 8 of the 11 participants were present. Following the methodological guidelines of
Krueger and Casey [24], in addition to the participants, 2 members of the research team
were also present, where one of the researchers played the role of moderator (J.N.), and the
other researcher played the role of assistant moderator (H.A.).
Int. J. Environ. Res. Public Health 2023, 20, 4898 4 of 16

2.4. Data Collection

The data collection for this study was performed through two focus groups, both
directed to the same participants, using a semi-structured interview guide, in order to
allow a greater degree of freedom in the participants’ answers, and the questions were
constructed according to the objectives of the study: (1) What is the relevant content for
a program to promote positive mental health literacy among adolescents in the stage
of early adolescence (10–14 years) in a school setting? (2) What length (total and per
session) and frequency should the program have? (3) What strategies do you think are
relevant to use (methods, pedagogical techniques and teaching resources)? (4) What is
the specific school context in which this program should be implemented? (5) What
requirements must participants have to be targeted by the program? (6) What are the
characteristics/requirements that facilitators must possess to implement the program?
(7) How should the program assessment be done? (8) When should the program assess-
ment be done? (9) What name do you suggest for the program? (10) Do you have any
other suggestions that you think are pertinent? To assess sociodemographic characteris-
tics, the researchers created an ad hoc form, through which it was possible to collect the
following data: age, gender, academic qualifications, main professional activity, number of
years of professional experience and number of years of experience working/researching
with adolescents.
The first focus group was held in July 2022 and the second in September 2022,
with a duration ranging from 90 to 120 min. During the focus groups, the moderator
(J.N.) was responsible for presenting the objectives of the study and conducting the
interviews, encouraging the intervention of all participants, especially the adolescents,
in order to prevent them from feeling inhibited among the professionals; the assistant
moderator (H.A.) was responsible for observing the focus group dynamics and taking
supporting notes.
We used audio and video recordings of each focus group, duly authorized by the
participants, and written supporting notes. Transcripts of the focus groups were made after
the focus groups ended and were not returned to the participants for possible corrections
or feedback.
After the second focus group, the authors considered that data saturation was achieved,
as the response pattern of the participants was consistent and no new relevant information
was obtained, which is consistent with what the literature says, i.e., that two to three focus
groups are sufficient to capture about 80% of the main themes/categories [26].

2.5. Data Analysis

The verbatim transcription of each focus group was done by the first author (J.N.) and
checked by the second author (H.A.). The data were then analyzed using content analysis
according to Bardin [27] in its different phases: (1) pre-analysis, (2) exploration of the
material and (3) treatment of results, inference and interpretation. In the pre-analysis phase,
the transcripts and the assistant moderator’s notes were subjected to “floating” reading
and editing procedures. In the material exploration phase, the first and second authors
proceeded to the coding of the data and the researchers’ triangulation to minimize biases,
and deductively coded four categories (structure; participants; assessment; others) and
twelve subcategories (context, format, contents, length and frequency, pedagogical meth-
ods, pedagogical techniques, resources, denomination, target group, program facilitators,
timings, evaluation instruments). Finally, in the results treatment phase, the name of the
category “others” was changed to “other components” and six more subcategories emerged
inductively (planning, articulation and adaptation, involvement, training, special situations,
partnerships, referral).
Int. J. Environ. Res. Public Health 2023, 20, 4898 5 of 16

The context units selected to illustrate the results obtained were identified by the code
that was assigned to each participant in order to ensure anonymity, e.g., P1_SpNurs1_F1
means that the context unit comes from participant 1 who is a specialist nurse and partici-
pated in the first focus group.
Throughout the analysis procedure, the two authors (J.N. and H.A.) were concerned
with the observation of the objectivity and pertinence of the categories, allowing this process
to systematize them, in a reconfiguration procedure until reaching the final “Tree of Nodes”.
We also observed validity, linking the objectives of the work, the emerging categories and
the content included. We checked for exhaustiveness, ensuring the inclusion of input from
a variety of data sources. Rigor was always a concern, in relation to the theme; the use of
various informants and experts was a resource to ensure credibility; and transferability was
observed, making rigorous reports in order to allow the transfer of knowledge supported
by the results. We also emphasized the discussions between researchers, not only around
the findings, but also on the methodological route, in an attempt to avoid distortions and
once again control the reliability [28].
NVivo® 12 software (version 12, QSR International, Ltd., Daresbury Cheshire, UK)
was used to perform data analysis and treatment. The participants gave favorable feedback
on their results after their analysis was returned to them.

3. Results
3.1. Characteristics of Participants
In focus group 1, eleven participants were present (P1–P11), of which nine were
professionals (P1–P9) and two were adolescents (P10–P11). Focus group 2 was attended by
eight of the eleven participants (P1–P2, P5 and P7–P11).
Of the total of eleven participants who took part in the focus groups, the majority
were female (88.9%). The group of professional experts was composed of five specialist
nurses in mental health nursing and psychiatry, one researcher, one psychologist, one child
psychiatrist and one teacher in basic education; their ages ranged from 26 to 57 years; most
of them had a master’s degree (66.7%); their professional experience ranged from 5 to
28 years; and their experience in research/work with adolescents ranged from 0 to 27 years.
The adolescent group consisted of two adolescents, both 14 years old and attending the
ninth grade. A more detailed view of the participants’ characteristics can be found in
Supplementary Materials Table S1.

3.2. Categories and Subcategories

With the two focus groups, we obtained in total four categories and eighteen subcat-
egories, as shown in Figure 1. While performing phase 3 of the content analysis process,
according to Bardin [27], i.e., the phase of treatment of results, inference and interpretation,
the following six subcategories emerged inductively: planning, articulation and adaptation;
involvement; training; special situations; partnerships; referral. All other subcategories had
been deductively identified before the focus groups were conducted. A detailed view of
the tree nodes showing all categories and subcategories as well as the number of references
included in each can be found in Supplementary Materials Table S2.

3.2.1. Structure
Context. The participants suggested that the implementation of the program should
take place mainly in citizenship classes, as this is the subject whose contents are best suited
to the theme of the program we are designing (P4_Teach_F1, P9_SpNurs5_F1, P10_Ad1_F1,
P11_Ad2_F1, P2_Psy_F2, P11_Ad2_F2); however, they also suggested the possibility of this
program covering other subjects in the curriculum plan (P4_Teach_F1, P6_ChildPsy_F1):
We have some disciplines in schools that can collaborate a lot with this [program], such
as citizenship. (P4_Teach_F1)
Should ideally be a transversal intervention, not in a particular discipline; it could be
included in the content of several disciplines. (P6_ChildPsy_F1)
 Viruses
Int. J. Environ. Res. 2022,
Public 1, 0 2023, 20, 4898
Health 6 of 16 2 of 4

Figure 1.and sub-categories resulting from the content analysis.

Figure 1. Categories

Format. It was considered by the participants that the program should have a
modular format (P1_SpNurs1_F1, P7_SpNurs3_F1), organized by sessions (P7_SpNurs3_F2,
Int. J. Environ. Res. Public Health 2023, 20, 4898 7 of 16

P8_SpNurs4_F2), and they highlighted the importance of being based on the adolescents’
needs (P7_SpNurs3_F1, P1_SpNurs1_F2, P2_Psy_F2):
It can be more modular. (P1_SpNurs1_F1)
I think that being organized by sessions is perfect; there has to be a logical following.
(P7_SpNurs3_F2)
It doesn’t make sense to me to do a comprehensive promotion or prevention program
for everyone, maybe more targeted and more individualized to the needs of each one.
(P7_SpNurs3_F1)
Contents. There was consensus among the participants that the contents should be
based on the factors of the Multifactor Model of Positive Mental Health, i.e., personal satisfac-
tion, pro-social attitude, self-control, autonomy, problem-solving and self-actualization, and
interpersonal relationship skills (P1_SpNurs1_F1, P2_Psy_F1, P4_Teach_F1, P8_SpNurs4_F1,
P10_Ad1_F1), and should have as background the health literacy matrix, especially the dimen-
sion of ‘apply’ (P1_SpNurs1_F1, P2_Psy_F1, P3_SpNurs2_F1, P5_Res_F1, P8_SpNurs4_F1,
P1_SpNurs1_F2, P5_Res_F2, P8_SpNurs4_F2):
If we intend to have an intervention, a literacy program and to focus on positive mental
health, then it is important that we base our content on the foundations of positive mental
health. (P8_SpNurs4_F1)
The issue of ‘access’, ‘understand’ and ‘apply’ is important for literacy, and [it should
be] very focused on ‘apply’. (P1_SpNurs1_F1)
The participants also emphasized the importance of addressing emotions in order to
clarify them for adolescents and to differentiate them from diagnoses of mental disorders
(P1_SpNurs1_F1, P2_Psy_F1, P3_SpNurs2_F1, P4_Teach_F1, P5_Res_F1, P9_SpNurs5_F1,
P11_Ad2_F1, P1_SpNurs1_F2). They recommended that special emphasis be placed on
positive emotions and praise (P4_Teach_F1, P5_Res_F1, P6_ChildPsy_F1, P9_SpNurs5_F1),
as well as on coping/resilience strategies (P2_Psy_F1, P6_ChildPsy_F1):
There is a confusion between emotions and diagnoses. (P3_SpNurs2_F1)
( . . . ) maybe we won’t talk about all of them [emotions],; we talk about the primary
emotions eventually for the level of development they [adolescents] are at, [and] we talk
about the most primary emotions. (P1_SpNurs1_F2)
( . . . ) to praise strength, (...) working on positive emotions. (P5_Res_F1)
Also in this subcategory, participants pointed out that the content should be based on
the adolescents’ needs (P7_SpNurs3_F1, P2_Psy_F2):
According to the needs of the target audience itself. (P2_Psy_F2)
In addition, it was suggested by some of the participants that the Delphi technique
should be used to validate the content of each module and session (P1_SpNurs1_F2,
P8_SpNurs4_F2):
( . . . ) to validate this [session content], is to look at it thoroughly, maybe with a Delphi
technique; I think it’s the simplest way to do it. (P8_SpNurs4_F2)
Length and frequency. It was suggested by participants that the program must
have a well-defined start and end date for implementation (P7_SpNurs3_F1) and that
it should have a regular frequency during implementation to ensure a certain continuity.
Every two weeks or monthly implementation was suggested (P1_SpNurs1_F1, P2_Psy_F1,
P4_Teach_F1, P5_Res_F1, P6_ChildPsy_F1, P8_SpNurs4_F1, P9_SpNurs5_F1, P10_Ad1_F1,
P11_Ad2_F1), with concern that the frequency of implementation needs to be adapted to
the school context (P7_SpNurs3_F2, P10_Ad1_F2):
An intervention program at the literacy level has to be tight; it has to have a beginning
and an end. (P7_SpNurs3_F1)
Int. J. Environ. Res. Public Health 2023, 20, 4898 8 of 16

Frequency every 2 weeks or monthly. (P9_SpNurs5_F1)

In relation to frequency, I think it can be variable; it differs from school to school, [and] it
depends on each school’s citizenship project. (P7_SpNurs3_F2)
Regarding the length of each session, participants proposed 45 min, which corresponds
to one class period (P7_SpNurs3_F1, P9_SpNurs5_F1, P10_Ad1_F2, P11_Ad2_F2), but pointed
out that the length may vary depending on the content to be covered and the dynamics
to be carried out, and that in some cases two class periods may be required, i.e., 90 min
(P1_SpNurs1_F1, P7_SpNurs3_F1, P8_SpNurs4_F1, P10_Ad1_F1, P1_SpNurs1_F2, P2_Psy_F2):
Maximum duration of 45 min. (P9_SpNurs5_F1)
I think that the duration is very relative, because it is very much associated with the
content. (P10_Ad1_F1)
( . . . ) the time I think has to be between 45 and 90 min; if we can negotiate, 90 min is
much easier. (P1_SpNurs1_F2)
Pedagogical methods. Participants recommended giving priority to the use of active/dy-
namic pedagogical methods (P1_SpNurs1_F1, P3_SpNurs2_F1, P8_SpNurs4_F1, P9_SpNur-
s5_F1, P10_Ad1_F1, P10_Ad1_F2), with a concern to be appropriate to the goal of each
session (P1_SpNurs1_F1, P8_SpNurs4_1, P7_SpNurs3_F2, P8_SpNurs4_F2). In addition,
they suggested using methods/models that have already demonstrated effectiveness
(P6_ChildPsy_F1):
( . . . ) in a more dynamic way and not exactly being closed in a room and listening to
what someone tells us. (P10_Ad1_F1)
If we have people who still do not have a basic knowledge of what we are going to explain,
maybe it is important to start with a more expository issue, then move on to the most
active strategies, so we already have a higher level of knowledge that is likely required for
the application. (P8_SpNurs4_F1)
( . . . ) trying to look for positive models that have already demonstrated success and try
to reproduce them. (P6_ChildPsy_F1)
Pedagogical techniques. Several pedagogical techniques were listed by participants that
they most recommend to be used during program implementation, such as role-play/theater
(P1_SpNurs1_F1, P3_SpNurs2_F1, P8_SpNurs4_F1, P9_SpNurs5_F1, P10_Ad1_F1, P1_Sp-
Nurs1_F2), games (P1_SpNurs1_F1, P3_SpNurs2_F1, P11_Ad2_F1, P11_Ad2_F2), group
dynamics (P1_SpNurs1_F1, P4_Teach_F1, P7_SpNurs3_F1), discussion and reflection (P8_SpN-
urs4_F1, P9_SpNurs5_F1, P9_SpNurs5_F2), group work (P9_SpNurs5_F1, P11_Ad2_F1),
online information searches (P9_SpNurs5_F1) and movies/videos (P1_SpNurs1_F2).
The importance of having a diversity of pedagogical techniques in each session and
throughout the program was also underlined (P1_SpNurs1_F1, P4_Teach_F1, P8_SpNurs4_F1):
I think that a 50-min class has to have 4 or 5 different activities to be dynamic and
to [encourage] interaction between the students and the facilitators of the program.
(P4_Teach_F1)
Resources. During the discussion, some participants suggested including technology
as a resource to be used in the program implementation (P2_Psy_F1, P3_SpNurs2_F1,
P5_Res_F1), because it is very suitable to the adolescents’ preferences, although they warned
about a careful use of these technologies (P2_Psy_F1, P3_SpNurs2_F1, P8_SpNurs4_F1) due
to the obstacles/problems they may imply, pointing out that there are also other resources
that can be used during the program (P4_Teach_F1, P10_Ad1_F1):
Adolescents like means of application; for example, any intervention must have digital
means. They are the Z generation, they are already the Alpha generation, they were born
in the digital environment, and this must be present.(P5_Res_F1)
Int. J. Environ. Res. Public Health 2023, 20, 4898 9 of 16

Technology is good, and it’s appealing, but it’s also distracting; there has to be a balance
between these two ideas of technology, yes, but with some caution because we can have a
lot of obstacles later in our program. (P8_SpNurs4_F1)
Schools sometimes don’t have internet and that doesn’t make it easy; however ( . . . ), they
[internet and apps] are not the only thing we can work with. (P4_Teach_F1)
Denomination. Although some suggestions for possible denomination of the program
were made, participants suggested that it would be more interesting if the name of the
program was chosen based on suggestions from the adolescents themselves, for example
through a competition or voting (P7_SpNurs3_F1, P11_Ad2_F1), keeping in mind that the
denomination needs to be short (P2_Psy_F2, P7_SpNurs3_F2):
[To determine] the name ( . . . ) do a competition, for example, to choose, or a student
vote. (P11_Ad2_F1)
The name, (...) it has to be something small to stay in memory, that is easier for diction.
(P7_SpNurs3_F2)

3.2.2. Participants
Target group. According to the participants, the program we are designing should
start being implemented from the fifth grade and then continue in the following school
years (P2_Psy_F1, P4_Teach_F1, P6_ChildPsy_F1, P11_Ad2_F1), i.e., start covering ado-
lescents from 10 years old on. Furthermore, they proposed keeping classes together
(P9_SpNurs5_F1, P11_Ad2_F1), dividing them into small groups during the sessions
(P4_Teach_F1, P5_Res_F1, P10_Ad1_F1, P11_Ad2_F1). The following context units demon-
strate the achieved findings:
Mental health literacy has to be worked on as early as possible, it has to start in the 5th
grade ( . . . ); however, it has to be worked on throughout life. (P4_Teach_F1)
I think it’s important to keep the class, because we know our colleagues better. (P11_Ad2_F1)
( . . . ) groups have to be smaller. (P5_Res_F1)
Program facilitators. Participants considered that the program facilitator team should
consist of health professionals and school professionals (P1_SpNurs1_F1, P3_SpNurs2_F1,
P4_Teach_F1, P9_SpNurs5_F1, P10_Ad1_F1, P11_Ad2_F1, P1_SpNurs1_F2) to enrich
the program:
( . . . ) always as a team: School Health, teachers, everyone, always a team. (P1_SpNurs1_F1)
I feel that we all have to be there because that’s the only way to bring even more benefits
because our views and our visions of everyone are important, (...) I speak (...) of nursing,
I also speak of the school psychologist, I speak of the professionals that we have available.
(P1_SpNurs1_F2)
Furthermore, two very important aspects were highlighted in the program design; on
the one hand, the team should be composed of at least two facilitators (P3_SpNurs2_F1,
P7_SpNurs3_F1, P9_SpNurs5_F1), and on the other hand, the facilitating team should be
maintained until the end of the program implementation (P7_SpNurs3_F1), to guaran-
tee continuity:
We need at least two program facilitators to implement the intervention/session plus the
class director, who is assisting, and a psychologist from the school. (P3_SpNurs2_F1)
The reference person who starts the program stays until the end ( . . . ) in order to give
continuity. (P7_SpNurs3_F1)

3.2.3. Assessment
Timing. Participants considered that evaluations should occur before the application
of the program and at the end (P1_SpNurs1_F1, P2_Psy_F1, P3_SpNurs2_F1, P4_Teach_F1,
P5_Res_F1, P7_SpNurs3_F1, P8_SpNurs4_F1, P9_SpNurs5_F1, P10_Ad1_F1), as well as
Int. J. Environ. Res. Public Health 2023, 20, 4898 10 of 16

during the follow-up (P4_Teach_F1, P6_ChildPsy_F1, P7_SpNurs3_F1, P9_SpNurs5_F1,

P1_SpNurs1_F2). At these moments, the adolescents would be subject to self-evaluation by
filling out instruments that will allow us to verify the existence or not of improvement in
the results. The following context units illustrate the results achieved:
It is important that we have a pre and post assessment here to see if there is effectively a
gain. (P8_SpNurs4_F1)
[Follow-up] Always! At least after 3 months. (P9_SpNurs5_F1)
Adolescent assessment was also recommended in each session (P1_SpNurs1_F1,
P2_Psy_F1, P4_Teach_F1, P5_Res_F1, P8_SpNurs4_F1, P9_SpNurs5_F1, P11_Ad2_F1, P1_S-
pNurs1_F2, P2_Psy_F2, P5_Res_F2), through a hetero-evaluation performed by the pro-
gram facilitators, to understand if the adolescents are able to apply the themes addressed
in the sessions, and to get answers to the program process indicators:
It is important to have an assessment of the process ( . . . ) in each session. It even gives us
feedback on the improvement of the sessions because we can always improve the program.
(P1_SpNurs1_F1)
[Ask the adolescents] “can you apply this information of positive psychology and
positive health literacy to your everyday life, even just one thing? If you did, what did you
apply it to?” This is what enriches the competences of these adolescents. (P5_Res_F2)
Evaluation instruments. Participants suggested the use of instruments that already
exist and are validated for the assessment of positive mental health and mental health
literacy (P1_SpNurs1_F1, P7_SpNurs3_F1, P8_SpNurs4_F1). However, they stated that
in order to be able to make a more specific evaluation of the results regarding positive
mental health literacy, the most correct thing to do would be to create an instrument
to evaluate the results of the application of this program, as well as observation grids
for the process evaluation in each session (P1_SpNurs1_F1, P2_Psy_F1, P3_SpNurs2_F1,
P5_Res_F1, P8_SpNurs4_F1, P9_SpNurs5_F1, P2_Psy_F2, P7_SpNurs3_F2). The following
context units demonstrate the results we obtained:
( . . . ) there is Claudia’s instrument, then there is Bjørsen’s own study. (P1_SpNurs1_F1)
( . . . ) throughout the sessions we have observation grids. (P1_SpNurs1_F1)
To have a questionnaire that gives you an answer, a test that gives an answer to your
program, you will probably have to build an instrument. (P8_SpNurs4_F1)
In addition, they recommended that the instruments should allow for the assessment
of acquired competencies and not just knowledge (P1_SpNurs1_F2, P2_Psy_F2, P5_Res_F2,
P8_SpNurs4_F2):
The instruments of evaluation cannot only be effectively instruments of knowledge; there
must also be competencies here. (P1_SpNurs1_F2)
( . . . ) a scale of ( . . . ) perceived competence or self-efficacy; it’s always easier for us to
see a difference here. (P8_SpNurs4_F2)

3.2.4. Other Components

Planning, articulation and adaptation. Participants mentioned that the program
should focus on practical things (P3_SpNurs2_F1, P5_Res_F1, P2_Psy_F2, P7_SpNurs3_F2,
P9_SpNurs5_F2), should be adapted to the adolescents’ and context’s needs (P1_SpNurs1_F1,
P4_Teach_F1, P2_Psy_F2, P9_SpNurs5_F2), that facilitators should be careful with the lan-
guage used (P5_Res_F1, P9_SpNurs5_F1) to make sure the message is delivered correctly,
and emphasized that, above all, good planning and articulation with the school is required
(P3_SpNurs2_F1, P4_Teach_F1, P9_SpNurs5_F1):
It is better to focus on simple and practical things and bring awareness and give tools.
(P3_SpNurs2_F1)
Int. J. Environ. Res. Public Health 2023, 20, 4898 11 of 16

It is good to have this flexibility and this possibility of being able to adjust the program
to the needs of the context, the needs of the adolescents and the capacity of the school.
(P1_SpNurs1_F1)
[The program] must be planned at the beginning of the school year so that we are
successful in the implementation. (P3_SpNurs2_F1)
Involvement. According to the participants, it is important that in the implementation
of the program, the adolescents themselves who are going to be targeted by the program
are involved (P3_SpNurs2_F1, P7_SpNurs3_F1, P1_SpNurs1_F2, P2_Psy_F2, P5_Res_F2),
as well as the parents/legal representatives (P2_Psy_F1, P3_SpNurs2_F1, P10_Ad1_F1,
P2_Psy_F2) and the school (P2_Psy_F1, P3_SpNurs2_F1, P2_Psy_F2):
Adolescents should have a voice and should be listened to in their needs. (P3_SpNurs2_F1)
I think it shouldn’t be something addressed just to us, but also to parents. (P10_Ad1_F1)
( . . . ) with the involvement of the school. (P2_Psy_F1)
Training. It was mentioned by the participants that it is essential to have prior training
for all facilitators about the program and its implementation (P5_Res_F1, P7_SpNurs3_F2,
P8_SpNurs4_F2):
So, I think it was important for us to talk about this, that in order to be applied, it is nec-
essary to provide training to those who are going to apply it, whether they are citizenship
teachers, which seems fine to me, or whether they are Class Directors. (P7_SpNurs3_F2)
Special situations. The participants warned that there may be adolescents with
special educational and health needs, but they should not be excluded from the appli-
cation of the program (P1_SpNurs1_F1, P3_SpNurs2_F1, P4_Teach_F1, P8_SpNurs4_F1,
P9_SpNurs5_F1). They also advised that special care should be taken with immigrant ado-
lescents (P7_SpNurs3_F1) and with adolescents with mental health concerns (P2_Psy_F2).
The following context units illustrate the findings obtained:
I think that no one from the class should be removed because they have some of these
criteria. I think that ( . . . ) someone who has a special need can continue to participate; it
may not have the best result we expected, but it is important that he/she continue in the
session anyway. (P8_SpNurs4_F1)
If we have foreign students, at least have care taken in the translation and in explaining
the terms. (P7_SpNurs3_F1)
Adolescents who already have some level of suffering associated, [should not be] excluded,
but perhaps the approach with these [students] will have to be different. (P2_Psy_F1)
Partnerships. It was mentioned by the participants that it would be interesting to
establish partnerships, for example, with institutions of higher education, for data analysis
(P3_SpNurs2_F1):
( . . . ) partnerships (...) to do the work of research data, because in clinical practice, I
cannot do research and clinical practice. (P3_SpNurs2_F1)
Referral. Finally, participants recommended procedures that should be in place if
facilitators identify adolescents who need specialized support (P1_SpNurs1_F2):
( . . . ) because when we have to refer a situation that we have identified, we will have to
refer it “outside ourselves”. (P1_SpNurs1_F2)
Through the visualization of the word cloud generated during the content analysis,
illustrated in Figure 2, we see that the most common words verbalized by the participants
in the focus groups are “think”, “adolescents”, “class”, “knowledge”, “school”, “session”,
“apply”, “needs”, “important”, “literacy”, “program”, “health”, with respectively a fre-
quency of 2.38%, 2.06%, 1.52%, 1.41%, 1.30%, 1.30%, 0.98%, 0.98%, 0.76%, 0.76%, 0.54%,
0.54%, which demonstrates the importance that participants attribute to the construction of
 illustrated in Figure 2, we see that the most common words verbalized by
in the focus groups are “think”, “adolescents”, “class”, “knowledge”, “sch
“apply”, “needs”, “important”, “literacy”, “program”, “health”, with
frequency of 2.38%, 2.06%, 1.52%, 1.41%, 1.30%, 1.30%, 0.98%, 0.98%, 0.76
Int. J. Environ. Res. Public Health 2023, 20, 4898 12 of 16
0.54%, which demonstrates the importance that participants attribute to
of a literacy-promoting program targeting adolescents, inserted in the
applied in school,
a literacy-promoting programand thatadolescents,
targeting containsinserted
sessions inclass,
in their whichthat isadolescents
applied t
in school, and that they
knowledge contains
aresessions in which
accessing andadolescents
apply think
it inabout
theirthedaily
knowledge
livestheyto prom
are accessing and apply it in their daily lives to promote their mental health, according to
health, according to their needs.
their needs.

Figure 2. Word
Figure cloudcloud
2. Word of the most
of thecited
mostwords by words
cited the participants (generated by the
by the participants software by the
(generated
NVivo® 12).
12).
4. Discussion
4.This study explored the perspectives of a group composed of professional experts and
Discussion
adolescents on the design of a proposal for a program to promote positive mental health
This adolescents.
literacy among study explored
As result,the perspectives
we were ofand
able to identify a describe
group the composed
componentsof prof
necessary to design the proposal
and adolescents on theofdesign
the mentioned program, and
of a proposal forthese components
a program towere
promote
grouped into four categories: structure, participants, assessment and other components.
health literacy among adolescents. As result, we were able to identify a
Regarding the category structure, the participants suggested that the program should
components
be offered necessary
to adolescents to design
at school, mostly the proposal
in citizenship classes, sinceof the are
schools mentioned
considered prog
by components
several authors to be a privileged
were groupedcontext
into for the categories:
four promotion of mental health,participants,
structure, HL and
MHL [2,7,9,17–20]. They suggested that it should have a modular format, with several
other components.
sessions, every two weeks or every month, each session lasting between 45 and 90 min,
Regarding
using mainly the category
active pedagogical structure,
methods, the participants
using pedagogical techniquessuggested that the
such as role-
play,
begames,
offered grouptodynamics, discussion
adolescents at and reflection,
school, among
mostly inothers, and eventually
citizenship classes, si
resorting to the use of technology, as long as it is very carefully selected so that it does not
become an obstacle. These suggestions from the participants are consistent with the studies
developed by other authors, namely Parnell et al. [29], Morgado et al. [9,30], Laranjeira &
Querido [31], Choi et al. [32] and Costa et al. [33]. The contents were thoroughly discussed
by all participants, and the consensus was that the Multifactor Model of Positive Mental
Health factors should be addressed, that is, personal satisfaction, pro-social attitude, self-
Int. J. Environ. Res. Public Health 2023, 20, 4898 13 of 16

control, autonomy, problem solving and self-actualization, and interpersonal relationship

skills. Special attention should be given to clarifying some emotions, emphasizing positive
emotions, emphasizing the practice of praise and teaching coping/resilience strategies.
On one hand, these proposals of the participants are in line with the new framework for
developing and evaluating complex interventions [23] in the sense that there is a theoretical
model at the basis of a complex intervention, which in our case will be the Multifactor
Model of PMH and the HL matrix. On the other hand, they are in line with what the study
by Carvalho et al. [16] indicated are the attributes of the concept of PMeHL. The participants
recommended that the contents should be approached based on the HL matrix, that is,
ensuring that adolescents develop access, comprehension and use competences regarding
the contents that will be worked on [10,11], emphasizing that this will be a great added
value of this program and will differentiate it from others that already exist. Indeed, in a
scoping review conducted by our research team in 2021, we found that the several studies
included referred to programs or interventions promoting adolescent MHL; however, only
a few were directed to the salutogenic dimension of MHL and promoted mainly access
to knowledge and not adolescent competences in the dimension of ‘apply’ [34]. It was
also suggested that the validation of the content of each session should be performed
through the Delphi technique, which is often used in health sciences to obtain consensus
on a particular subject or intervention [35], which is exactly what we intend to do in a
future stage. Regarding the denomination of the program, it was suggested that a vote or
competition should be held with the adolescents, in order to involve them in the process of
building the program itself.
In the category ‘participants’, it was consensual that the program should have as its
target group adolescents from the fifth grade on, and it was advised that the class to which
the adolescents belong should not be broken up, but the class should be divided into
small groups during the sessions [9,32,33,36]. Regarding the facilitators of the program, it
was recommended that a team should be formed with health professionals and education
professionals, which should remain unchanged from the beginning until the end of the
program implementation, and that at least two facilitators must work together to run each
session, which is in line with what is advocated by several authors [7,8,18,36].
In relation to the category ‘assessment’, participants advocated for evaluation before and
after program implementation and also during the follow-up [9,37,38], where adolescents
should be given instruments to evaluate PMeHL, either through instruments that already
exist and are properly validated and adapted or through an instrument that the research
team constructs specifically for program evaluation. In addition, they recommend that
during each session, the adolescents should be evaluated by the program facilitators
through the application of observation grids that the research team needs to create in order
to obtain information not only about the adolescents’ progress, but also suggestions for
improvement of the program in progress, as recommended by Richards & Halberg [37] and
by Morgado et al. [9,30].
Finally, in the category ‘other components’, there are several extra suggestions that may
contribute to a greater effectiveness and success of the program, which emerged from
the participants’ responses throughout the focus group. In particular: (1) the need for
good coordination with the school in terms of short- and medium-term planning; (2) the
importance of involving the adolescents themselves in the planning and implementation
of the program, giving priority to their expressed needs, their opinions and active partic-
ipation in decision-making, as well as the involvement of the school and parents/legal
representatives; (3) the requirement for the facilitating team to undergo training prior
to the implementation of the program; (4) the need to adopt inclusive and more protec-
tive measures in case there are adolescents with special health and educational needs,
or non-native speaking adolescents or adolescents with mental health concerns; (5) the
extreme importance of having a previously defined referral circuit for specialized care for
the adolescents that the facilitators identify during the implementation of the program; and
(6) the establishment of partnerships with some entities, for example, for the analysis of
Int. J. Environ. Res. Public Health 2023, 20, 4898 14 of 16

the data resulting from the evaluation instruments, but which may also be important in
the context of the aforementioned specialized care for adolescents. These suggestions are
consistent with several published works [2,7,9,33,36].
It is noteworthy that in several subcategories (throughout the two focus groups) the
participants emphasized that it was extremely important that the program be adapted
to the adolescents’ needs and also to the needs and characteristics of the school context,
which is in line with what the new framework for developing and evaluating complex
interventions [23] advocates, that is, the flexibility that interventions must have in order to
be effective.
Despite the methodological rigor and the relevance of the achieved findings, this
study has some limitations. First, the results cannot be generalized, since we used a non-
probabilistic sample. Second, the small number of adolescents that participated in the focus
groups and their limited diversity in terms of characteristics may have limited the diversity
of the perspectives obtained. Third, the unbalanced group of experts may have conditioned
the representativity of the various professional groups. Lastly, both focus groups included
the same participants.

5. Conclusions
In conclusion, the participants of this study expressed their ideas about the components
that a program to promote adolescents’ PMeHL should contain, thus contributing to the
design of the program proposal. They considered that it should be a program implemented
at school by a team of facilitators composed of health and education professionals. This
program should be aimed at adolescents from the fifth grade on, with a focus on citizenship
classes, composed of several modules, with each module organized into sessions, each
45–90 min long, with a quarterly or monthly application frequency. Active teaching
methods and techniques must be used. The contents should be based on the factors of
the Multifactor Model of PMH and based on the dimensions of access, understanding
and application of HL. This program should also include the application of adolescent
outcome assessment instruments before and after implementation and at follow-up, as well
as adolescent process assessment instruments at each session. To increase the program
success, participants recommended: good coordination with schools; the involvement
of adolescents, parents/legal representatives and the schools themselves; the adoption
of inclusive and protective measures for the most vulnerable adolescents, which should
include a referral circuit for specialized care; and the establishment of partnerships with
other entities.
In terms of implications for clinical practice, we believe that in the future, this program
will make an outstanding contribution to the promotion of adolescents’ mental health and
well-being by supporting professionals in clinical practice (nurses, clinical psychologists,
physicians) and educational professionals (teachers, educational psychologists) in their
care of this group of the educational community.
It will be necessary to develop further research studies to obtain a program properly
validated and adaptable to adolescents and their context, while having a standard base
structure. This means that it is important to conduct Delphi studies for the validation of the
contents of each session, to perform a pilot study, and after that to develop experimental or
quasi-experimental studies.
In future studies, the participants in the focus groups should be more balanced, re-
garding their number and their characteristics of experts and adolescents, to provide a
higher strength of the findings. In addition, separate focus groups should also be orga-
nized, i.e., one with experts and then one with adolescents, to enhance the expressivity of
adolescents’ perspectives and to contribute to their help to researchers in the applicability
of the proposals made by the experts. If possible, it would also be interesting to conduct
focus groups with different groups of experts and with different groups of adolescents, to
ensure an even higher degree of data saturation.
Int. J. Environ. Res. Public Health 2023, 20, 4898 15 of 16

Supplementary Materials: The following are available online at https://www.mdpi.com/article/10

.3390/ijerph20064898/s1, Table S1: Participants’ characteristics; Table S2: Tree Nodes.
Author Contributions: Conceptualization, J.N., C.F.-G. and C.S.; methodology, J.N., C.F.-G. and
C.S.; validation, all authors; formal analysis, J.N. and H.A.; investigation, J.N. and A.P.O.; re-
sources, J.N. and A.P.O.; data curation, J.N.; writing—original draft preparation, J.N., H.A. and F.M.;
writing—review and editing, J.N., H.A., F.M., C.F.-G. and C.S.; visualization, all authors; supervision,
C.F.-G. and C.S.; project administration, J.N., C.F.-G. and C.S. All authors have read and agreed to the
published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted according to the guidelines of
the Declaration of Helsinki and approved by the Ethics Committee of the Polytechnic Institute of
Portalegre-Portugal (SC/2000/106 on 29 January 2000).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Data available on request due to ethical restrictions.
Acknowledgments: The authors would like to thank all the participants in this study who so
generously gave their time to provide such valuable input for research in this area.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. World Health Organization. Adolescent Mental Health. Available online: https://www.who.int/news-room/fact-sheets/detail/
adolescent-mental-health (accessed on 4 April 2022).
2. World Health Organization. Guidelines on Mental Health Promotive and Preventive Interventions for Adolescents: Helping Adolescents
Thrive; World Health Organization: Geneva, Switzerland, 2020.
3. Campos, L.; Dias, P.; Duarte, A.; Veiga, E.; Dias, C.C.; Palha, F. Is It Possible to “Find Space for Mental Health” in Young People?
Effectiveness of a School-Based Mental Health Literacy Promotion Program. Int. J. Environ. Res. Public Health 2018, 15, 1426.
[CrossRef]
4. Campos, L.; Dias, P.; Palha, F. Finding Space to Mental Health—Promoting Mental Health in Adolescents: Pilot Study. Educ.
Health 2014, 32, 23–27.
5. Tay, J.; Tay, Y.; Klainin-Yobas, P. Mental Health Literacy Levels. Arch. Psychiatr. Nurs. 2018, 32, 757–763. [CrossRef] [PubMed]
6. World Health Organization. Comprehensive Mental Health Action Plan 2013–2030; World Health Organization: Geneva, Switzerland,
2021; Volume 1999.
7. World Health Organization. Mental Health in Schools: A Manual.; World Health Organization, Regional Office for the Eastern
Mediterranean: Cairo, Egypt, 2021.
8. Naccarella, L.; Guo, S. A Health Equity Implementation Approach to Child Health Literacy Interventions. Children 2022, 9, 1284.
[CrossRef]
9. Morgado, T.; Loureiro, L.; Rebelo Botelho, M.A.; Marques, M.I.; Martínez-Riera, J.R.; Melo, P. Adolescents’ Empowerment for
Mental Health Literacy in School: A Pilot Study on ProLiSMental Psychoeducational Intervention. Int. J. Environ. Res. Public
Health 2021, 18, 8022. [CrossRef] [PubMed]
10. Sørensen, K.; Van Den Broucke, S.; Fullam, J.; Doyle, G.; Pelikan, J.; Slonska, Z.; Brand, H. Health Literacy and Public Health: A
Systematic Review and Integration of Definitions and Models. BMC Public Health 2012, 12, 80. [CrossRef]
11. Center for Disease Control and Prevention. What Is Health Literacy; Center for Disease Control and Prevention: Atlanta, GA,
USA, 2022.
12. Jorm, A.F.; Korten, A.E.; Jacomb, P.A.; Christensen, H.; Rodgers, B.; Pollitt, P. “Mental Health Literacy”: A Survey of the Public’s
Ability to Recognise Mental Disorders and Their Beliefs about the Effectiveness of Treatment. Med. J. Aust. 1997, 166, 182–186.
[CrossRef]
13. Kutcher, S.; Wei, Y.; Coniglio, C. Mental Health Literacy: Past, Present, and Future. Can. J. Psychiatry 2016, 61, 154–158. [CrossRef]
14. Kutcher, S.; Wei, Y.; Costa, S.; Gusmão, R.; Skokauskas, N.; Sourander, A. Enhancing Mental Health Literacy in Young People. Eur.
Child. Adolesc. Psychiatry 2016, 25, 567–569. [CrossRef]
15. Lluch-Canut, T.; Sequeira, C. Saúde Mental Positiva [Positive Mental Health]. In Enfermagem em Saúde Mental—Diagnósticos e
Intervenções [Mental Health Nursing—Diagnosis and Intervention]; Sequeira, C., Sampaio, F., Eds.; Lidel—Edições Técnicas: Lisboa,
Portugal, 2020; pp. 61–63.
16. Carvalho, D.; Sequeira, C.; Querido, A.; Tomás, C.; Morgado, T.; Valentim, O.; Moutinho, L.; Gomes, J.; Laranjeira, C. Positive
Mental Health Literacy: A Concept Analysis. Front. Psychol. 2022, 13, 877611. [CrossRef]
Int. J. Environ. Res. Public Health 2023, 20, 4898 16 of 16

17. Bjørnsen, H.N.; Eilertsen, M.E.B.; Ringdal, R.; Espnes, G.A.; Moksnes, U.K. The Relationship Between Positive Mental Health
Literacy and Mental Well-Being Among Adolescents: Implications for School Health Services. J. Sch. Nurs. 2019, 35, 107–116.
[CrossRef] [PubMed]
18. Yamaguchi, S.; Ojio, Y.; Foo, J.C.; Michigami, E.; Usami, S.; Fuyama, T.; Onuma, K.; Oshima, N.; Ando, S.; Togo, F.; et al. A
Quasi-Cluster Randomized Controlled Trial of a Classroom-Based Mental Health Literacy Educational Intervention to Promote
Knowledge and Help-Seeking/Helping Behavior in Adolescents. J. Adolesc. 2020, 82, 58–66. [CrossRef] [PubMed]
19. Seedaket, S.; Turnbull, N.; Phajan, T.; Wanchai, A. Improving Mental Health Literacy in Adolescents: Systematic Review of
Supporting Intervention Studies. Trop. Med. Int. Health 2020, 25, 1055–1064. [CrossRef] [PubMed]
20. Amado-Rodríguez, I.D.; Casañas, R.; Mas-Expósito, L.; Castellví, P.; Roldan-Merino, J.F.; Casas, I.; Lalucat-Jo, L.; Fernández-San
Martín, M.I. Effectiveness of Mental Health Literacy Programs in Primary and Secondary Schools: A Systematic Review with
Meta-Analysis. Children 2022, 9, 480. [CrossRef]
21. Olyani, S.; Gholian Aval, M.; Tehrani, H.; Mahdizadeh-Taraghdari, M. School-Based Mental Health Literacy Educational
Interventions in Adolescents: A Systematic Review. J. Health Lit. 2021, 6, 69–77. [CrossRef]
22. Santini, Z.I.; Torres-sahli, M.; Hinrichsen, C.; Meilstrup, C.; Madsen, K.R.; Rayce, S.B.; Baker, M.M.; Have, M.T.; Schotanus-
dijkstra, M.; Koushede, V. Measuring Positive Mental Health and Flourishing in Denmark: Validation of the Mental Health
Continuum-Short Form (MHC-SF) and Cross-Cultural Comparison across Three Countries. Health Qual. Life Outcomes 2020,
18, 297. [CrossRef]
23. Skivington, K.; Matthews, L.; Simpson, S.A.; Craig, P.; Baird, J.; Blazeby, J.M.; Boyd, K.A.; Craig, N.; French, D.P.; McIntosh, E.; et al.
A New Framework for Developing and Evaluating Complex Interventions: Update of Medical Research Council Guidance. BMJ
2021, 374, n2061. [CrossRef] [PubMed]
24. Krueger, R.; Casey, M.A. Focus Groups: A Practical Guide for Applied Research, 5th ed.; Sage Publications: Newbury Park, CA, USA, 2014.
25. Tong, A.; Sainsbury, P.; Craig, J. Consolidated Criteria for Reporting Qualitative Research (COREQ): A 32-Item Checklist for
Interviews and Focus Groups. Int. J. Qual. Health Care 2007, 19, 349–357. [CrossRef]
26. Guest, G.; Namey, E.; McKenna, K. How Many Focus Groups Are Enough? Building an Evidence Base for Nonprobability Sample
Sizes. Field Methods 2017, 29, 3–22. [CrossRef]
27. Bardin, L. Análise de Conteúdo [Content Analysis], Reprint, J.; Edições 70: Lisboa, Portugal, 2022.
28. Streubert, H.; Carpenter, D. Investigação Qualitativa Em Enfermagem: Avançando o Imperativo Humanista [Qualitative Research in
Nursing: Advancing the Humanistic Imperative], 2nd ed.; Lusociência: Loures, Portugal, 2002.
29. Parnell, T.A.; Stichler, J.F.; Barton, A.J.; Loan, L.A.; Boyle, D.K.; Allen, P.E. A Concept Analysis of Health Literacy. Nurs. Forum
2019, 54, 315–327. [CrossRef]
30. Morgado, T.; Loureiro, L.; Botelho, M. Intervenção Psicoeducacional Promotora Da Literacia Em Saúde Mental de Adolescentes
Na Escola: Estudo Com Grupos Focais. Rev. Enferm. Ref. 2021, 5, 1–10. [CrossRef]
31. Laranjeira, C.A.; Querido, A.I. Assertiveness Training of Novice Psychiatric Nurses: A Necessary Approach. Issues Ment. Health
Nurs. 2021, 42, 699–701. [CrossRef] [PubMed]
32. Choi, S.; Bang, K.-S.; Shin, D.-A. EHealth Literacy, Awareness of Pandemic Infectious Diseases, and Healthy Lifestyle in Middle
School Students. Children 2021, 8, 699. [CrossRef] [PubMed]
33. Costa, T.F.O.; Sampaio, F.M.C.; da Cruz Sequeira, C.A.; Lluch Canut, M.T.; Moreno Poyato, A.R. Nurses’ Perspective about the
Mental Health First Aid Training Programmes for Adolescents in Upper Secondary Schools: A Focus Group Study. J. Psychiatr.
Ment. Health Nurs. 2022, 29, 721–731. [CrossRef]
34. Nobre, J.; Oliveira, A.P.; Monteiro, F.; Sequeira, C.; Ferré-Grau, C. Promotion of Mental Health Literacy in Adolescents: A Scoping
Review. Int. J. Environ. Res. Public Health 2021, 18, 9500. [CrossRef]
35. Niederberger, M.; Spranger, J. Delphi Technique in Health Sciences: A Map. Front. Public Health 2020, 8, 457. [CrossRef]
36. Smith, C.; Goss, H.R.; Issartel, J.; Belton, S. Health Literacy in Schools? A Systematic Review of Health-Related Interventions
Aimed at Disadvantaged Adolescents. Children 2021, 8, 176. [CrossRef]
37. Richards, D.; Hallberg, I. Complex Interventions in Health, 1st ed.; Routledge, Taylor & Francis Group: New York, NY, USA, 2015.
38. Bjørnsen, H.N.; Moksnes, U.K.; Eilertsen, M.E.B.; Espnes, G.A.; Haugan, G. Validation of the Brief Instrument “Health Literacy
for School-Aged Children” (HLSAC) among Norwegian Adolescents. Sci. Rep. 2022, 12, 22057. [CrossRef]

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual
author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to
people or property resulting from any ideas, methods, instructions or products referred to in the content.