The +Contigo Project in the Voice of Eight-Grade Students

Abstract

The +Contigo Project is a longitudinal research project based on a multilevel network intervention aimed at promoting mental health and well-being and preventing suicidal behaviors. Students participate in social skills training sessions on the stigma of mental disorders, adolescence, self-esteem, problem-solving skills, and well-being. Problem statement: To identify the qualitative impact of the +Contigo Project. Objectives: To identify the importance of the project for students, the problem situations which it helped to solve, and its impact on an individual level. Research methods: Content analysis (Bardin, 2009) with categorical identification. Semi-structured interview guide with 5 questions. A convenience sample of 16 students, from three schools of one school cluster in the Center Region of Portugal, was used. The ethical aspects of parental consent, voluntary participation and data confidentiality were addressed. Findings: Fourteen categories emerged from the data analysis. The answers to Question 4 ‘How was this project important to you?’ were particularly relevant. Students mentioned that it improved their self-esteem by increasing self-confidence and interpersonal skills, and that it increased their reflection and awareness on problems with which they learned how to cope during the sessions. Conclusions: All interviewees considered that the +Contigo project helped them to solve problems, improve their interpersonal skills and cope with the adolescence period. Students improved their self-esteem and self-knowledge, and were able to apply what they had learned in the sessions in their daily lives. We concluded that the project had a positive impact on the students’ mental health.

Keywords: Mental health, promotion; prevention, suicidal behavior, intervention, school

Introduction

The United Nations Convention on the Rights of the Child (UN, 1989 cited in WHO, 2001) recognizes that children and adolescents have the right to appropriate services which should be coordinated with schools and primary health care. With regard to interventions targeting specific contexts, the World Health Report on Mental Health considers that schools play a key role in preparing children for life, but alerts to the need of a greater involvement of children and adolescents in a healthy social and emotional development. Teaching lifelong skills, such as problem-solving, critical thinking, communication, interpersonal relations, empathy and emotion-coping methods, will allow children and adolescents to develop a strong and positive mental health (Mishara & Ystgaard, 2000).

According to the National Program for School Health (DGS, 2015), evidence allows us to affirm that multidimensional approaches are today more effective. We observe that interventions have a greater impact when they focus on risk reduction and involve the community. School Health intervention has a new paradigm that “aims to contribute to obtaining health gains through the creation of health-promoting school environments” (DGS, 2015, p.18). According to this Program, Mental Health promotion is at the core of School Health interventions, sustained by active methodologies and projects that focus on empowering young people for decision-making through the promotion of social and emotional skills with the purpose of increasing health protective factors. More specifically, adolescent-oriented interventions applied in these settings aim at the reduction of risky behaviors concerning the use of psychoactive substances and the problems of anxiety, depression, suicidal risk, and self-harm. These aspects are also covered in the 2013-2017 National Plan for Suicide Prevention (DGS, 2013).

Health and education professionals must acquire new or complementary skills to become increasingly capable of promoting mental health and healthy lifestyles at school through the implementation of projects in a relational support environment.

Problem statement

The assessment stage is extremely important for the whole process of design and implementation of health intervention projects, since it is the only way of knowing if the proposed objectives were achieved through an intervention or a series of interventions. The assessment helps to clearly and objectively understand all the work developed, always from a perspective of continuous learning and combining research with action.

The post-project monitoring or impact assessment phase allows determining if there were changes in people’s lives as a result of the intervention, if these changes persist and if there is the possibility of generalization to other contexts of daily life. These changes can affect not only those who participate in the project, but also others who, although not directly involved, may benefit from it, the environment itself and the school community.

As previously mentioned, although the effectiveness of the +Contigo Project has been assessed through a quantitative study, the results do not allow a complete understanding about the underlying details, both in terms of meaning and motivation. Therefore, assuming that the use of different tools to assess the same variable provides a broader view, we decided to conduct this pilot study to identify the qualitative impact of a school-based project aimed at promoting mental health and preventing suicidal behaviors.

Research questions

What is the impact of the implementation of the +Contigo Project on the mental health of eight grade students?

Purpose of the study

- To identify the importance assigned by students to the +Contigo Project;

- To identify problem situations whose resolution was facilitated by the project;

- To identify the project’s impact on an individual level.

Research methods

Design - This is a qualitative-descriptive study, aimed at increasing knowledge based on the adolescents’ opinions, attitudes, motivations and meanings concerning the phenomenon under study.

Sample and setting - The sample was composed of 16 8^th-grade students (5 girls and 11 boys) from three schools of the same school cluster in the Center Region. These students represent 10% of the total number of students in the experimental group and were referred by the teachers to the interview. Thus, this was a convenience sample. The geographical proximity and the fact that these students had participated in the project since its beginning were the criteria used for choosing this school cluster.

Instrument and data collection procedures - The project’s coordination team discussed the conduction of this study with the schools. The class directors referred the students to the interview. The interviews followed a 5-question semi-structured script and students were asked to talk about the following aspects “”; “”; “”; “” and “”. The individual interviews were carried out in June 2015 by two members of the team coordinating the project. Each interview lasted around 15 minutes and took place after the classes, according to the students’ availability, in a vacant room. The interviews were audio recorded.

Ethical considerations - As previously mentioned, the project’s implementation at the schools was authorized by the Services of Educational Projects of the Directorate-General for Education (Survey no. 0224900002). In addition, it was integrated in the Educational Plan of this School Cluster and the annual plan of activities of the School Health team. Parents and tutors gave their consent for the development of this study and were also informed of its voluntary nature. The confidentiality and anonymity of the obtained individual data were ensured, thus protecting the individuals involved in the study. With the purpose of ensuring the representativeness of the sample, we took into account the following conditions: the interviews were conducted in private; the participants were blinded to their colleagues’ answers; and the questions were restricted to a particular field of knowledge (Thiry-Cherques, 2009). To reduce the bias in social desirability, we conducted 16 interviews (Guest, Bunce & Johnson, 2006).

Data analysis - The interviews were fully transcribed. Bardin’s content analysis (2009) was used, in which categories were identified. We performed a comprehensive reading of the answers for an exploratory analysis of the text, which allowed us to start organizing the encoding and the indicators. We chose the category as the unit of record, and the sentence as the unit of context. With regard to the enumeration rule, we selected the frequency as counting measure for the number of times that a category emerged in the text. The criterion chosen for the categorical encoding corresponds to common aspects identified during the reading of the documental corpus through semantic concordance. Taking into account the amount of material to be analyzed, data were treated manually.

As regards the internal validity of the category system, we rigorously followed all of the steps provided for in the categorization process, from the composition of the corpus of analysis to the choice of the units of analysis and the quantification system. As regards the reliability of the content analysis, we observed the requirements previously set out: after the detailed explanation of the category system and the codification and analysis criteria, two external experts categorized a random sample of the documental corpus. A concordance rate above 80% was obtained, which can be considered satisfactory (Daval, 1964; Vala, 2009).

For each question, the answers were encoded using the letters of the alphabet, which were assigned according to the interview sequence, followed by the question number (e.g., A1 - A16; B1 - B16; E1 - E16). Taking into account the amount of material to be analyzed, data were treated manually.

Findings

Since we analyzed the data separately for each question, the results are presented on a per-question basis. A total of 14 categories emerged. Given the amount of information, we only present the data and discuss the results concerning the first four questions and corresponding 13 categories (Table 1).

The results are presented on a per-question basis with the corresponding discussion.

With regard to the first question (), the three categories identified highlight the importance of the project in the participants, which is a common aspect among the respondents. More specifically, the first category created was. Since students have understood the various steps in the problem-solving process, i.e. they are able to deconstruct the problem situation in four moments (What do I see? What do I imagine? What do I feel? What do I want?), this difficult situation becomes less catastrophic and easier to understand. Through this step-by-step strategy, which is taught and trained in the classroom, adolescents are able to better define and understand the problem, seeking to establish priorities and solve it by focusing on the most important aspect. The accounts concern not only the adolescents themselves, but also the whole class, which becomes evident in the following units of context: C1 “; D1 “E1”; G1 “J1 “”; M1 “”.

People with suicidal behaviors have difficulty in solving daily life problems due to their low level of social skills, sometimes associated with some cognitive rigidity (Cruz, 2006; Walsh & Eggert, 2007). Some studies have also demonstrated that interventions at the level of problem-solving and, consequently, in the acquisition/development of effective coping strategies can contribute to preventing suicidal behaviors (Santos et al., 2014). Through the intervention dynamics, adolescents begin understanding that some problem-solving strategies are more effective than others, and that these may change over time; they learn new strategies or adjust the existing ones to each situation. This Project also conveys the message that some problems are more complex and more difficult to solve than others, and that adolescents may need the help of other people, such as parents, teachers, friends, and health care professionals. Therefore, there are no “endless, insurmountable and intolerable” problems (Santos et al., 2014, p.69).

With regard to the second category,, the accounts focus on group issues, class cohesion and friendship, as can be seen in the following examples: B1 “I1 “L1 “.

These results refer to the opinions of authors who believe that collaborative work promotes and facilitates the development of key competences (such as leadership, interpersonal communication, decision making, and problem-solving). In a group, hence more restricted, context, it allows its members to try to solve their own problems in a more socially acceptable way, as well as to manage conflicts, by fostering group development, strengthening it. The group’s gains/productivity, the development of communication and an overall development of the participants are some of the advantages of collaborative group work (Jardim & Pereira, 2006; Lopes, Rutherford, Cruz, Mathur & Quinn, 2006). Other authors also consider the importance of certain key elements in a collaborative or cooperative learning situation, namely teamwork; negotiation skills (as the opposite of imposing a given task or opinion, negotiating means arguing, standing for something, persuading); interdependence and positive interaction (in which group members know that they will not succeed if they do not work together for a common purpose). It is necessary to coordinate efforts and understand that one person’s actions affect/depend on everyone’s actions and vice versa (Silva, 2008).

The third category,, refers to new and sometimes difficult situations, to the discovery of this new phase of growth/development, its challenges and how to overcome them: A1 “; H1 “(…)”; P1 “.

This awakening to a different experience at this stage of the life cycle (adolescence) falls within stage five “‘Identity versus Role Confusion” of Erikson’s theory of psychosocial development (1976). Its main task is the successful resolution of the personal identity crisis, considering the as the way in which we see ourselves and how others see us, embracing a double component of personal identification. Adolescents build their self-concept and self-esteem based on their own personal representations. For individual personality to become stable, their development needs to be based on strong and solid foundations, such as their relationships with family, friends, and significant persons. The existence of this type of social support, which includes the school, is a fundamental network to reduce the risk of experiencing rupture points or problems seen as unsurmountable by the adolescents (Claudino, Cordeiro & Arriaga, 2006).A brainstorming on adolescence is performed through a classroom intervention. Some of the most common expressions/ideas were “body changes, group, conflicts, school, autonomy, decisions, convictions, (…), experiences, sex, drugs, alcohol, crisis, passions, rebelliousness, friendship, autonomy, independence” (Santos et al., 2014, p. 55). The key ideas conveyed to the group are that “adolescence is a phase of life like any other phase. It is not synonymous with problems or suffering (…). It is a phase of growth and transformation and of making some important decisions. It is a period of discovery and important achievements (…). Mistakes are made and lessons are learned in this phase, as in any other phase in life” (p. 55). There are more complex situations that sometimes require help from other people and it is important to recognize it and be able to ask for help.

Most of the answers to the second question () relate to, a category which stood out due to the high number of accounts. These activities are the basis for the classroom dynamics during the project’s intervention sessions and relate to the type of participation and strategies used: H2 “”.

was the second category emerging from the content analysis to this question and can be seen in the following account: G2 “; H2 “.

also emerged as a category, despite being less mentioned than the other categories: C2 “What I liked most was the positivity, because we are very negative sometimes and the project brings us a lot of positivity to believe in ourselves, believe in the good things, that everything will be ok (…)”.

Among these results, we emphasize the games, the exercises, the possibility of learning new theoretical contents, the fact that students had fun participating in the project, the work done together with colleagues, and the possibility of being able to speak openly and discuss issues which somehow worried them. The activities are similar to those developed in the +Contigo Day (role-playing, writing poems, creating bookmarkers with positive messages, music and dance, launching balloons with project-related sentences, distributing smiley cookies, etc.) had a similar purpose. These results are in line with Durlak, Weissberg, and Pachan (2010), who consider that the most active and diverse strategies are the most effective way for adolescents to learn social skills. The friendly atmosphere experienced in the sessions contributed to the group strengthening based on trust, support, companionship and friendship, which is in line with other qualitative studies conducted within this scope (Murta et al., 2009; Simões, 2010). The possibility of spending time with colleagues who are in the same circumstances offers reassurance to the adolescents, allowing them to experience their emotions, talk about their concerns and difficulties, without feeling pressured, in an emotionally supportive environment (Dias, Matos & Gonçalves, 2007; Loureiro, Frederico-Ferreira & Santos, 2013; Matos & Sampaio, 2009). The classroom dynamics combined with a group reflection promote the acquisition of positive social skills and the creation of protective factors based on a healthy personal development that promotes a good mental health.

With regard to the third question (), the completion of the questionnaires was clearly considered to be a less interesting task when compared to the session dynamics. The respondents also disliked some theoretical aspects that were discussed in the sessions to help consolidate some knowledge. Although the categorywas only mentioned three times, it still should be discussed. We illustrate it with the following unit of context: G3 “”.

Although the group activities took place in the protected environment of the classroom, with their peers and people who already know them, adolescents may feel somewhat uncomfortable as a result of having to remember and talk about situations that could have been more difficult to solve in the past or that might still be very much present in their minds. Even minimizing the individual exposure within the group, dealing with these situations requires a great sensitivity from the health care professionals leading these sessions, who must be trained in Mental Health. Therefore, the facilitator’s personal characteristics and professional competences are important factors for the success of this type of interventions (Loureiro, 2013). The facilitator should have an attitude of leadership based on a helping relationship, i.e. understand the other in an empathic, judgment-free way, promoting a relationship of trust, while being able to keep the group active and cohesive and achieve the set out objectives by promoting skills training. These characteristics, combined with a more differentiated knowledge, the use of humor, conflict management and problem-solving skills, a sense of coherence, wholehearted respect, genuine interest, and assertiveness, fall within the profile of competencies of the Mental Health RNs in Portugal.

The ability to listen without judging, to correctly decode silence or what is indirectly said, believing that adolescents are capable of changing less healthy behaviors and maintaining positive health behaviors, are some of the competencies and beliefs that Mental Health RNs should possess in their daily practice and in this type of interventions to better understand the adolescents’ health needs and concerns (Loureiro, 2013).

The fourth question () resulted in four categories of analysis which mainly refer to improved interpersonal relationships, increased self-esteem and self-knowledge, and the possibility of using in everyday situations the strategies/knowledge learned throughout the intervention. We describe the categories below, illustrating them with some units of context.

: B4 “(…) I also made new friends because of the song, I didn’t know most of the others, (…) and I also get along with some friends of my friends, it helped… it helped me a lot. It also helped the other students, some of them didn’t behave so well before and now they are behaving a bit better”; J4 “It helped me to deal with many situations, sometimes it was more difficult for me to talk with my friends and my parents and it helped me to communicate in a more open way, communicate more with other people, have more conversations with my colleagues, parents and teachers”.

These results are in line with those of authors who emphasize the positive development of interpersonal relationships as one of the consequences of social skills training (Coplan, Schneider, Matheson & Graham, 2010; Harrell, Mercer & DeRosier, 2009; Jones & Lavallee, 2009).

: D4 “(…) it helped me to feel good about myself, have more self-esteem, more confidence in my abilities, because I know that I have good skills, and that I have to use them in a good, positive way, that’s it, the +Contigo Project helped me a lot”; F4 “(…) I was having a few problems with my height, because I am very short, sometimes that is a disadvantage but other times it is also an advantage … and the project helped me feel good about myself and who I am. If someone doesn’t like me, it’s their bad…”.

As a self-concept component, self-esteem is a dimension that is positively associated with assertive communication. The greater the self-respect, self-appreciation and self-affection, the easier is the relationship with the others, i.e. self-esteem is associated with a successful social performance (Alberti & Emmons, 1983; Galassi & Galassi, 1977). On the other hand, the scientific evidence points to an association between suicidal ideation and suicide attempts and low self-esteem (Fergusson, Beautrais & Horwood, 2003). Low levels of self-esteem lead to a negative self-evaluation, difficulties in dealing with everyday problems, and to face the future with pessimism. Through the participation in the sessions, adolescents spend time with others, listening to them, processing the information and reflecting on what was said. This makes them feel important, and facilitates the reflection on feelings and the increase of self-esteem (Castanyer, 2004). All these studies show the importance of the assertive behavior as a predictor of a healthy development and a proper social experience with high levels of self-esteem and self-confidence, which is expected to be a good strategy for the promotion of healthy behaviors.

: A4 “Yes, because it helped me to know myself better and also understand things which I thought were, like, head problems, simple things”; E4 “In a way, it helped me find myself, to question if I’m a troublemaker… It also helps us to reflect a bit on how to act, or to change or if we want to keep our behavior”; G4 “It helped me to reflect about myself. It gave me a lot of information and helped me change my behavior in some situations (…)”; H4 “(…) It made me think of a lot of things and reflect on my attitudes (…)”.

This category encompassed the recognition of beliefs, values, attitudes, behaviors and emotions, the understanding of the impact of self-knowledge on the person and the others, and the understanding that our behavior interferes with our relationship with the others. Among the reported aspects, we emphasize the possibility of raising the respondents’ awareness of their own behavior in social interactions, the possibility of self-control, becoming aware of what they do and what they feel, being capable of showing their emotions, not isolating themselves, appreciating what they feel and enjoying talking about themselves. This finding is also in agreement with the results of other studies (Minto, Pedro, Netto, Bugliani & Gorayeb, 2006; Rocha & Monteiro, 2012; Simões, 2010). Thus, this ability to talk about themselves with a more critical perspective about what they feel and how they behave can be related to the group as a “source of exchange of meanings of the experienced events” (Murta et al., 2009, p.185), which may lead to the development of adaptive functional strategies to cope with their own difficulties. The phase of adolescence includes the task designated by Erikson (1976) as “Identity Crisis Resolution”. The question is answered through an increasingly greater self-knowledge, with the group having a relevant role of privileged support network that helps overcome this task successfully.

: H4 “(…) and still today I try to improve myself with the advices that I have learned in the sessions because I think they are useful and needed in everyday life”; P4 “(…) they gave me suggestions that I apply in my day to day and now everything is OK”.

Most accounts indicate a perception of a positive change in terms of the adolescents’ relationship with the self and with others. These results are important since they refer to the possibility of adaptation to new situations, given the changes in social behaviors. The school-based interventions targeting social skills training allow the translation into real-life situations, thus facilitating the generalization of the outcomes to different contexts, allowing the adolescent to adapt to new situations (Evans, Langberg & Williams, 2003; Spence, 2003). The major challenge of this type of interventions is the opportunity to change social behaviors, in such a way that they can extend from the setting into the daily social interactions (Barrett, Lock & Farrel, 2005; Coplan et al., 2010; Evans et al., 2003).

These results are very positive. More importantly, the interviewed adolescents show a perception of positive change at various levels (intrapersonal, interpersonal and group). Although this paper focuses on the results of the study conducted with 8^th-grade students, another study was also conducted, using the same methodology and similar questions, with 3 teachers and 2 nurses who acted as facilitators in the intervention sessions. The existing data confirm the students’ perceptions concerning the change of behavior in the class due to greater group cohesion, improved interpersonal communication and increased self-esteem among the students who participated in the project. Thus, more than one source of information was used to check what really happens in the actual context of social interaction.

Conclusions

According to all interviewed adolescents, the +Contigo Project helped them to solve problems, to establish an assertive communication, and to experience adolescence. It also contributed to improve their self-esteem, self-knowledge and interpersonal relationships so that they could apply in their day-to-day the knowledge acquired during the sessions. We also observed a strengthening of group/class cohesion. The project had a very positive impact on the participating students, and its objectives can be considered as accomplished since all the students understood the importance of the +Contigo Project and identified situations which their participation in the project helped solve. The +Contigo Project contributed directly to the students’ well-being and a good relationship within the educational community. It also improved the relationship between the educational community and the local health services. Networking allows increasing prevention, and the development of these socioemotional skills can contribute to reduce suicidal behaviors.

Taking into account the initial research questions, we concluded that the project had a positive impact on the students’ mental health.

Although the results on the impact of the intervention are quite positive, we require data to validate these results as a whole. However, we cannot fail to emphasize that most answers seem to point to the importance of the perception of change.

These results are relevant, but must be relativized since the group strategy, despite its positive aspects, can also be a limiting factor for preventing an individual approach to each student. The use of a convenience sample may also have influenced the results. It is important to use more than one source of information and several interaction settings for an accurate validation of the changes perceived by the participants.

Acknowledgements

The authors would like to thank everyone involved in this study for their time and availability.

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