Thesis for the degree of Doctor of Philosophy, Sundsvall 2010

LIFE CIRCUMSTANCES AND ADOLESCENT MENTAL HEALTH

Perceptions, associations and a gender analysis

Evelina Landstedt

Supervisors:
Katja Gillander Gådin
Kenneth Asplund

Department of Health Sciences

Mid Sweden University, SE-851 70 Sundsvall, Sweden

ISSN 1652-893X
Mid Sweden University Doctoral Thesis 93
ISBN 978-91-86073-89-3
Akademisk avhandling som med tillstånd av Mittuniversitetet i Sundsvall
framläggs till offentlig granskning för avläggande av filosofie doktorsexamen 17
december, 2010, klockan 10.30 i sal M108, Mittuniversitetet Sundsvall.
Disputationen kommer att hållas på svenska.

LIFE CIRCUMSTANCES AND ADOLESCENT MENTAL HEALTH

Perceptions, associations and a gender analysis

© Evelina Landstedt, 2010

Department of Health Sciences

Mid Sweden University, SE-851 70 Sundsvall
Sweden

Telephone: +46 (0)771-975 000

Printed by Kopieringen Mid Sweden University, Sundsvall, Sweden, 2010

i
 To my brother Niklas

ii
ABSTRACT

Evelina Landstedt (2010)

Life circumstances and adolescent mental health: perceptions, associations and a
gender analysis
Department of Health Sciences, Mid Sweden University, Sundsvall, Sweden
ISBN 978-91-86073-89-3; ISSN 1652-893X, Doctoral Thesis 93

Despite a well-documented gender pattern of adolescent mental health, public

health research investigating possible influencing factors from a gender-theoretical
approach is scarce. This study aimed to explore what factors and circumstances are
related to adolescent mental health and to apply a gender analysis to the findings
in order to improve the understanding of the relationships between life
circumstances and the gendered patterning of mental health among young people.

The study population was 16-19-year-old Swedish students and data was collected
by means of focus groups (N=29) and self-administered questionnaires (N=1,663,
78.3% response rate) in school settings. Mental health problems were defined in a
broad sense including the adolescents’ own understandings, perceived stress,
psychological distress and deliberate self-harm.

The mental health problems of perceived stress, psychological distress and

deliberate self-harm were twice as common among girls as boys. The findings
suggest that adolescent mental health is associated with the life circumstances of
social relationships, demands and responsibility taking and experiences of violence
and harassment. Supportive relationships with friends, family and teachers were
found to be of importance to positive mental health, whereas poor social
relationships, loneliness and lack of influence were associated with mental health
problems. Perceived demands and responsibility taking regarding school work,
relationships, future plans, appearance and financial issues were strongly related
to mental health problems, particularly among girls regardless of social class. The
results indicate that physical violence, sexual assault, bullying and sexual
harassment are severe risk factors for mental health problems in young people.
Boys and girls experienced different types of violence, and the victim-perpetrator
relationships of physical violence differed. These diverging experiences appeared
to influence the associations with mental health problems in boys and girls.

A gender analysis provides the tools to gain knowledge about the ways that boys’
and girls’ lives are shaped by gender relations and constructions at different levels

iii
in society and how these life circumstances represent risk- or protective factors for
mental health. For example, unequal power structures and the ways girls are
expected to ‘do’ femininity likely influence their life circumstances in ways that
place them at greater risk of mental health problems. Hegemonic constructions of
masculinity and advantaged positions likely contribute to life circumstances that
are positive for mental health but are also implying risk factors for poor mental
health among boys, e.g., violence. It is also important to recognise how the
intertwined cultural and structural aspects of gender and social class influence the
lives and mental health of boys and girls. In conclusion, gendered and class-related
mechanisms at the different levels in society influence the distribution of risk
factors unevenly among boys and girls, which could be a possible explanation for
the gender differences in reports of perceived stress, psychological distress and
deliberate self-harm.

The likelihood of gender and socioeconomic differences in mental health problems

should be taken into account in prevention and health promotion strategies at all
levels in society. A greater awareness about gender relations and the gendered
social circumstances under which young people live is required. The school
environment is an important arena with respect to prevention and health
promotion. There is also a need for a joint action against violence and harassment
at all levels in society. Implications do not only concern young people; social policy
and legislation should focus on reducing gender and class inequalities in general.

Key words: Stress; Psychological distress; Deliberate self-harm; Students;

masculinity, femininity; social determinants; social relationships; demands;
responsibility taking; violence and harassment; school.

iv
SAMMANFATTNING

Svensk titel: Livsvillkor och ungdomars psykiska hälsa: uppfattningar,

associationer och en genusanalys.

Trots ett väldokumenterat genusmönster i ungdomars psykiska hälsa finns det en

kunskapslucka i den folkhälsovetenskapliga forskningen avseende genusteoretiska
analyser av sambanden mellan ungas livsvillkor och psykisk hälsa. Föreliggande
studie syftade till att undersöka vilka faktorer och omständigheter som är
relaterade till psykiska problem, samt att analysera fynden ur ett genusperspektiv
för att fördjupa förståelsen av relationerna mellan ungas livsvillkor och
genusmönster i psykiska hälsa.

Studiepopulationen var gymnasielever i åldern 16-19 år. Studien genomfördes i

skolmiljö och data insamlades genom fokusgrupper (N=29) och en enkätstudie
(N=1,663, 78.3% svarsfrekvens). En bred definition av psykisk ohälsa tillämpades
vilken representerades av ungdomarnas egen förståelse, samt de psykiska
problemen upplevd stress, psykiska besvär samt självskadebeteende.

Resultaten visade att stress, psykiska besvär och självskadebeteende var dubbelt så
vanligt bland flickor som bland pojkar. Psykiska problem var relaterade till
livsvillkoren sociala relationer, krav och ansvarstagande samt utsatthet för våld
och trakasserier. Stödjande relationer med vänner, familj och lärare var av stor
betydelse för psykisk hälsa medan dåliga relationer, ensamhet och brist på
inflytande var relaterat till psykiska problem. Psykiska problem var starkt
kopplade till erfarenheter av höga krav och ansvarstagande avseende skolarbete,
relationer, framtidsplaner, utseende och ekonomi, i synnerhet bland flickor oavsett
socioekonomisk bakgrund. Resultaten indikerar att olika former av våld och
trakasserier är allvarliga riskfaktorer för psykiska problem och att flickors och
pojkars skiljda erfarenheter av olika former av våld samt relationen till förövaren,
kan vara relaterade till skillnader i psykiska problem.

Genusanalysen av resultaten föreslår att flickors livsvillkor påverkas av ojämlika

maktstrukturer och konstruktioner av femininitet och att dessa livsvillkor bidrar
till en ökad risk för psykisk ohälsa bland flickor. Livsvillkor kopplade till manlig
överordning och hegemoniska konstruktioner av maskulinitet influerar sannolikt
pojkars psykiska hälsa positivt. Dessa villkor kan dock också innebära risk faktorer
för psykiska problem, t.ex. i fråga om våld. Studien uppmärksammar även hur
kulturella och strukturella aspekter av både genus och social klass kan påverka

v
livsvillkor och psykisk hälsa för pojkar och flickor. Studiens slutsats är att
genusifierade och klassrelaterade mekanismer på olika nivåer i samhället bidrar till
en skev fördelning av riskfaktorer för psykiska problem vilket kan vara en möjlig
förklaring till skillnaderna mellan pojkar och flickor i fråga om upplevd stress,
psykiska besvär och självskadebeteende.

Genus- och socioekonomiska skillnader i psykiska problem bör tas i beaktande i

preventivt och hälsofrämjande arbete på alla nivåer i samhället. Detsamma gäller
för en ökad medvetenhet om hur ungas livsvillkor är relaterade till psykisk hälsa
och hur dessa villkor är genus- och klassrelaterade. Studien uppmärksammar
skolan som en viktig arena för preventivt och hälsofrämjande arbete samt att
gemensamma insatser krävs på olika arenor för att motverka våld och trakasserier.
Implikationer av studien omfattar även generella samhällspolitiska insatser för
minskad ojämlikhet.

Nyckelord: Stress; psykiska besvär; självskadebeteende; gymnasieelever;

maskulinitet; femininitet; sociala determinanter; sociala relationer; krav;
ansvarstagande; våld och trakasserier; skola.

vi
TABLE OF CONTENTS
ABSTRACT.............................................................................................................. III

SAMMANFATTNING ................................................................................................V

LIST OF PAPERS .....................................................................................................X

PREFACE ................................................................................................................. 1

BACKGROUND ........................................................................................................ 2

CENTRAL CONCEPTS IN THE THESIS .....................................................................................3

Adolescence ....................................................................................................................3
Mental health .................................................................................................................3
Life circumstances ..........................................................................................................4
Gender ............................................................................................................................4
Social class/Socioeconomic status .................................................................................4
MENTAL HEALTH PROBLEMS - PREVALENCE AND UNDERSTANDINGS ..................................5
Stress ..............................................................................................................................5
Depression, anxiety and psychological distress .............................................................5
Deliberate self-harm ......................................................................................................6
How young people understand mental health ................................................................6
THEORETICAL FRAMEWORK ................................................................................................7
A public health approach ...............................................................................................7
A gender theoretical approach .......................................................................................8
SOCIAL DETERMINANTS OF ADOLESCENT MENTAL HEALTH ..............................................11
Family and peers ..........................................................................................................11
School ...........................................................................................................................11
Structure .......................................................................................................................12
Socioeconomic patterning ...................................................................................................... 12
Culture and media – Body image ........................................................................................... 12
Violence and harassment ........................................................................................................ 13
PREVALENT HYPOTHESES OF GENDER DIFFERENCES IN MENTAL HEALTH..........................13
WHY THIS STUDY? ............................................................................................................14
THE STUDY – AIMS AND RESEARCH QUESTIONS.................................................................16

METHODS .............................................................................................................. 17
MULTI-METHOD APPROACH ..............................................................................................17
CONTEXT ..........................................................................................................................18
THE QUALITATIVE STUDY (PAPER I)..................................................................................19
Grounded Theory .........................................................................................................19

vii
 Focus groups ................................................................................................................19
Participants ..................................................................................................................19
Procedure .....................................................................................................................20
Analysis ........................................................................................................................21
THE QUANTITATIVE STUDIES (PAPERS II, III, IV) ..............................................................21
Data collection and procedure .....................................................................................21
Participants ..................................................................................................................21
The questionnaire .........................................................................................................22
Measures ......................................................................................................................22
Dependent variables – mental health outcomes ...................................................................... 22
Stress and stressors............................................................................................................. 22
Psychological distress ........................................................................................................ 23
Deliberate self-harm (DSH) ............................................................................................... 24
Independent variables ............................................................................................................. 24
Control variables .................................................................................................................... 24
Analyses .......................................................................................................................25
ETHICAL CONSIDERATIONS ...............................................................................................27
The qualitative study ....................................................................................................27
The quantitative study ..................................................................................................27

FINDINGS ............................................................................................................... 28
HOW IS MENTAL HEALTH UNDERSTOOD BY YOUNG PEOPLE? (PAPER I) ............................28
WHAT IS THE PREVALENCE OF MENTAL HEALTH PROBLEMS AND HOW ARE MENTAL
HEALTH PROBLEMS PATTERNED? (PAPERS II, III, IV)........................................................ 28
HOW ARE SOCIAL RELATIONSHIPS RELATED TO MENTAL HEALTH?
(PAPERS I, II, IV) ..............................................................................................................31
HOW ARE EXPERIENCES OF DEMANDS AND RESPONSIBILITY RELATED TO MENTAL HEALTH?
(PAPERS I, II, IV) ..............................................................................................................33
Demands and responsibility – achievements ................................................................33
Demands and responsibility – gender performance, social relationships and financial
issues ............................................................................................................................34
HOW ARE EXPERIENCES OF VIOLENCE AND HARASSMENT RELATED TO MENTAL HEALTH?
(PAPERS I, III, IV) .............................................................................................................35
Victim-perpetrator relationship of physical violence ...................................................38

DISCUSSION .......................................................................................................... 40
ON THE RESULTS ...............................................................................................................40
Mental health problems ................................................................................................40

viii
 Understandings ....................................................................................................................... 40
Prevalence and patterning ....................................................................................................... 40
Factors and circumstances related to mental health problems ....................................41
Social relationships................................................................................................................. 41
Demands and responsibility-taking ........................................................................................ 43
Achievements ..................................................................................................................... 43
Doing girl – doing boy ....................................................................................................... 45
Financial issues .................................................................................................................. 46
Violence and harassment ........................................................................................................ 47
Joking ................................................................................................................................. 47
Gender patterning, associations and a gender analysis ....................................................... 47
Summary of the gender analysis ...................................................................................52
Critical reflections on applying a gender analysis .......................................................53
METHODOLOGICAL CONSIDERATIONS ...............................................................................53
Multi-methods ..............................................................................................................53
The qualitative study ....................................................................................................53
The quantitative studies ................................................................................................55
IMPLICATIONS AND FUTURE RESEARCH .............................................................................58

CONCLUSIONS ...................................................................................................... 61

ACKNOWLEDGEMENTS....................................................................................... 62

REFERENCES ........................................................................................................ 64

APPENDICIES ........................................................................................................ 78

APPENDIX 1. INTERVIEW GUIDE – AN EXAMPLE ................................................................78

APPENDIX 2. EXAMPLES OF QUESTIONS IN THE QUESTIONNAIRE .......................................79
APPENDIX 3. EXAMPLES OF RESPONSES ON SPECIFIC QUESTIONS ......................................81
APPENDIX 4. OVERVIEW OF INTERACTION EFFECTS ..........................................................82

ix
LIST OF PAPERS

The thesis is based on the following papers, which are referred to in the text by
their Roman numerals:

I. Landstedt E, Asplund K, Gillander Gådin K (2009) Understanding

adolescent mental health: The influence of social processes, doing gender
and gendered power relations. Sociology of Health and Illness. 31(7), 962-78.

II. Landstedt E, Gillander Gådin K. Seventeen and stressed – do gender and

class matter? Submitted manuscript.

III. Landstedt E, Gillander Gådin K. Experiences of violence and reported

psychological distress in 17-year-old students: a gender analysis.
Resubmitted manuscript.

IV. Landstedt E, Gillander Gådin K. (2010) Deliberate self-harm and associated

factors in 17-year-old Swedish students. Scandinavian Journal of Public
Health. DOI number: 10.1177/1403494810382941. In press.

Published papers are reprinted with the permission of the copyright holders.

x
PREFACE

”Child and adolescent mental health is a necessary priority for the healthy development of
societies.” (WHO 2010).

This thesis investigates what factors and circumstances are related to adolescent
mental health and how a gender analysis can contribute to a deeper understanding
of the links between life circumstances and the mental health of boys and girls in
late adolescence. This research is inspired by my strong beliefs in equality, change
and young people’s rights to well-being as well as and an endless curiosity, which
has made and is still making me ask ‘why?’

From an early age, I have had deeply rooted beliefs in equality. In addition to
leading me into the social and political arenas, these beliefs have inspired me to
pursue university studies in philosophy, sociology and gender studies. Later on,
these social, political and theoretical paths merged into the study of public health
sciences. I became more aware of inequalities in health and the social and gendered
distribution of determinants of health. Around year 2001, alarming reports about
the deterioration of young people’s mental health, particularly among girls,
became increasingly frequent. Adolescent mental health was on the public health
agenda, and in my view, young people’s rights to health and well-being were
under threat. I believe in the rights of young people, and I strongly object to
circumstances that jeopardise their rights and well-being, such as drugs,
marginalisation, violence, inequality and mental ill health.

I have not only been driven by a commitment to political and social issues, but I
am also and have always been driven by a curiosity that I have had the chance to
develop in academia. Through questions like ‚how is knowledge created and how
does knowledge lead to change?‛, research became tremendously interesting and
appealing. An undergraduate thesis in sociology gave me the opportunity to start
exploring the field of adolescent mental health. The key insights I gained from this
work include the tendency in research to acknowledge the persistent gender
patterning of mental health but to not ask the question of why it exists or apply a
critical gender analysis. These issues were further developed in an empirical
master’s thesis in public health sciences and, currently, in a Ph.D. project. Not only
is it social injustice in itself that a generation of young people report elevated levels
of mental health problems, but the prevalent gender pattern raises gender-equality
issues both in terms of the need to acknowledge the existing gap between boys and
girls, but also and foremost to better understand what is creating this inequality.
Such knowledge is needed in order to prevent mental ill-health, and more
importantly, to promote good mental health. This thesis, I hope, is one way of
making advances towards those goals.

1
BACKGROUND

Adolescence represents a complex transition from childhood to adulthood, which

inevitably implies new challenges for boys and girls. These challenges include
aspects related to mental well-being that not only stem from changes in
relationships and demands related to the emergence into adulthood in a globalised
world, but also from existential thoughts and developmental changes (Rutter and
Smith 1995; Zubrick et al. 2000). That is to say, one could neither expect nor strive
for the total absence of mental distress in young people; it is a part of being young
(Michaud and Fombonne 2005). Nevertheless, there are many reasons to be
worried about the mental health of adolescents, of which some are outlined below.
First and foremost, mental ill-health (including mental disorders) represents a
major global health problem that affects young people (Kolip and Schmidt 1999;
Patel et al. 2007). Apart from the individual suffering, the burden of mental ill-
health can be quantified by the measure of disability-adjusted life years (DALY).
According to a review of research on adolescent mental health, mental disorders in
young people contribute to up to 70 percent of the total DALY (Patel et al. 2007).
Poor mental health during adolescence is also a risk factor for mental illness in
adulthood (Aalto-Setälä et al. 2002; Fergusson and Woodward 2002).

In addition, over the past decades, there has been an increase in the rates of self-
reported mental health problems among young people in Western countries, but
there has been no comparable rise in those rates in older age groups (Rutter and
Smith 1995). This trend has also been shown in a Nordic context (Berntsson and
Köhler 2001; Hagquist 2009) as well as in other European countries (Collishaw et
al. 2004; Fombonne 1998; Gunnell et al. 2000; West and Sweeting 2003). It has also
been found that this increase is particularly prevalent among 15-year-old girls
(Hagquist 2010, Hagquist 2009, Sweeting et al. 2009). Less is known about the
trends among girls and boys in late adolescence. Although the trends in the
occurrence of mental ill-health in young people are alarming and deserve
attention, they are not the main focus of this thesis.

Taken together, mental health problems represent a significant burden to both

adolescents and societies and are public health issues of high priority (Kolip and
Schmidt 1999; Patel et al. 2007; Sawyer et al. 2007; Zubrick et al. 2000).

2
Central concepts in the thesis
Adolescence
Adolescence is a fluid, culturally sensitive concept that can be defined as a phase in
life between the ages of 10-19 years (WHO 2005). Others prefer using the notion of
‘young people’ when referring to individuals aged between 12 and 24 years (Rutter
and Smith 1995). This thesis focuses on people of ages 16-19 years, which is a
period described as ‘late adolescence’ and the individuals who are the subject of
this thesis are referred to as ‘adolescents’, ‘students’ and ‘young people’.

Mental health
The field of research on adolescent mental health encompasses a wide range of
disciplines, such as psychology, psychiatry, sociology, education and the public
health sciences. Consequently, the list of definitions of mental health is endless,
although it is likely that most scholars within these fields would agree that mental
health refers to an individual’s emotional and psychological well-being as well as
the presence or absence of a mental disorder. The World Health Organisation
argues that mental health is more than the absence of a disorder and defines it as
follows: ‚Mental health can be conceptualized as a state of well-being in which the
individual realizes his or her own abilities, can cope with the normal stresses of
life, can work productively and fruitfully, and is able to make a contribution to his
or her community‛ (WHO 2007). In this thesis, a broad empirical conceptualisation
of mental health, or more precisely, mental health problems, is asserted. Rather
than targeting specific disorders (e.g., diagnosed depression or anxiety syndrome)
several self-reported mental health problems are in focus: perceived stress,
psychological distress (mainly depressive and anxiety-related problems) and
deliberate self-harm. These problems are considered to represent different aspects
of mental health, which although not investigated in detail here, are assumed to be
interrelated. This interrelationship is exemplified in Figure 1, which also illustrates
the three mental health problems on a continuum where perceived stress
represents the least severe state and deliberate self-harm the most severe state.

Figure 1. Schematic illustration of the mental health problems examined and the
relationships between them.

3
Life circumstances
The concept of ‘life circumstances’ refers to the material as well as cultural and
psychosocial conditions under which people live. Other terms used in this thesis
are ‘contextual’ or ‘environmental’ factors. Life circumstances relate to the social
determinants of health, which are considered in more detail and with examples in
the section on the public health approach and the review of the literature on factors
associated with adolescent mental health.

Gender
Gender refers to the cultural and social constructions of what it means to be a
man/boy or a woman/girl in a given society and how that is enacted in social
practice. Gender also refers to a fundamental organisational principle in society as
well as social relations and hierarchies. The concept of gender is used throughout
the thesis. However, in the statistical analysis, gender was operationalised as a
binary category (boy/girl), and the adolescents were ascribed to each category
based on their own indication in the questionnaire. Given that the focus groups
were single sex and self selected, the participants chose their gender
identity/position for themselves. All non-mixed groups were, however, constituted
by biologically defined boys and girls. No transgender persons took part in the
study. Because gender is the social structure that is central to this thesis, the
concept is elaborated upon in more detail below.

Social class/Socioeconomic status

The terms social class and socioeconomic status (SES) are conceptualisations of the
locations of people and groups of people within a social structure. There is a vast
amount of theoretical and empirical work on the matter, for example, the Marxian,
Weberian and Bourdieuan schools of thought, which are unfortunately beyond the
scope of this thesis. Despite the risk of mixing theoretical understandings and
definitions by using two concepts, social class and socioeconomic status (and in
some occasions also socioeconomic position) both refer to the material (e.g., access
to resources) as well as cultural and psychosocial aspects (e.g., education, values
and ‘social capital’) of social stratification (Lynch and Kaplan 2000, Skeggs 1997). It
is notable that most existing conceptualisations and measures regard adults and
there is an ongoing discussion as to whether adolescents’ socioeconomic status can
or should be defined and measured according to their parents’ class/SES (e.g.,
household income or education level) and to what extent young people’s own
perception or indication of their socioeconomic status should be taken into account
(Goodman et al. 2007; Hagquist 2007; West and Sweeting 2004). In the present
thesis, this is of particular interest because the adolescents of interest (16-19-year-
olds) are in the transition to adulthood. Details on the indicators of social class/SES
used are found in the methods section.

4
Mental health problems - prevalence and understandings
Stress
Stress can be regarded as both an exposure (stimulus) and a response (outcome)
(Ollfors and Andersson 2007). In the present thesis, perceived stress is seen as an
outcome and a dimension of general mental health. Stressors, on the other hand,
are considered sources of stress. As illustrated in Figure 1, it is likely that there is
overlap between stress and psychological distress. Several studies suggest that
stress is a mediator between, for example, an individual’s environment and mental
health problems (Bovier et al. 2004; Hazel et al. 2008; Wagner and Compas 1990).
There is also a large body of evidence showing associations between stress and
various mental health problems (Adkins et al. 2008; Byrne et al. 2007; Compas et al.
1993; Hankin et al. 2007, McLaughlin and Hatzenbuehler 2009, Meadows et al.
2006; Rudolph 2002; Torsheim and Wold 2001).

There is consistent evidence of girls reporting higher levels of general stress than
boys (Gillander Gådin 2002; Rudolph 2002; Ystgaard 1997). Swedish data from the
Health of School Children Study (HBSC) show that girls in grade nine
(approximately 15-16-year-olds) report significantly higher levels of perceived
stress than boys (Danielson 2006), a result also shown by a report on upper
secondary school students from the Swedish Agency of Education (2007). Less
scientific evidence is available on stress levels in older Swedish adolescents.
However, Ollfors and Andersson (2007) concluded that, relative to boys, 16-19-
year-old girls reported higher levels of stress on the majority of the stressor
investigated, for example stress related to school work, demands and the physical
environment.

Depression, anxiety and psychological distress

The rate of mental health problems linked to depression and/or anxiety is
approximately 15-25 percent in the general adolescent population in Western
countries (Hankin et al. 1998; Patel et al. 2007, Sawyer et al. 2007, Zubrick et al.
2000). Overall, there is a substantial gender pattern where girls and young women
are 1.5 to 3 times more likely than boys/young men to report depressive and
anxiety symptoms (Aalto-Setälä et al. 2002; Ge et al. 1994; Hankin et al. 1998;
Lewinsohn et al. 1998; Nolen-Hoeksema and Girgus 1994; Patel et al. 2007). With
respect to a broader notion of self-reported psychological distress, a large body of
evidence shows the same trends. For example, in a Scottish sample of 15-year-old
students, psychological distress (measured by the General Health Questionnaire
GHQ-12) was reported by 44.1 percent of the girls and 21.5 percent of the boys
(Sweeting et al. 2009). The corresponding GHQ-rates among young adults in
Sweden (18-24-year-olds) has been found to be 32.9 percent among young women
and 17.3 percent among young men (Nilsson et al. 2010). Similarly, according to a

5
Swedish study, psychosomatic symptoms were nearly three times as common
among 15-16-year-old girls (19.8 percent) as boys (7.4 percent) (Hagquist 2009).
Results from the cross-national study Health Behaviour among School Children
(HBSC) showed that approximately 25 percent of European and North American
girls (15-year-olds), compared to 16 percent of boys, reported having symptoms of
psychological distress several times a week (Torsheim et al. 2006). In addition to
showing the salient gender differences in adolescent mental health, this short
review highlights the lack of studies of young people in their late adolescence.

Deliberate self-harm
Deliberate self-harm has been referred to as an act with a non-fatal outcome in
which an individual deliberately initiates specific behaviours (e.g., self-cutting) or
ingests a substance, drug or object with the intention of causing self-harm (Hawton
et al. 2002; Ystgaard et al. 2009). Some researchers also include in the definition that
the self-injury is not life-threatening and is without suicidal intent (Laye-Gindhu
and Schonert-Reichl 2005). Evidence from population- or community-based
American, Australian and European studies in young people report a lifetime DSH
prevalence of 7-15 percent (8-24 percent among girls and 4-10 percent among boys)
(De Leo and Heller 2004; Hawton et al. 2002; Laye-Gindhu and Schonert-Reichl
2005; Madge et al. 2008; Nixon et al. 2008 ; Young et al. 2007; Zøllner and Jensen
2010). Overall, most research on DSH is conducted on in-patients (Fliege et al. 2009;
Lowenstein 2005). To my knowledge, there is only one Swedish, community-based
peer reviewed study in which 40.2 percent of 14-year-old students (girls: 47.6
percent, boys: 33.3 percent) reported a lifetime history of self-harm related
behaviour (Bjärehed and Lundh 2008). The high prevalence found in this study
might be due to their broad definition of self-harm behaviours, namely, at least one
act of DSH out of nine suggested by the Deliberate Self-Harm Inventory. For
instance, if a girl or a boy had indicated ‘yes’ on the item ‘Carving words, pictures,
etc. into skin’, he or she was classified as a DSH case.

How young people understand mental health

According to qualitative research, young people understand mental health as an
emotional experience (Johansson et al. 2007) and adherence to normality
(Armstrong et al. 2000; Secker et al. 1999). Young people’s perceptions of mental
health tend to be associated with negative feelings such as sadness, worry,
depression, loneliness, anger, or fear (Armstrong et al. 2000). With regard to young
peoples’ understandings of depression, a Canadian study indicated that
depression was mainly perceived as a withdrawal from others (Hetherington and
Stoppard 2002).

6
Theoretical framework
A public health approach
Within the field of psychology and psychiatry, mental ill-health has historically
been conceptualised as individual problems for which the sources are to be found
within or in close attachment to the individual (Horwitz and Scheid 1999). Such
individual sources of mental ill-health are, for example, hormones or genetics,
(Angold et al. 1998; Costello et al. 2006; Zubrick et al. 2000), psychological
characteristics (personality traits, rumination style) (Nolen-Hoeksema et al. 1999),
and co-morbidity (other types of mental health problems) (Costello et al. 2006;
Fliege et al. 2009; Patel et al. 2007). However, the underlying assumption of this
thesis is that the main sources of adolescent mental health are to be found in the
life circumstances of young people. This does not mean that individual-oriented
approaches are irrelevant. As noted by a range of authors, the most likely
explanatory model includes a combination of biological, psychological and
environmental factors (Nolen-Hoeksema and Girgus 1994; Patel et al. 2007;
Piccinelli and Wilkinson 2000; Zubrick et al. 2000). Nevertheless, this thesis is
situated in the fields of public health sciences and medical sociology. Within these
disciplines, it is argued that inequalities in health arise from the structural and
organisational aspects of social inequalities, for example, how the unequal
distribution of power and resources affect peoples’ lives and influence their risk of
poor health (Baum 2003; Horwitz and Scheid 1999; Marmot 2007; Pickett and
Wilkinson 2009). Given this perspective, mental well-being is assumed to
deteriorate with declining social status and poor life circumstances (Aneshensel et
al. 1991; Brown and Harris 1978; Kemper 1991; Pickett and Wilkinson 2009). A
central component of this approach is to acknowledge the health promotion
potential in identifying factors and circumstances that are possible to change and
can be subjected to political influence and other influences (Dahlgren and
Whitehead 2006). Hence, a public health approach focuses on social determinants
of health: factors at different levels of society that influence or may influence health
positively or negatively (Dahlgren and Whitehead 2006; Marmot 2007). Although
somewhat simplified, these levels of social determinants are illustrated in Figure 2.

Dahlgren and Whitehead (2006) underline the interaction between the levels:

‚This model for describing health determinants emphasizes interactions:

individual lifestyles are embedded in social norms and networks, and in living and
working conditions, which in turn are related to the wider socioeconomic and
cultural environment.‛ (Dahlgren and Whitehead 2006, p. 19).

7
Figure 2. Model of social determinants of health. The model is derived from Dahlgren and
Whitehead (2006).

Although this model pedagogically illustrates the determinants of health, one

central social structure is neglected, namely, that of gender relations. In the original
Dahlgren and Whitehead model of the social determinants of health, ’sex’ is
referred to as an example of the biological characteristics of individuals ‚that
influence their health and that are largely fixed‛(Dahlgren and Whitehead 2006, p.
19-20). As will be outlined below, it is important to acknowledge more aspects than
biological sex in relation to mental health, such as what it is means to be a man/boy
or a woman/girl. Given the public health recognitions of the social and structural
determinants of health, it is striking how questions of gender as a social structure
and the experiences of being a boy or a girl have received so little attention in
research on adolescent mental health. As shown in Figure 2, gender has been
added to the model in order to highlight its relevance as a social determinant of
health on various levels in society.

A gender theoretical approach

The theoretical framework employed is based on a social constructionist gender
theory that recognises gender as a fundamental, although complex, organisational
principle in society. As illustrated in Figure 2, gender deals with gendered aspects
of social structure (e.g., distribution of power and resources), culture (e.g.,
language, ideologies, sports, fashion, media), organisations (e.g., work-life,
institutions, schools) and personality (e.g., identification, behaviour,
sexuality)(Connell 2009; Kimmel 2008). Importantly, in contrast to the biological

8
category of sex, gender is not something we have - it is something we do, or perform,
in social practice (Butler 1990; West and Zimmerman 1987). Such social practice is
guided by discourses of masculinities and femininities, and is shaped by and
reshapes structures in society. Moreover, as gender is ‘performative’, boys and
girls are not passively socialised into static sex roles; young people learn to ‘do’
gender and many find these practices joyful (Connell 2009; Paechter 2007). There
are, however, numerous examples of the restraining effects of practices of gender.
Despite the existence of multiple representations of femininity and masculinity,
girls and boys relate to, and are encouraged to adopt, dominant constructions and
norms in terms of gendered beliefs and behaviours. That is, they are encouraged to
adopt what is considered in Western society to be an acceptable performance of
male or female gender within a heterosexual norm (Paechter 2006). Peachter (2006)
argues that the ‘dominant’ versions of femininity and masculinity are ideal types
rather than examples of how real people act and live their lives. Such dominant
‘ideal types’ of gender have been conceptualised as ‘hegemonic’ masculinity
(Connell 2005) and ‘emphasised’ femininity (Connell 1987) or ‘hyperfemininity’
(Paechter 2006).

According to Kenway and Fitzclarence (1997), hegemonic versions of masculinity

represent ‚dominant and dominating forms of masculinity, which claim the
highest status and exercise the greatest influence and authority and which
represent the standard-bearer of what it means to be a ‘real’ man or boy‛ (Kenway
& Fitzclarence, 1997, pp. 119–120). ‘Doing boy/man’ according to hegemonic
masculinity involves, for instance, heterosexuality, sporting prowess, being
capable of violence, toughness, inhabiting or aiming for power positions,
competitiveness, strength and risk-taking. Another conceptualisation is that ‘doing
boy’ is centred on not ‘doing girl’ (Connell 2005, 2009).

Although there is a range of ways in which girls construct and enact collective
femininity and their individual femininities, there are femininities that are more
highly valued in contemporary culture (Paechter 2006). It has been argued that
such ‘emphasised femininity’ or ‘hyper femininity’ are represented by, for
instance, compliance, passiveness, dependence, beauty, empathy, sexually
attractiveness and nurturance (Connell 1987; Paechter 2007). Femininities, or ways
of ‘doing girl/woman’, do not confer power in the same ways as constructions of
masculinity (Connell 1987). Instead, most femininities are constructed as various
negations of the masculine; ‚the practice masculinity becomes ‘what men and boys
do’, and femininity, ‘the Other of that’‛ (Paechter 2006, p.254).

This illustrates that gender is a social relation, that is, ways that people, groups and
organisations are connected and divided. Enduring or widespread patterns among
such social relations constitute organisational specific arrangements (gender

9
regimes) as well as the overarching structure, gender order (or patriarchy), of a
society (Connell 2009; Walby 1990). There are also power relations embedded in
how individuals relate to and practice dominant ideals of masculinity and
femininity (Connell 2009). Although structural arrangements are dynamic, the
gender order is characterised by the inequality of men and boys collectively
possessing higher status, more resources and greater power than women and girls.
Power relations are maintained via cultural discourses as well through overt acts
of dominance, such as violence (Connell 1987; Walby 1990). Being a boy or a girl is
thus constrained by the opportunities and resources available. With regard to
gender as a social determinant of health, a recent WHO report stated:

‚Gender relations of power constitute the root causes of gender inequality and are
among the most influential of the social determinants of health.‛(Sen and Östlin
2007, p. xii)

Gender is not only about differences between men and women, but also about
constructions and relations within the groups of boys and girls. Gender is
intersecting with other relations and structures such as social class, ethnicity/race,
age, disability, sexual orientations (Shields 2008; Walby 1990; Walkerdine et al.
2001). The intersectional approach employed in this thesis implies acknowledging
the ways young people’s lives and experiences are influenced by the complex
interplay of gender and social class, more precisely, how mental health problems
can be responses to the ways the interplay of gender and class inequalities shapes
young people’s lives.

10
Social determinants of adolescent mental health
This brief literature review focuses on mental health correlates on three different
levels: family and peer relationships, school and structure (society) (see Figure 2).
Because violence cuts across all these levels, this dimension is presented under the
structural level. The literature review also covers some suggested hypotheses of
the root causes of gender differences in mental health.

Family and peers

An extensive body of literature suggests that peer and family relationships are
both risk and protective factors with respect to mental health problems among
adolescents. There is, for example, strong evidence of the protective contribution of
stable and supportive relationships (Armstrong et al. 2000; Haraldsson et al. 2010;
Johansson et al. 2007; Patel et al. 2007; Rudolph 2002). With respect to risk factors,
relational problems in the family and with peers, as well as in romantic
relationships, have been found to be related to increased levels of stress in young
people, especially among girls (Byrne et al. 2007; Rudolph 2002; Wagner and
Compas 1990; Ystgaard 1997). Similarly, loneliness and relational problems (e.g.,
peer and parental conflicts, lack of social support) have been identified as risk
factors for depression, anxiety and emotional problems (Brage and Meredith 1994;
Brolin Låftman and Östberg 2006; Hankin et al. 2007; Heinrich and Gullone 2006;
Kapi et al. 2007a; Kraaij et al. 2003; Wisdom et al. 2007). Prior research has also
indicated that young people who self-harm report a history of poor social
relationships and boyfriend/girlfriend problems (Bjärehed and Lundh 2008; De Leo
and Heller 2004; Fliege et al. 2009).

School
The mental health associations of school-related factors are mainly centred around
two dimensions: the school context as well as the content of school work. Both
dimensions are highly relevant because young people spend a great deal of their
time in school and doing school work.

With respect to the school context, prior research suggests that adolescent mental
health is influenced by the academic context of the school classroom, the
socioeconomic standing of the school and the psychosocial work environment
(Gillander Gådin and Hammarström 2003; Goodman et al. 2003a; Saab and Klinger
2010; Torsheim and Wold 2001). Other contextual factors related to mental health
are student influence, student-teacher relationships and safety (Ellonen et al. 2008;
Konu and Lintonen 2006; Modin and Östberg 2009; Simovska 2004). In their
studies on health in 9-15-year-old pupils, Gillander Gådin and Hammarström
(2003) recognise schools as gendered institutions and argue that gender relations in
school settings may influence children’s health. With regard to safety, there is

11
strong support for negative mental health consequences of various forms of
harassment in school. These aspects will be outlined in the section on mental health
correlates of violence.

Studies on the mental health influence of the content of school work (e.g., exams,
marks, pressure) tend to be centred on two main paths. First, there is evidence of
academic ability and success as being associated with positive mental health
(Kaplan and Maehr 1999). Secondly, numerous studies show that academic
stressors as well as pressure and worries about academic performance are risk
factors for stress, psychological symptoms as well as DSH (Byrne et al. 2007; Hjern
et al. 2008; Mahadevan et al. 2010; Murberg and Bru 2004; West and Sweeting
2003).

Structure
As noted above, the social structure in focus in this thesis is mainly gender, and to
some extent, social class/socioeconomic status. A review of gender patterns in
mental health problems was provided in the previous section on mental health
problems - prevalence and understandings.

Socioeconomic patterning
The evidence on socioeconomic patterning is somewhat inconsistent. Many studies
show associations between disadvantaged social status and mental health
problems. For example, young people of low socioeconomic status report elevated
rates of stress, depressive symptoms and psychological distress, as well as
deliberate self-harm (Goodman et al. 2005; Hawton et al. 2001; West and Sweeting
2003; Wight et al. 2006; Young et al. 2007). At the same time, there is evidence of
weak support for SES associations (West and Sweeting 2004), especially if social
class is indicated by parental SES (Hagquist 2007). It appears that the subjective
perception of social class/SES, as opposed to family income or parental education
level, better predict mental health in young people (Goodman et al. 2007; Hagquist
2007).

Culture and media – Body image

One aspect at the societal level is the strong influence of cultural and media
messages on young peoples’ perception of themselves and others (Aubrey 2007).
Such messages and the hegemonic ideals of bodily shapes, beauty, trends and
attributes, inevitably shape how young people relate to their bodies (Bengs 2000),
which in turn, affects mental health (Siegel et al. 1999; Wisdom et al. 2007). A
negative body image has been identified as a strong risk factor for low self-esteem
and depression in both girls and boys (Allgood-Merten et al. 1990; Siegel et al.
1999). Others suggest that girls are more dissatisfied with their looks and bodies

12
than are boys, which potentially causes more mental health problems among girls
(Polce-Lynch et al. 2001; Tolman et al. 2006; West and Sweeting 2003; Wisdom et al.
2007).

Violence and harassment

There is consistent evidence that experiencing bullying and sexual harassment is
related to mental health outcomes such as depression, psychological distress and
DSH (Abada et al. 2008; Gruber and Fineran 2008; Nansel et al. 2004; Portzky et al.
2008). Several researchers argue that girls respond to sexual harassment more
negatively than boys in terms of mental health (Gillander Gådin and
Hammarström 2005; Gruber and Fineran 2008). It is also well established that
experiences of physical and sexual violence/abuse are risk factors for depression,
psychological distress and DSH in young people (Ackard and Neumark-Sztainer
2003; Fredland et al. 2008; Hawton et al. 2002; Schraedley et al. 1999; Thompson et
al. 2004). Sexual and physical abuse have been found to be particularly detrimental
for mental health among girls and young women (Fergusson et al. 2002; Hand and
Sanchez 2000; Romito and Grassi 2007; Sundaram et al. 2004), whereas others
identified stronger associations between sexual abuse and mental health problems
among boys than girls (Haavet et al. 2004; Schraedley et al. 1999). Studies on
violence within romantic intimate partner relationships (dating violence), suggest
strong associations with mental health problems, especially among girls (Banister
et al. 2003; Glass et al. 2003; Hanson 2002; Molidor and Tolman 1998).

Prevalent hypotheses of gender differences in mental health

Attempts to explain gender differences in mental health problems target various
levels, including biological factors, psychological traits, psychosocial factors and
structural circumstances (Nolen-Hoeksema and Girgus 1994; Piccinelli and
Wilkinson 2000; Stoppard 2000). With respect to gender differences in depression,
reviews of existing evidence show inconsistent or weak support for biological
explanations (Nolen-Hoeksema and Girgus 1994; Piccinelli and Wilkinson 2000).
According to Nolen-Hoekseema and Girgus (1994), gender differences in
depression in adolescents may arise because girls, compared to boys, have more
pre-existing risk factors for depression before adolescence (e.g., a ruminative
coping style and low levels of aggression and dominance in peer-interactions), and
these risk factors cause depression when they interact with gender-specific
biological (e.g., dissatisfaction with bodily changes) and social challenges that
emerge in adolescence (e.g., sexual abuse and restraining feminine sex role).

According to the gender intensification theory, many gender differences in mental

distress are due to girls’ experiences of pressure to conform their behaviour to

13
gender expectations when they reach puberty (Priess et al. 2009; Wichström 1999).
Similarly, gender conflict theory postulates that gender roles may result in
personal restriction, devaluation or the violation of the self or others, which in turn
may have negative consequences on mental well-being (Watts and Borders 2005).
Pollack (2006), for instance, argues that a ‘boy code’ (e.g., shaming of emotional
expressions) in society and the ways boys are socialised have negative effects on
their mental health (Pollack 2006).

Why this study?

Despite a well-documented, consistent gender pattern in adolescent mental health
and a growing body of knowledge on the mental health importance of life
circumstances, there are several gaps in the research. Overall, the general picture
that emerges from the research reviewed is that the individual-focused approach is
pervasive, and there is a profound lack of studies employing a gender analysis. For
example, with respect to peer and family relationships, more knowledge is needed
on the character of such relationships in girls and boys from different social
backgrounds. In addition, research applying a gender analysis (and not a sex-role
approach) is scarce. As noted, several aspects of the school environment have been
shown to influence adolescent mental health. However, there is a gap with respect
to the mental health associations of gender and the meaning of academic demands
and success, including responsibility-taking. More research is also needed on
gender and the school context in late adolescence. With regard to the structural
level, few studies have jointly explored social and gender patterns in adolescent
mental health. Mendelson et al. (2008) argue that the interaction between several
sources of social disadvantage may cause ‘double jeopardy’ in terms of mental
health influence. Despite some initial strong evidence, more research is needed
regarding how different types of violence are related to mental health in adolescent
boys and girls as well as whether patterns in victimisation are related to the rates
of mental health problems. In addition, little is known about mental health
associations of the victim-perpetrator relationship. In Sweden, this omission is
particularly apparent in the case of dating violence. In addition, research within
this field is often lacking a gender perspective and most work has focused on
younger adolescents or on young adults and not the age group included in the
present study. The currently prevalent explanations of gender differences in
mental health distress are characterised by a deterministic perspective of gender
role socialisation and a failure to acknowledge structural power relations. Great
emphasis appears to be placed on individualistic perspectives of gender regarding
‘style’, traits and sex roles. Ideas of socialisation into sex roles have been critiqued
for being dualistically deterministic and for assuming young people to be passive
victims of society (Connell 2009; Hammarström 2002). Sex role theory also fails to

14
grasp the relational and power aspects of gender, such as the structural factors that
restrain or directly affect girls and boys differently (Connell 2009; Hammarström
and Ripper 1999).

To summarise, in order to better understand, predict and prevent mental health

problems and promote positive mental health among young people, advanced
knowledge is needed on the relationships between mental health and the
circumstances under which young people live. In addition, a gender analysis may
provide new understandings of the links between such life circumstances and
mental health. Another reason for this study is the sparse knowledge about life
circumstances and mental health in late adolescence.

15
The study – aims and research questions
The aim of the study was twofold. First, it aimed to explore understandings and
prevalence of mental health problems and to investigate what factors and
circumstances are related to adolescent mental health. The specific research
questions were as follows:
1. How is mental health understood by young people?
2. What is the prevalence and patterning of the mental health problems
o Perceived stress
o Psychological distress
o Deliberate self-harm
3. How are social relationships related to mental health?
4. How are perceived demands and responsibility taking related to mental
health?
5. How are experiences of violence and harassment related to mental health?

Secondly, the study aimed to apply a gender analysis to the findings in order to
improve the understanding of the relationships between life circumstances and the
gendered patterning of mental health among young people.

Papers in the thesis

I II III IV
Q1

Q2

Aim 1
Q3

Q4

Q5

Aim 2

Discussion

Figure 3. Overview of how the aims and research questions are

covered in the included papers. Q = research question.

16
METHODS

Multi-method approach
The thesis comprises four papers based on two sets of data generated by both
qualitative and quantitative methods. One part originates from a focus group
study with 16-19-year-old upper secondary school students. The other set of data is
based on a questionnaire study of 17-year-old upper-secondary school students.
Hence, the data were generated by a multi-method approach (Cowman 1993). The
use of several methods improves the possibilities to produce rich data from which
new understandings and knowledge could be generated. The project started with a
qualitative study (grounded theory; see details below) that aimed to study
experiences and perceptions related to mental health that are difficult to illuminate
and capture in a quantitative study. These qualitative results guided the paths
taken for the other three quantitative studies by inspiring the construction of the
questionnaire. The quantitative approach provided tools to investigate prevalence,
distributions, correlations and associations.

Table 1. Overview of design and methods used in the thesis.

Paper Design Participants Data Method of
collection analysis
I Qualitative Upper secondary school students age Focus group Constant
Grounded 16-19 years, 29 focus groups, N=104 interviews comparative
theory analysis
Explorative

II Cross-sectional Upper secondary school students, Questionnaire Chi-square test

Descriptive age 17 years. N=1663 Factor analysis

III Cross-sectional Upper secondary school students, Questionnaire Chi-square test

Descriptive age 17 years. N=1663 Logistic
Analytical regression
Rasch
Factor analysis

IV Cross-sectional Upper secondary school students, Questionnaire Chi-square test

Descriptive age 17 years. N=1663 Logistic
Analytical regression

17
Context
The research project was carried out in upper-secondary schools in the County of
Västernorrland, Sweden. This region has seven municipalities in both urban and
rural areas and has approximately 250,000 inhabitants. The two largest
municipalities have 95,000 and 55,000 inhabitants, respectively. Historically, the
region has had an industrial socio-economic base supported by the forest industry.
Over the past few decades, however, it has shifted towards a more post-industrial
service economy. Approximately 38 percent of young people (males 32 percent;
females 44 percent) who complete upper secondary education begin university
studies within three years (The County Administrative Board of Västernorrland
2009). The unemployment rate among young people (15-24 year-olds) in the region
is 29.5 percent compared to the national average of 25 percent (Statistics Sweden
2009).

The study was school based. By the time data collection was conducted, there were
18 upper-secondary schools in the region, ranging in size from approximately 100
to 1,500 students. Most schools were public, although the number of independent
schools has been increasing, particularly in the largest municipality. However, by
law, no tuition fees are allowed in independent schools. The Swedish upper
secondary school education is three years, normally starting when students are at
the age of 16. It is not mandatory, although 98 percent of those who finish
compulsory school (year 9) start upper secondary school. Of those, approximately
25 percent disrupt their education (The Swedish National Agency for Education
2008). The school system is organised into 17 educational programmes of different
orientations, which can be broadly classified into ‘higher education preparing’
programmes (academic) and ‘occupational training’ programmes (vocational). The
academically oriented education includes programmes on the social sciences,
natural sciences, economics, languages, information technologies and art. The
vocationally oriented programmes focus on, for example, child and recreation;
construction; electrical engineering; vehicle engineering; business and
administration; handicrafts; hotel, restaurant and catering services; industry;
media production and health care. The vocational programmes are strongly
gender-segregated (The Swedish National Agency for Education 2008). Existing
data indicate that young people with working-class backgrounds and low parental
education level are overrepresented in vocational programmes, whereas those with
middle-class background and high parental educational levels to a greater extent
choose academic programmes (The Swedish National Agency for Education;
Hagquist 2007).

18
The qualitative study (Paper I)
Grounded Theory
The qualitative study relies on principles of constructivist grounded theory
(Charmaz 2005, 2006). This approach was chosen because of the explorative aim of
the study. The suggested flexible guidelines, principles and practises for sampling,
data collection and analyses (Charmaz 2006) were also suitable for the study.
Generally, grounded theory is used as a method to construct theories grounded in
data (Strauss and Corbin 1998). However, this study neither aimed for, nor claimed
to, develop a comprehensive new theory. Instead, through the recognition of social
processes, the focus was to elaborate upon existing theories and evidence within
the field (Charmaz 2006). Charmaz (2006) argues that rather than ‘neutrally
discovering’ features in the data, constructivist grounded theory acknowledges
that the analyses are social constructions and that they are contextually and
theoretically situated and emerge from the researcher’s interactions within the field
and interpretations of the data. One aspect of the constructivist grounded theory
approach is to be theoretically sensitive and acknowledge how power relations
should be recognised in research, for not only the power relation between the
researcher and the participants but also the potential hierarchies within the context
where the study is undertaken (Charmaz 2005).

Focus groups
The choice of focus groups was motivated by the method’s potential to generate
rich data and capture cultural norms and shared experiences in a social context
(Kitzinger 1994; Morgan 1996). Hence, group discussions can help the participants
to explore, share and clarify their views in their own vocabulary (Kitzinger 1995).
This was particularly important because the focus of interest was the dominant
discourses to which the adolescents relate regarding mental health and the life
circumstances that they believe influence mental health. Furthermore, focus groups
may generate a feeling of confidence among the participants and reduce the power
asymmetry in relation to the researcher, especially given the age difference
between the students and the researcher (Gillander Gådin 2002; Kitzinger 1994).

Participants
Participants were recruited from schools in six municipalities. In order to obtain
broad variation in experiences, focus groups were recruited with the goal of
obtaining a sample with maximum variation (Patton 2002). This was mainly
obtained through a selection of first-, second- and third-year school-classes
representing different educational programmes (academic, vocational, male-
dominated and female-dominated). All students in each school class approached
were asked to participate and the groups were self-selected, as discussed by
Kitzinger (1994). At first, six focus groups were recruited. After the initial analysis

19
of the data, a theoretical sampling (see Charmaz 2006) was used, and the
recruitment of another three groups was carried out due to perceived gaps in the
data or identified issues we intended to further explore. Additional groups were
recruited from theoretical educational programs and female-dominated school
classes. Seven of the nine groups were then interviewed a second time. Of the two
groups that were not interviewed a second time, participants in one group
declined further participation and the participants in the second group declined for
practical reasons. In order to broaden the background of the participants and
further enrich the data, another 13 focus groups were carried out, predominately in
the more rural areas of the region. The focus groups comprised three to eight
students. As described above, the total sample varied by age and socioeconomic
and demographic characteristics. Specific personal data were not collected at the
individual level.

The choice of single-sex groups was based on two main arguments. First, as
Morgan (1996) argues, homogenous groups are preferable because they facilitate a
context for confident discussions. Second, it was assumed that the impact of
asymmetric gender-based power relations would be less prevalent in single-sex
groups than in mixed-gender groups, as previously suggested (Gillander Gådin
2002). The students were asked to form single-sex groups. There was no intention
of excluding anyone who wanted to participate; therefore, four mixed groups were
included according to the students’ requests. Twelve of the focus groups were
conducted with male groups, 13 were conducted with female groups and four
groups were gender mixed.

Procedure
The focus groups were conducted in the participants’ schools. They lasted 60-120
minutes and were tape-recorded and transcribed. In order to generate a common
point of departure for the following discussion, the participants were asked to
reflect upon what they thought about and associated with the concept of ‚mental
health‛ *In Swedish: psykisk hälsa+. Following this, the question ‚what do you
think is important for adolescent mental health?‛ was asked. The discussions were
intended to be broad and centred on the topics raised by the participants. The
interviewer was guided by different themes such as friends, school, family, future
plans and relationships (see Appendix 1.). According to the principles of
constructivist grounded theory (Charmaz 2006), the content of the discussions was
adjusted as the study proceeded to some extent and new insights regarding the
processes influencing mental health were gained. Nevertheless, the main structure
of the discussions was consistent throughout the study.

20
Analysis
The analysis was conducted in a stepwise procedure. Initially, the material was
read through several times in order to obtain a comprehensive picture of what the
data were saying. Line-by-line coding was then carried out to conceptualise ideas,
codes and expressions for what the participants described. Identified patterns or
similarities influenced the direction of the discussion in the forthcoming focus
groups as well as the coding process. Consequently, a constant comparative
method was developed early in the analysis process to facilitate simultaneous
involvement in data collection and analysis (Charmaz 2006). Preliminary broad
categories were constructed by selecting relevant codes using a process of focused
coding, followed by a process in which the properties of the categories were
specified. The relations between the categories (social interaction, performance and
responsibility) were further scrutinised and specified by theoretical coding
(Charmaz 2006). Through a deductive analysis, the categories were revised and
confirmed against the data. Workshops were also held with student groups not
included in the actual focus groups. These discussions shed new light on the
results as they emphasised slightly different aspects such as the importance of
supportive family relations and financial issues. However, the outcome of these
workshops generally confirmed the results.

The quantitative studies (Papers II, III, IV)

Data collection and procedure
The data were collected by means of a self-administered questionnaire during
school hours and included 17 upper secondary schools in the region. Data
collection took place during two weeks in April 2007 (mid-term) and was carried
out with the assistance of teachers. The questionnaires were personally distributed
to the teachers and collected by the same person (E.L). Answering the
questionnaire took approximately 20-30 minutes.

Participants
The study population consisted of all students enrolled in year two of upper
secondary school across all municipalities in the region. In five out of seven
municipalities, students in all classes were invited to participate. In the other two
municipalities (the largest municipalities), 50 percent of the school classes were
randomly sampled. This method was developed mainly for practical reasons
(primarily time limits). The total sample was 2,123 students. In the analyses, the
random sampling was accounted for by a weight variable to make it possible to
generalise the findings to an estimated full population sample of second year
students in the region (approximately 3,195). In total, 1,688 students (79.5 percent)
completed the questionnaire. After excluding those with missing data on gender,

21
the sample on which the analyses were based was 1,663 students (78.3 percent).
Fifty-one percent (n=826) of the respondents were girls, and 49 percent (n=837)
were boys. Forty-five percent of the students (n=709) attended academic
educational programmes and 55 percent attended vocational educational
programmes (n=861). Ninety-three students (5.6 percent) did not indicate the
educational programme.

Of the 455 students who did not complete the questionnaire, 12 percent (n=55)
were whole school classes under vocational training at work places. Other
plausible reasons were absence due to illness or absenteeism. In some school-
classes, the non-response rate was approximately 50 percent, which might be due
to data collection being carried out during a lesson in which the school class was
divided into two groups. According to the notes from teachers, only two
individuals openly declared that they did not want to participate.

The questionnaire
The content of the questionnaire was inspired by the findings of the qualitative
study, such as the sections on stress, violence and psycho-social school
environment. The content was also inspired by other questionnaires such as the
WHO Health Behaviour of School Children study (HBSC) (Currie et al. 2008),
‘Young in Värmland’ (Hagquist and Forsberg 2007), and Statistics Sweden surveys
(Jonsson et al. 2001; Statistics Sweden 2010). For further details on the measures of
mental health problems, see the section on measures. Questions were discussed in
focus groups and can thus be considered validated by a ‚think-aloud method‛
(Presser et al. 2004). Data collection was carried out over a short period of time,
which did not make a pilot study possible. In total, the questionnaire comprised 61
questions, of which many were instruments consisting of several items.

Measures
Dependent variables – mental health outcomes
Stress and stressors
In order to assess the perceived level of stress, respondents were asked to indicate
how often during the past three months he/she had felt stressed. This way of
assessing stress is similar to the methods used in other studies (Byrne et al. 2007;
Ollfors and Andersson 2007; Torsheim and Wold 2001), although most research on
adolescent stress has used checklists of stressful events to assess levels of stress
(e.g., Compas et al. 1987). Response alternatives were on a scale from ‘always’ to
‘never’. Subsequently, perceived stress was categorised into three levels: ‘Any level
of stress’ (always; often; sometimes; seldom); ‘High level of stress’ (always or
often) and ‘Very high level of stress’ (always). Those who indicated any level of
stress were asked to rate to what degree they experienced various factors as

22
stressful: ‘school marks’, ‘demands on oneself’, ‘future plans’, ‘lack of money’,
‘taking responsibility for others’, ‘looks’ (to look and dress in a specific way),
‘relationships with friends’, ‘home situation’ and ‘leisure-time activities’. These
stressors were categorised into ‘yes’ (always/often) and ‘no’ (sometimes, seldom,
never).

As a means of exploring the dimensions of stressors, principle component analysis

was employed and produced two factors with eigenvalues of 3.50 and 1.05 that
explained 50.54 percent of the variation. Varimax rotation showed that the major
component comprised social and relational stressors (lack of money, responsibility
taking for others, looks, friends, home, leisure time) and the second factor
comprised stressors related to achievements (marks, own demands and future
plans).

Psychological distress
Psychological distress was measured using an index of six items. Respondents
were asked: ‚How often during the past three months have you felt: nervous,
anxious/worried, depressed/low, irritable, worthless or resigned‛. The instrument
has similarities with other measures of psychological distress: the HBSC symptom
check list, the Psychosomatic problem scale, GHQ-12 and Kessler scale (Andrews
and Slade 2001; Dao et al. 2006; Hagquist 2009; Sweeting et al. 2009; Torsheim et al.
2006). The response alternatives were: 0. Never; 1. Seldom; 2. Sometimes; 3. Often;
and 4. Always. A summed score for the six items ranging from 0-24 was calculated
for each respondent (the higher the score, the worse the psychological distress).
Similar to other studies (Griffin et al. 2002; Hagquist 2007) quartiles were used to
classify individuals into cases and non cases. That is, individuals who scored 12 or
higher (upper quartile) were considered to be cases of ‘psychological distress’. This
cut-off is similar to the one suggested for the Kessler-6 scale (Kessler et al. 2002).
The reliability of the scale was estimated using the Cronbach alpha coefficients
resulting in a value of 0.83, which exceeded 0.70 and was thus acceptable (Kline
2000).

The psychometric properties of the scale were evaluated by factor analysis as well
as by the Rasch latent trait analysis and were found to meet the requirements of
unidimensionality. The dimensionality of the scale was evaluated by exploratory
factor analysis using Kaiser's criterion (eigenvalue >1) and Principal Component
analysis and estimated by the maximum-likelihood method. The six items all
loaded on one component, which explained 54.93 percent of the variance. The
loadings for each item were: ‘Low’: 0.83; ‘Worried/anxious’: 0.81, ‘Worthless’: 0.79;
‘Resigned’: 0.70; ‘Irritable’, 0.67; ‘Nervous’: 0.62. The Kaiser-Meyer-Oklin value
was 0.83, which exceeded the recommended value of 0.6, and the Bartletts Test of
Sphericity reached statistical significance.

23
Based on concurrently approximations of item difficulty and person ability, the
Rasch model focuses on the operating characteristics of a latent trait (Bond and Fox
2007). With respect to the goodness of fit (i.e., whether the items form a
unidimensional construct and all items work in the same direction) the Rasch Infit
MSQ ranged from 0.77 (worried/anxious) to 1.26 (worthless), which indicated a
good fit to the Rasch model (Bond and Fox 2007). Different item functioning
analysis (DIF) showed no difference in the systematic patterning of responses
between boys and girls (DIF contrast 0.11 – 0.37). The item location analysis, i.e., a
comparison of the distribution of item difficulty (severity) and person measures
(‘ability’) along the latent trait, indicated that the items seem to function well to
discriminate on the upper part of the scale (worse psychological distress) whereas
items did not tap the lower end of the scale. This result is perhaps not a weakness
since the measure of psychological distress (the latent trait) was aimed to identify
those with the most severe psychological distress.

Deliberate self-harm (DSH)

A lifetime experience of deliberate self-harm was indicated by affirmation of one or
both of these questions: ‘Have you ever deliberately inflicted harm to yourself (e.g.,
cut or burn yourself)?’ and/or ‘Have you ever deliberately taken overdoses of
medicine in order to harm yourself? The response alternatives were ‘no’; ‘yes,
once’; ‘yes a few times’; ‘yes, several times’. Those indicating any ‘yes’ were
categorised as having a lifetime experience of DSH. The measure employed in the
present study is similar to that of Hawton et al. (2002) and Ystgaard et al. (2009),
which enabled comparisons of DSH-prevalence between countries.

Independent variables
The independent variables (i.e., potential risk factors) are summarised in Table 3.

Control variables
Controlling for confounding variables is crucial in research on health in order to
reduce the risk that the effect of the exposure on the outcome is mixed up by
factors associated with both the exposure and the outcome, such as demographic
variables (Rothman 2002). Selected demographic variables are presented in Table 2.
Educational programme and parental employment status were used as control
variables in Papers III, IV and in the additional analyses presented in Table 6 and 7.
In Paper IV, foreign extraction and family structure (the family structure the
participant is currently living with) were also included as control variables.

24
Table 2. Demographic control variables used in analyses.
Variable Questions/items Scale/Categories
Educational ‘Which educational Academic
program programme do you Vocational
attend?’ Indication of social class/SES

Parental ‘What do your Employed (both parents having a full or part time work or
employment parents do/work running own business).
status with?’ Not employed (one or both parents not having a full-time
or part time job or running own business). The non-
employed category comprised those who were
unemployed, retired, on sick leave, on parental leave,
students, housewives/men, other and do not know.
Indicator of financial standard in the family and SES.

Foreign ‘Where were your Both parents born in Sweden

extraction parents born?’ One or both parents were born outside of Sweden

Living ‘Who do you live Two adults (both parents or parent with new partner)
situation with, most of the Single parent or other (one adult, alone, own partner,
time?’ relative, other)

Analyses
Statistical analyses were performed using SPSS version 17 and Winsteps for the
Rasch analysis. Factor analysis and Rasch analysis were used to evaluate
composite measures. Between group differences were tested using Pearson chi-
squared statistics. Logistic regressions were used to examine the associations
between potential risk factors and the mental health outcomes (very high level of
stress, psychological distress and deliberate self-harm). All independent variables
were categorical. First, unadjusted odds ratios were calculated for each
independent variable in univariate logistic regressions. Secondly, each
independent variable was adjusted for demographic control variables. All logistic
regressions were performed separately for boys and girls, and 95 percent
confidence intervals were calculated. The alpha-level of p<0.05 was set for
statistical significance.

25
Table 3. Independent variables used in analyses.
Variable Questions/items Scale/Categories
Social and
school-related
factors
Hostile school ‘Do you perceive sexual harassment, bullying and/or racism No (never/seldom)
environment to be problems in your school?’ Yes (sometimes,
often or always)
Teacher support ‘Teachers care about me as a person’ Yes (always, often
or sometimes)
No (never/seldom)
Influence in ‘I can influence the content and structure of teaching’ Yes (always, often
school or sometimes)
No (never/seldom)
Satisfaction ‘I am satisfied with my achievements in school’ Yes (always, often
with school or sometimes)
achievements No (never/seldom)
Perceived heavy ‘There is a heavy work-load in school’ No (never, seldom
work-load in or sometimes)
school Yes (always/often)
Friends in ‘I have friends in school’ Yes (always/often)
school No (never, seldom
or sometimes)
Exposure to All questions on violence were coded as follows:
violence Not exposed (No, never)
Exposed (Yes, several times; Yes, a few times; Yes, once).
Bullying in During the past 12 months, experienced one or several of the Not exposed
school a following acts in school: ‘Been socially excluded’; Exposed to one act
‘Experienced somebody spreading false rumours about you’ Exposed to two or
and/or ‘Been exposed to racist comments or actions’ three acts
Sexual During the past 12 months, experienced one or several of the Not exposed
harassment in following acts in school: ‘Received unwelcomed comments Exposed to one act
schoola on body or appearance’; Been called ‘whore’, ‘fag’, ‘cunt’ or Exposed to two acts
other ‘four-letter words’; ‘Been pawed or forced to touch Exposed to three or
somebody in a sexual way’; ‘Received degrading comments more acts
about your gender or sexuality’ and/or ‘Been grabbed or
shouldered/cornered’
Physical ‘Have you been exposed to physical violence during the past Not exposed
violence twelve months?’ Exposed

‘Have you been exposed to physical violence earlier in your Not exposed
life?’ Exposed

Perpetrator of If you have been exposed to violence – who did it to you? Not exposed
violence (past ‘Unknown male’, ‘Unknown female’, ‘Known male’, ‘Known Unknown person;
12 months)a female’,’Teacher’, ‘Mother’, ‘Father’, ‘Boyfriend’, ‘Girlfriend’ Known person;
and ‘Other person’ Parent; Partner;
Other

Sexual assault ‘Have you ever felt that you were forced to have sex?’ Not exposed
Exposed
a Categorical indicator variables including more than two categories.

26
Ethical considerations
The study was reviewed by the ethical research committee at Mid Sweden
University and was found to be in accordance with ethical standards (Dnr MIUN
2005/1126). Although participating students were under the age of 18, parental
consent was not judged to be necessary. This is supported by the Swedish law on
ethics in research which state that parental consent is not necessary if the research
subject is 15-18-years-old and realises what the research means to him or her.

The qualitative study

All participants in the focus groups were given verbal and written information
about the aim of the study, the persons were responsible for conducting it, the
contact information of the researcher and also contact information to relevant
services in case they felt the need for professional support. They were also
informed how the results were to be presented and that their identities would not
be revealed. However, focus groups are accompanied with an ethical dilemma
because of the lack of confidentiality and the fact that the researcher has no control
over how the discussions might affect the participants after the actual data
collection. Participants were kindly reminded to only reveal what they desired to
disclose in the discussions and to treat each other respectfully.

The quantitative study

Respondents were given written information (on the first page of the questionnaire
and in an additional cover letter) about the aim of the study, the persons were
conducting it, the contact information of the researcher as well as of relevant
services in case they felt the need for professional support. Information about the
anonymity of responses and participation being voluntary was emphasised. The
teachers who helped out with the data collection received additional information
on the ethical aspects as well as practical instructions and guidelines of how to, for
example, arrange the classroom when the students were to fill in the
questionnaires. The questionnaires were labelled with a code that made it possible
for the responsible researcher (E.L.) to keep track of the response rate on a school-
class level. Individual respondents could not be identified either in the
questionnaire or in the data file. Responses were registered by mechanical
scanning of the questionnaires. Given the sensitive nature of some of the questions,
for example, those on sexual assault and deliberate self-harm, discussions on
specific ethical issues were held with colleagues prior to data collection. There is,
however, evidence that asking young people about sensitive issues is not unethical
per se (Helweg-Larsen et al. 2004). In addition, school nurses at all participating
schools were contacted and given information about the study. Moreover, as noted
above, the students were given information about services to which they could
turn in case they felt the need for professional support.

27
FINDINGS

How is mental health understood by young people? (Paper I)

According to the focus groups (I), mental health was understood as an emotional
experience and described as ‚how you feel‛ in terms of self-esteem, stress and
confidence. Mental health was mainly associated with negative aspects, distress or
illness. With regard to influencing factors, the participants emphasised the
importance of social and psychosocial circumstances in relation to adolescent
mental health.

What is the prevalence of mental health problems and how are

mental health problems patterned? (Papers II, III, IV)
The correlations between the mental health problems investigated in Papers II, III
and IV ranged from 0.175 (perceived stress always – DSH) to 0.309 (psychological
distress – DSH). According to Paper IV, there was a strong association between
psychological distress and deliberate self-harm. High levels of stress (II) (always or
often the past three months) were reported by 54.9 percent of the students, and 10
percent reported that they always felt stressed. Given the predefined cut-off, the
three month prevalence of psychological distress was 25 percent (III). A lifetime
experience of deliberate self-harm was indicated by 17.1 percent of the sample (IV).
Gender-specific prevalence of mental health problems are presented in Figure 4.
All mental health problems were significantly more common among girls than
among boys. A more detailed presentation of the responses is displayed in
Appendix 3. In addition, girls reported multiple experiences of mental health
problems to a higher degree than boys. For example, 16 percent of the girls
indicated two mental health problems compared to 3.5 percent of the boys
(p<0.001). Analyses of the associations between background variables (educational
programme, parental employment status, foreign extraction and whether they are
currently living with two adults) and mental health outcomes (Table 5) show that
educational programme and parental employment were most strongly associated
with mental health outcomes. This is also shown in Table 4, which indicates that
perceived stress, psychological distress and DSH were generally higher among
girls and boys attending vocational programmes and among those who reported
that one or both of their parents were not employed.

28
 70
59.9 ***
60
Boys
50
Girls

40
% 32.1 ***
29.1
30
23.3 ***

20 15.2
14.3 ***
10.5
10 5.6

0
Perceived stress Perceived stress Psychological Deliberate self-
(always/often) (always) distress harm

Figure 4. Prevalence of mental health problems (percentage) in boys and girls.

Gender differences indicated by Chi-Square test. ***p<0.001.

Table 4. Prevalence (percentage) of mental health problems in boys and girls by social class
background (educational programme and parental employment status). Group differences
indicated by Chi-Square test.
Boys Girls
Mental health By educational By parental By educational By parental
problems programme employment statusa programme employment status
Aca Voc 2 par. 1-2 par. Aca Voc 2 par. 1-2 par.
empl. not empl. empl. not empl.
Perceived stress
Always/often 26.4 31.5 27.3 33.6 60.1 58.9 57.2 67.6***
Perceived stress
Always 4.8 6.4 4.8 8.1* 13.1 15.9 12.1 20.4***
Psychological
distress
Cases (>75%) 12.3 17.0* 13.4 20.0* 26.7 36.3*** 30.8 36.4
Deliberate self-
harm
Lifetime experience 5.4 14.6*** 9.2 15.5** 14.9 30.5*** 19.6 34.9***
*p<0.05; **p<0.01***p<0.001.
a 2 par. empl. = both parents currently employed or running their own business. 1-2 par. not empl. = one or two

parents not currently employed or running their own business.

29
 Table 5. Demographic factors. Prevalence (percentage) and associations with mental health problems (Odds ratios, 95% CI).

Prevalence Associations with mental health problems (unadjusted)

Perceived stress (always) Psychological distress Deliberate self-harm

Na Boys Girls Boys Girls Boys Girls Boys Girls
% % OR (CI) OR (CI) OR (CI) OR (CI) OR (CI) OR (CI)
Edu. programme 1570
Academicb 45.4 45.2 Ref. Ref. Ref. Ref. Ref. Ref.
Vocational 54.6 54.8 1.34 (0.79 – 2.24) 1.25 (0.91 – 1.73) 1.46 (1.03 – 2.06) 1.56 (1.21 – 2.01) 2.93 (1.87 – 4.59) 2.52 (1.89 – 3.37)
Par. employment status 1623

30
Both employedb 78.6 73.7 Ref. Ref. Ref. Ref. Ref. Ref.
One or both not employed 21.4 26.3** 1.79 (1.04 – 3.09) 1.87 (1.34 – 2.61) 1.60 (1.10 – 2.32) 1.29 (0.98 – 1.69) 1.85 (1.22 – 2.79) 2.24 (1.69 – 2.97)
Foreign extraction 1603
Swedishb 87.1 86.9 Ref. Ref. Ref. Ref. Ref. Ref.
One or both parents 12.9 13.1 1.58 (0.81 – 3.11) 1.37 (0.89 – 2.12) 1.26 (0.79 – 2.03) 0.81 (0.56 – 1.17) 2.00 (1.23 – 3.25) 1.53 (1.06 – 2.21)
not Swedish
Living with 1579
Two adultsb 66.8 57.6 Ref. Ref. Ref. Ref. Ref. Ref.
Not two adults 33.2 42.4*** 1.20 (0.71 – 2.04) 0.96 (0.70 – 1.33) 1.03 (0.72 – 1.47) 0.90 (0.71 – 1.16) 1.15 (0.77 – 1.73) 1.43 (1.09 – 1.87)
Chi-Square test. *p<0.05; **p<0.01***p<0.001
a Number of respondents answering the question.

b Reference category.
How are social relationships related to mental health?
(Papers I, II, IV)
Results of the qualitative (I) and the quantitative studies (II and IV) showed that
social relationships were related to mental health. With respect to positive aspects,
the focus group study (I) indicated that being respected and having supportive
relations with friends, school mates, teachers, family and partner is fundamental
for good mental health. The participants underscored how mental well-being to a
large extent depends on perceived respect, being well-treated and having someone
to trust. The positive mental health outcomes of good relations with others were
exemplified as happiness, self-confidence and joy. Negative aspects were also
brought forward. Participants expressed how poor support, loneliness and
disrespectful treatment were likely to influence mental health negatively in term
of, for example, worry, insecurity, stress and sadness. Relationships in school and
the overall social climate in school, such as different forms of harassment, were
also emphasised as important factors in relation to mental health.

According to Paper II, 8.1 percent of the boys and 11.4 percent of the girls who
reported any degree of stress reported relationships with friends as always or often
stressful (p=0.009). Relationships with friends was more stressful to students in
vocational programmes (12.8 percent) than their counterparts in academic
programmes (6.4 percent; p<0.001). A similar gender and class pattern was found
with regard to stress due to responsibility-taking for others (see Figure 5). With
respect to social relationships and influence in school, Paper IV showed that
deliberate self-harm (DSH) was associated with ‘having no friends in school’,
‘experiences of poor teacher support’ and ‘experiences of a hostile school
environment’1. ‘Poor influence in school’ was only significantly related to DSH in
girls. In the present results section, a comprehensive analysis (Table 6) showed that
these negative aspects of social relationships were also associated with perceived
stress and psychological distress. Poor teacher support appears to be strongly
associated with perceived stress among boys. The comprehensive analysis also
revealed a high odds ratio for the association between ‘hostile school environment’
and DSH among boys.

1
Perception of sexual harassment, bullying or racism as problems in school .This phenomenon will also
be presented in the results section on violence and harassment.

31
 Table 6. Social relationship factors. Prevalence (percentage) and associations with mental health problems (Odds ratios, 95% CI).

Prevalence Associations with mental health problems (adjusted odds ratios)b

Perceived stress (always) Psychological distress Deliberate self-harm

Na Boys Girls Boys Girls Boys Girls Boys Girls
% % OR (CI) OR (CI) OR (CI) OR (CI) OR (CI) OR (CI)
Hostile school 1,606
environment
Yes 30.9 30.4 1.90 (1.12 – 3.20) 1.52 (1.08 – 2.15) 2.12 (1.48 – 3.04) 1.50 (1.14 – 1.97) 3.39 (2.24 – 5.13) 1.45 (1.07 – 1.95)
Teacher support 1,634

32
Poor 15.6 15.2 4.77 (2.77 – 8.22) 2.67 (1.82 – 3.91) 2.73 (1.80 – 4.14) 2.76 (1.98 – 3.85) 2.35 (1.47 – 3.77) 1.92 (1.35 – 2.74)
Friends in school 1,639
No 7.6 5.9 1.62 (0.71 – 3.69) 2.32 (1.34 – 4.02) 2.40 (1.38 – 4.16) 3.41 (2.07 – 5.60) 2.45 (1.38 – 4.38) 3.11 (1.86 – 5.21)
Influence in 1,627
school
Poor 29.2*** 22.3 1.93 (1.14 – 3.26) 2.12 (1.49 – 3.01) 1.51 (1.04 – 2.18) 2.42 (1.82 – 3.23) 0.93 (0.60 – 1.46) 1.65 (1.20 – 2.26)
Chi-Square test. *p<0.05; **p<0.01***p<0.001
a Number of respondents answering the question.

b Adjusted for educational programme (vocational) and parental employment status (one or both parents not having a part-time or full-time job or running their own business).
How are experiences of demands and responsibility related to
mental health? (Papers I, II, IV)
According to the findings (I, II, IV), demands and responsibility-related factors are
particularly important factors and circumstances related to mental health among
adolescents. Demands and responsibility refer to achievements related to school
and leisure time activities as well as to relational and economic demands and
gendered expectations.

Demands and responsibility – achievements

The presence and scope of demands and expectations were found to be highly
relevant factors for mental health. With respect to positive influence, the focus
group study (I) showed that reaching goals, receiving compliments, or gaining
appreciation and recognition for their achievements contributed to self-esteem,
self-worth, confidence and happiness. However, the results (I, II, IV) mainly
displayed negative outcomes of demands and responsibility taking. Focus group
participants (I) explained that high demands, pressure, fear of failing and
burdensome responsibilities could cause stress, shame, low self-worth and anxiety.
Both boys and girls recognised that girls experienced greater pressure. One
explanation offered for this difference was that girls thought that they constantly
had to prove that they are good enough. They seemed to doubt their own capacity
and expressed dissatisfaction with their accomplishments, which both boys and
girls recognised as negative for mental health. Some girls expressed that they could
not ‘take the risk’ of not prioritising school work. The participants linked less
perceived demands and responsibility taking among boys to boys being more
prone to feeling confident and that they have learnt that they are good enough.
This may contribute to boys feeling more relaxed in relation to demands,
expectations and responsibility taking. However, it is worth noting that although
girls appeared to experience particularly heavy pressure, boys also expressed
negative outcomes of high pressure and demands. Moreover, worries and
perceived demands about the future could also produce feelings of anxiety, guilt
and inadequacy. Mainly girls expressed feelings of stress and pressure regarding
their education, professional careers, family and economy-related issues. It was
also expressed that expected gender differences in wages in the labour market
could be a reason for boys being more reluctant to put efforts into studies. They
referred to the fact that boys, as adults, are likely to get higher incomes than girls,
which might influence them to not study as much as the girls do to reach their
goals.

The quantitative findings point in the same direction. In Paper II, for example,
achievement-related stressors (‘marks’, ‘demands on oneself’ and ‘future plans’)
were found to be more stressful to girls than boys, regardless of educational

33
programme (indicator of social class). With respect to class patterns, academic
programme students reported stress from ‘marks’ and ‘demands on oneself’ to a
higher degree than their peers in vocational programmes. In addition, Paper IV
shows that dissatisfaction with school achievements was significantly associated
with DSH in both boys and girls, although the association was stronger among
girls. Moreover, being a girl attending a vocational programme who is dissatisfied
with her school achievements was associated with a particularly increased risk for
DSH. Perception of a high work load in school was significantly associated with
DSH in the adjusted model among girls. In a comprehensive analysis (not shown
in table) these two achievement variables were strongly related to stress and
psychological distress (odds ratios ranging from 1.45 to 10.25), which was
particularly strong among the girls (odds ratios around 4 compared to
approximately 2 among boys).

Demands and responsibility – gender performance, social relationships and

financial issues
The findings (I, II) showed that pressures to look and behave according to
gendered expectations were linked to negative mental health, predominately
among girls. Many female focus group participants (I) expressed experiences of
exhaustion by the practice, as well as perceived expectations, of being pretty, nice,
happy and sweet. Boys also identified the great pressure on the appearance and
behaviour among girls as potential factors contributing to elevated levels of mental
health problems in girls. Most boys neither expressed experiences of nor reflected
on gender performance-related pressures as negatively affecting mental health.
Similarly, according to Paper II, stress due to the pressure to look and dress in a
particular way was more common among girls than boys, and particularly among
girls attending vocational programmes. However, both boys and girls in the focus
groups (I) noted the societal pressures on boys that might contribute to their
mental distress as a consequence of being harassed if not adhering to the male
norm of being ‘macho’ by, for instance, openly expressing emotions in school. Boys
did, however, state that they had no problems sharing their feelings with their
partner or a close friend.

As noted in the previous section on social relationships, demands and

responsibility to maintain good relationships with their family, partner and friends
were described as possible sources of stress, guilt and anxiety (I). In particular,
girls expressed how they took responsibility for the feelings of others. For example,
according to Paper I, many girls did not express how they feel with concern for the
feelings of others because they did not want to be a problem for others. Paper II is
pointing in the same direction; stress due to ‘responsibility for others’ was more
frequently reported by girls than boys.

34
 With respect to demands and responsibilities related to economic issues, stress due
to ‘lack of money’ (II) was strongly patterned by both gender (girls) and class
(vocational programme students); stress due to lack of money was especially
frequent among girls in vocational programmes.

80

70

60

Boys academic
50
Girls academic
%
Boys vocational
40
Girls vocational

30

20

10

0
Marks Demands on oneself Future plans Lack of money Responsibility for Looks
others

Figure 5. Reports on stressors (percentage) among boys and girls attending academic and
vocational programmes.

How are experiences of violence and harassment related to

mental health? (Papers I, III, IV)
It was found that experiences of violence and harassment, as well as the exposure
of observing others being harassed appeared to be a part of young peoples’
everyday life and potential risk factors for mental health problems. The qualitative
study (I) highlighted an elusive form of verbal harassment as potentially affecting
mental health negatively, namely the phenomenon of ‘joking’. That is, rough
language or jargon and actions that would be considered rude or insulting outside
of the context of a peer group. Although ‘joking’ was perceived as a way of
bonding within a peer group, jokes were often mean and insulting and thus
referred to as humiliation through humour. Both boys and girls described joking as
mainly practiced by dominant boys targeting more submissive peers.

35
As shown in Table 7, reports of bullying and sexual harassment in school were
common (III, IV). Experiences of bullying were more common among girls than
among boys and experiences of sexual harassment were slightly more common
among boys. The qualitative study (I) suggest that sexualised name-calling was
experienced by both boys and girls, although the most commonly expressed
scenario was that of boys harassing girls or other boys. Physical violence during
the past year was more frequently reported by boys than by girls, whereas girls
were nearly three times more likely to report a lifetime experience (ever
occurrence) of sexual assault (III, IV). In the focus groups (I), both girls and boys
perceived that girls were more exposed to sexual harassment and sexualised
violence than boys. Experiences of sexual harassment and fear of sexualised
violence were viewed as restricting the girls’ space of action, as they avoided
perceived risky situations or areas (I).

According to the focus groups (I), violence and harassment were associated with
mental health in terms of humiliation, worry, anxiety, fear, loss of self-worth, stress
and insecurity. Importantly, it was brought forward that violence and harassment
can influence students’ mental health regardless of whether they directly
experienced it or not. This relates to the concept of a ‘hostile school environment’
previously presented in the results section on social relationships. The results from
Paper III and IV (as well as the additional analysis displayed in Table 7) showed
that experiences of all types of violence (bullying, sexual harassment, physical
violence and sexual assault,) were associated with an increased risk of reporting
stress, psychological distress and DSH in both boys and girls. However, in
comparison with the results among boys, lower levels of bullying and sexual
harassment were required to generate significant associations with stress and
psychological distress as well as DSH (lower level of sexual harassment only)
among girls. There were also some interaction effects, mainly among girls,
indicating that being a girl attending vocational programmes or not having both
parents currently employed, when combined with experiences of violence,
increased the odds of reporting mental health problems (see Appendix 4 for an
overview).

36
 Table 7. Experiences of violence and harassment. Prevalence (percentage) and associations with mental health problems (Odds ratios, 95% CI).

Prevalence Associations with mental health problems (adjusted odds ratios)b

Perceived stress (always) Psychological distress Deliberate self-harm

Na Boys Girls Boys Girls Boys Girls Boys Girls
Type of violence % % OR (CI) OR (CI) OR (CI) OR (CI) OR (CI) OR (CI)
Past 12 months
Bullying 1,602 ***
Experienced 1 act 23.1 31.4 1.24 (0.62 – 2.48) 1.86 (1.24 – 2.78) 1.59 (1.00 – 2.51) 1.60 (1.16 – 2.12) 4.16 (2.34 – 7.40) 1.98 (1.41 – 2.78)
Experienced 2-3 acts 16.6 20.3 3.31 (1.83 – 6.02) 3.50 (2.32 – 5.26) 5.46 (3.56 – 8.36) 3.97 (2.85 – 5.52) 12.97 (7.58 – 22.21) 3.90 (2.73 – 5.56)
Sexual harassment 1,588 *

37
Experienced 1 act 22.5 21.3 0.65 (0.29 – 1.46) 1.76 (1.15 – 2.70) 1.18 (0.72 – 1.94) 1.69 (1.21 – 2.35) 1.48 (0.68 – 3.23) 2.43 (1.67 – 3.52)
Experienced 2 acts 12.5 9.8 1.12 (0.47 – 2.65) 1.81 (1.03 – 3.20) 1.26 (0.68 – 2.33) 4.03 (2.61 – 6.21) 6.12 (3.01 – 12.43) 5.11 (3.23 – 8.07)
Experienced 3-5 acts 14.0 12.9 3.12 (1.69 – 5.92) 3.32 (2.13 – 5.19) 5.60 (3.55 – 8.82) 4.68 (3.18 – 6.91) 18.95 (10.20 – 35.22 5.31 (3.53 – 8.00)
Physical violence 1,611
Experienced 24.8*** 15.0 1.35 (0.77 – 2.37) 2.33 (1.57 – 3.46) 1.90 (1.31 – 2.76) 2.68 (1.90 – 3.77) 2.78 (1.83 – 4.22) 4.28 (3.01 – 6.10)
Lifetime
Physical violence 1,507
Experienced 51.0*** 33.8 1.84 (1.03 – 3.30) 2.49 (1.77 – 3.49) 2.64 (1.77 – 3.92) 2.67 (2.03 – 3.51) 5.42 (3.12 – 9.40) 4.33 (3.21 – 5.83)
Sexual assault 1,601
Experienced 6.4 17.3*** 3.27 (1.51 – 7.07) 1.98 (1.34 – 2.91) 5.11 (3.02 – 8.64) 2.68 (1.95 – 3.70) 7.56 (4.32 –13.24) 4.37 (3.12 – 6.12)
Chi-Square test. *p<0.05; **p<0.01***p<0.001
a Number of respondents answering the question.

b Adjusted for educational programme (vocational) and parental employment status (one or both parents not having a part-time or full-time job or running their own business).
Victim-perpetrator relationship of physical violence
Among those who had experienced physical violence during the past 12 months,
the most frequently reported perpetrator was a male. Moreover, whereas boys
almost entirely reported the perpetrator of physical violence to be another male,
girls appear to be offended by a range of perpetrators and were more likely than
boys to report the perpetrator to be a person with whom they presumably have a
close relationship (parent or partner). According to the findings, it seemed that the
victim-perpetrator relationship influenced the odds of psychological distress. In
focus was whether the perpetrator was unknown or known as well as a parent or a
partner. The perpetrator being an unknown person was associated with
psychological distress among boys, whereas the categories ‘known person’,
‘partner’ and ‘other’ significant associations with psychological distress among
girls. Tendencies towards significance were observed for ‘known person’ among
boys and ‘unknown person’ among girls. One of the key findings was that girls to
a high degree had been offended by their boyfriends and that this victim-
perpetrator relationship, compared to not having experienced violence, showed a
strong association with psychological distress among girls.

60

49***
50
Boys
Girls
40

% 32***
30

20*** 19***
20 18

11
8 9*** 9** 9
10 6***
4 3
1 2 1
0,5 0,4
0

Figure 6. Reports (percentage) of perpetrator of physical violence during the past year.
Gender differences indicated by Chi-Square test. *p<0.05; **p<0.01***p<0.001.

38
Table 8. Associations between category of perpetrator of violence (during the past 12
months) and psychological distress.

Associations with mental health (adjusted odds ratios)a

Boys Girls
OR CI OR CI
Perpetrator category
Not exposed Ref. Ref.
Unknown person 1.89 1.18 – 3.02 2.18 1.00 – 4.77
Known person 1.69 0.96 – 2.96 2.53 1.34 – 4.77
Parent n.a. 1.86 0.83 – 4.16
Partner n.a 2.87 1.38 – 6.00
Other 1.12 0.25 – 5.09 3.65 1.79 – 7.43
a Adjusted for educational programme (vocational) and parental employment status

(one or both parents not having a part-time or full-time job or running their own business).
n.a. = not applicable due to the low number of cases.

39
DISCUSSION

On the results
The aim of this thesis was to explore the relationships between life circumstances
and adolescent mental health. Importantly, such a focus was also emphasised by
the participants in the focus groups in study I. Consistent with previous research
(Wisdom et al. 2007) and in accordance with a public health approach (Baum 2003),
the participants emphasised the importance of social and psychosocial
circumstances as influences on adolescent mental health. Boys’ and girls’
perceptions of factors and circumstances being important for mental health were
similar, but their experiences of them differed. This observation as well as the
quantitative findings will be elaborated on in the forthcoming discussion.

Mental health problems

Understandings
According to Paper I, mental health was understood as an emotional experience
and predominately described negatively (e.g., experiencing distress, feeling low, or
stress). These findings are consistent with a Swedish study exploring how 13-16-
year–old adolescents perceive the concept of mental health (Johansson et al. 2007)
as well as a qualitative study in which the adolescents associated the concept of
mental health with mental distress (Armstrong et al. 2000).

Prevalence and patterning

Self-reports of perceived stress, psychological distress and deliberate self-harm
were common, although the prevalence was approximately twice as high among
girls as boys. In general, these findings confirm the gender pattern identified in
previous research (Madge et al. 2008; Ollfors and Andersson 2007; Sweeting et al.
2009; Torsheim et al. 2006). However, given the variety of measures employed
within the field, specific identifications of similarities and differences with other
studies is somewhat limited. Nevertheless, the high prevalence of girls reporting
that they always or always/often have felt stressed during the past three months is
noteworthy and should be taken seriously. With regard to psychological distress, it
was predefined with a given cutoff point in the scale (upper quartile). The gender
difference within this group was substantial; twice as many girls as boys fell into
the category of experiencing psychological distress. The overall prevalence of
lifetime experience of deliberate self-harm was slightly higher than in previous
studies (except that of Bjärehed and Lundh, 2008) and also revealed a relatively
high rate among boys. The high prevalence might be a reflection of particularly
poor mental health and destructive behaviour among young people in the region.
It is also possible that the high prevalence was due to methodological issues. The
study concerned lifetime experience, which could have generated a higher

40
prevalence than reports of DSH during, for instance, the past year (see e.g., Madge
et al. 2008). It is also possible that there was an overestimation of DSH because we
could not discern the methods used, the students’ intentions, or how the students
interpreted the questions. Nevertheless, given the sparse research on Swedish non-
clinical young populations, this study contributes new important knowledge.

Girls were also overrepresented in the group with multiple mental health
problems; having two or more mental health problems was more than four times
more common among girls than among boys. This finding is central as it further
highlights the heavy burden of mental ill health experienced by girls. As argued by
others (Stuart 2006), the clustering of mental distress should be acknowledged in
health promotion interventions.

With regard to patterning due to social class, the findings support the research
showing higher rates of psychological distress and DSH among youths from low
SES backgrounds (Goodman et al. 2003b; Hawton et al. 2001; West and Sweeting
2003; Wight et al. 2006). However, findings did not confirm evidence of elevated
levels of stress among those of disadvantaged social status (Goodman et al. 2005;
Turner and Avison 2003). Similarly to Hagquist (2007), it seems that educational
programme was more strongly associated with mental health problems than
parental indicators of SES.

Factors and circumstances related to mental health problems

Social relationships
Social relationships appeared to play a central role in identifying possible
determinants of mental health among both boys and girls, particularly as a source
of good mental health, as shown in Paper I. This observation is supported by
previous research (Haraldsson et al. 2010; Johansson et al. 2007; Rudolph 2002).
However, the findings showed that relationships with friends could be stressful,
and that both poor social relationships and responsibility-taking regarding
relationships were associated with mental health problems. These findings add to
the existing qualitative and quantitative evidence linking social relationships and
reports of poor mental health (Armstrong et al. 2000; Bjärehed and Lundh 2008;
Gillander Gådin and Hammarström 2003; Heinrich and Gullone 2006; Johansson et
al. 2007; Kraaij et al. 2003). It is also worth noting that good relationships in school
seem to be of great value with respect to mental health.

The findings suggest that social relationships are more strongly related to mental
health problems among girls than among boys, supporting previous findings
(Rudolph 2002; Wagner and Compas 1990; Ystgaard 1997). Rudolph (2002)
suggested that this is due to a female ‘relational-orientation style’ (greater female

41
sensibility to relational problems) and differential interpersonal stress exposures in
girls and boys (Rudolph 2002). From a gender perspective, there are several
questions to be addressed in relation to these arguments. Rudolph (2002) seems to
presume that girls and boys are living in two parallel worlds, which ignores the
relational component of gender. In addition, quite frequently there are
generalisations of how girls are, for example, that relationships are more central to
girls’ identity than boys’ and that girls and boys have different psychological
characteristics (e.g., ‘relational orientation styles’). According to the gender
theoretical framework, girls’ and boys’ experiences and self-constructions are more
than expressions of socialised sex-role identities; gender is learned through
‘performance’, and it is a social relationship as well as a structure (Butler 1990;
West and Zimmerman 1987). Girls are likely to relate to and practice dominant
discourses of femininity in which caring and taking social responsibility is central
(Connell 2009; Walkerdine et al. 2001). Such practice as well as the expectations of
such practice, appears to be stressful and may contribute to mental health
problems among girls. The findings also suggested that students attending
vocational programmes were more stressed about peer-relationships and taking
responsibility for others than their counterparts in academic programmes. Perhaps
girls and boys from low-SES backgrounds need to take more responsibility for
others and therefore reported it as more stressful.

The results highlighted the mental health importance of the influence of social
relationships in school, student-teacher relationships and a safe school
environment. In accordance with the present findings, poor teacher-student
relationships and lack of opportunities to influence the structure and content of
their studies were found to be correlates of stress in a recent study on adolescent
girls (Haraldsson et al. 2010). However, the results from the additional analysis in
this thesis (Table 6) showed that poor teacher support seemed to be particularly
strongly associated with high levels of stress among boys. Social support in school
and student participation have been identified as central to adolescents’ mental
well-being, although most research is conducted on adolescents younger than 17
years (Ellonen et al. 2008; Gillander Gådin 2002; Konu and Lintonen 2006;
Simovska 2004).

In line with prior evidence (Gillander Gådin and Hammarström 2003; Gillander
Gådin and Hammarström 2000), poor influence in school appeared to be
particularly salient for mental health among girls. Moreover, as will be discussed
in more depth in the next section, schools are important arenas in the construction
and reconstructions of gender (Mac an Ghaill 1996; Paechter 2007). While schools
inherit a great potential for health promotion interventions, they are also central in
advancing the understanding of gender relations and hierarchies and the links to

42
mental health. The discussion on safety and hostility in schools is in the section on
violence.

Demands and responsibility-taking

Demands and responsibility-taking represented particularly important life
circumstances in relation to adolescent mental health. The results indicate that
more than boys, girls experienced great pressure and responsibilities regarding
academic success, social relationships and attractiveness, which were experiences
that were plausible sources of stress and mental health problems.

Achievements
The results suggest that factors and circumstances related to school performance,
demands and responsibility-taking were strongly associated with mental health
problems. Given the large body of research on academic pressure and problems
with studies as possible predictors of mental health problems (Byrne et al. 2007;
Murberg and Bru 2004; Torsheim and Wold 2001; West and Sweeting 2003; Young
et al. 2007), the following discussion will focus on specific aspects of the findings:
gender and class patterning, school environment effects and a gender analysis.

Achievement-related factors such as the pressure for good marks and future plans
as well as dissatisfaction with school achievements were found to be of greater
importance to mental health among girls than among boys, which confirms
existing evidence (Murberg and Bru 2004; Ollfors and Andersson 2007; West and
Sweeting 2003). With regard to class patterning, the present findings support
previous research, although the classification of SES might differ. It has, for
example been found that students of middle-class backgrounds report greater
worries about academic achievements than those of working-class backgrounds
(West and Sweeting 2003). However, in contrast to West and Sweeting (2003) who
identified a strong association between such worries and psychological distress in
middle-class girls, the present study suggest school achievement-related to be
strongly related to mental health problems among girls regardless of educational
programme. That is, socioeconomic status seems to be of less importance among
girls than boys with respect to experiences of academic demands and mental
health. Similarly, a recent Canadian study found that, in comparison with girls,
boys’ subjective health appeared to benefit more from the increasing
socioeconomic status of the school area (Saab and Klinger 2010).

Against this background, it can be presumed that adolescent mental health is

linked to the school-class context in terms of ‘academic standing’, expectations
from teachers and perceptions of the meaning of school achievements,
socioeconomic indicators as well as psychosocial work environment (Gillander
Gådin and Hammarström 2003; Goodman et al. 2003a; Hjern et al. 2008; Modin and

43
Östberg 2009; Saab and Klinger 2010; Torsheim and Wold 2001). The present
findings indicate that a school context of academic pressure and expectations is
predominately experienced by students attending academic programmes and by
girls (in both academic and vocational programmes). In line with this
interpretation, the lower rates of achievement-related mental distress among boys
in vocational programmes may be a reflection of a school context less characterised
by academic pressure. On the other hand, if the school environment does not
encourage academic achievements and give limited access to such ‘capital’, those
students might be at risk of stressful marginalisation in flexible labour markets,
which impose high demands on individual life-management skills such as
attaining high education levels (Furlong et al. 2006; Plug et al. 2003). Hence,
although academic responsibility-taking and negative mental health consequences
from such pressure are likely to be more prevalent among students aiming for
university studies, the key finding is that the relationship between school-related
demands and responsibility-taking and mental health is stronger among girls than
among boys. These results should be seen in light of the constructions and
practices of masculinity and femininity as well as the power dynamics embedded
in the relation between such practices. Structural aspects in terms of power and
resources are also central to recognise.

For example, although many boys reported being stressed by school marks, being a
boy appears to imply the possibility to ’play around’ and reject responsibility
taking regarding achievements and the future. These findings are supported by the
literature on boys and schooling, which suggests that academic success and being
‘studious’ are not honoured in constructions of hegemonic masculinity (Jackson
2002; Mac an Ghaill 1994; Renold 2004). Hence, ‘anti-swot’ or ‘laddish’ behaviours
can be interpreted as ways of practicing hegemonic masculinity (Jackson 2002).
Given the methods used by (mainly) boys in policing the boundaries of acceptable
male behaviour and identity, ‘anti-swot practices’ and rowdiness might be
strategies to avoid harassment (Dalley-Trim 2007; Jackson 2002). At the same time,
lower rates of mental distress and rejecting responsibility-taking regarding school
work are plausible consequences of perceived higher status gained from
hegemonic masculinity (Courtenay 2000; Dalley-Trim 2007). For example, if boys
already feel confident and recognised without the pressure of ‘proving’ their
worth, it may imply fewer experiences of factors capable of eliciting negative
mental health. This does not, of course, include all boys as there are multiple ways
of practicing masculinity. Possibly, prioritising school work is more socially
acceptable among boys from middle-class backgrounds (Mac an Ghaill 1994;
Renold 2004). However, it is possible that boys find the negotiation between
academic demands/responsibility-taking and maintaining a position in the male
hierarchy to be stressful and negative for mental health, especially in a highly
competitive society placing great value in successful achievements (Jackson 2002).

44
With regard to the findings in girls, academic demands as well as pressures about
responsibility-taking and future plans are reflecting discourses of a (predominately
middle-class and neo-liberal) ‘good girl’ femininity in which being studious and
responsibility-taking is emphasised (Renold and Allan 2006; Skeggs 1997;
Walkerdine et al. 2001). Adhering to this type of femininity appears to place great
pressure on girls regardless of social class and, thus, represents a potential risk
factor for mental health problems. At the same time, Paper I suggested that there
was a negotiation in which crossing the boundaries of achievement-focused
femininity was perceived as a potential risk of losing advantages gained from good
marks.

Moreover, relational and structural class and gender inequalities should also be
taken into account; boys’ and girls’ practices (within as well as between gender
categories) constitute positions that interact with each other. That is, if somebody
does not take responsibility, somebody else has to. The dimensions of power are
embedded in these practices and the relations between them. For example, if boys
can relax, whereas girls cannot, it may contribute a reconstruction of male
dominance over girls. Girls experienced demands to perform well in order to be
recognised and respected. However, while doing so they experienced stress,
feelings of inadequacy and anxiety, which are also risk factors of further
subordination. An interpretation would be that if they do not take school seriously,
they risk to remain in positions of low status. That is to say, responsibility taking
may also be strategic for girls. Responsibility-taking and aiming for good marks
might be a means for girls to gain success and respect and possibly, overcome
gendered obstacles in an unequal society in which boys and men, on a collective
level, benefit from greater economic, political and personal resources and power
(Connell 2005; Kimmel 2008). Having responsibility has, for instance, been
identified as a source of social power among young people (Powers and Reiser
2005). Another interpretation is that responsibility-taking represents a means of
‘becoming an adult’ and gaining better status from the benefits of adulthood
(Westberg 2004). Understanding responsibility as being a gendered phenomenon
does not imply that all boys practice limited responsibility-taking and that all girls
perceive it as burdensome. However, the gender analysis suggests that such
responsibility can be a disadvantage for girls and an advantage for boys in terms of
mental health.

Doing girl – doing boy

It was found that factors related to pressure on how to look and dress were more
strongly associated with mental health problems among girls than among boys.
These findings, alongside a considerable amount of prior research, indicate a
strong pressure on girls to perform bodily constructions of femininity, such as

45
beauty, sexiness and thinness, which in turn are plausible sources of mental
distress (Frost 2003; Paechter 2007; Tolman et al. 2006; Walkerdine et al. 2001). Girls
appeared to experience a complex balance between a desire and a resistance to the
practice of widely-accepted notions of femininity, and it was mainly experienced
as demanding, controlling and stressful. This finding is consistent with an
interview study on depressed adolescents where both girls and boys identified
high expectations for girls to achieve cultural ideals of beauty and associated a
failure to do so with feeling hopeless and depressed (Wisdom et al. 2007). The wish
to ‘pass’ as attractive might also be motivated by potentially negative experiences
associated with crossing norms. For example, Polce-Lynch and co-workers (2001)
identified lower self-esteem among girls who did not adhere to stereotypical
feminine ideals regarding body image. In contrast to research identifying negative
body image as a risk factor for low self-esteem and depression in both girls and
boys (Allgood-Merten et al. 1990; Siegel et al. 1999), boys in the present study
appeared to experience fewer demands and less pressure regarding attractiveness
and gendered expectations than did girls and were less inclined to considered such
pressure as a risk factor for mental health problems. However, it is likely that boys
may also suffer from mental health problems as a consequence of meeting bodily
demands such as being fit, strong and tall (Bengs 2000; Connell 2005; Frosh et al.
2002). Although the findings mainly highlighted the negative influences of factors
related to appearance and body shape, it is notable that ‘doing’ femininity and
masculinity via physical display could also be joyful (Connell 2009).

Moreover, negotiating hegemonic ‘macho’ masculinity may be stressful to boys

and potentially linked to other types of poor mental health. It has, for example,
been argued that adhering to hegemonic masculinity, such as avoiding the sharing
of their feelings in fear of being harassed for not being manly, may have emotional
costs (Connell 1996; Courtenay 2000). Crossing such boundaries may imply giving
up of their power and jeopardise their position in a male hierarchy, which might be
a risk for mental health (e.g., through harassment). Boys in this study did,
however, state that they had no problems sharing their feelings; they just needed to
feel safe in doing so (e.g., talking to a partner or close friend). This finding
illustrates that gender is dynamic and relational. A broader repertoire of practices
seems to be possible if they perceive low or no risk of being harassed. Further
reflections on demands related to femininity and ‘doing’ girl are found in the
previous section on social relationships.

Financial issues
With regard to demands and responsibility-taking about financial issues, the
findings revealed a picture strongly patterned by gender and class. The results on
stress due to lack of money correspond to research suggesting greater financial
strain in low SES youth (Fröjd et al. 2006) and oppose the research suggesting no

46
gender differences in economic stress (Byrne et al. 2007). It is worth considering,
however, that low SES adolescents do not necessarily have less disposable income
than their wealthier peers (West et al. 2006). Stress due to ‘lack of money’ was
particularly prevalent among female vocational students, which indicated
experiences of multiple disadvantages. According to the intersectional analysis and
what Mendelson et al. (2008) call ‘double jeopardy’, elevated financial stress
among girls in vocational programmes is potentially linked to the interaction
between female gender and a disadvantaged position in the social structure.

Violence and harassment

In contrast to most research on violence and adolescent mental health, the present
study examined several types of violence and emphasised the importance of
recognising the victim-perpetrator relationship as well as the context of violence
when researching the links between victimisation and psychological distress in
youth. Experiences of violence and harassment were found to be frequently
reported by both boys and girls. The findings also suggest that experiences of
verbal, physical and sexual abuse are risk factors for mental health problems in
both girls and boys, particularly among students of low SES background (mostly
girls). Although the findings confirm existing evidence (Fliege et al. 2009; Gillander
Gådin and Hammarström 2005; Gratz et al. 2002; Hawton et al. 2002; Kaltiala-
Heino et al. 2000; Schraedley et al. 1999; Sundaram et al. 2004), the present study
offers new insights regarding joking, gender patterning, associations with mental
health and, importantly, a gender analysis.

Joking
Although ‘joking’ was not perceived entirely negatively, such ‘jargon’ was
identified as potentially harmful. Moreover, joking was identified as a being ‘done’
mainly by boys. It is relevant to draw upon the existing literature on joking as a
way of constructing masculinity and maintain hierarchies among boys (Connell
2000; Frosh et al. 2002). Frosh (2002) argues, for example, that joking is a gendered
practice of the tougher over the less tough who easily can be ‘accused’ of not being
able to handle ‘joking banter’. Hence, consistent with previous research (Eliasson
2007), joking can be seen as a type of (predominately male) verbal
abuse/aggression likely to influence adolescent mental health negatively.

Gender patterning, associations and a gender analysis

Some key findings were the high rates of school-based bullying and sexual
harassment among both boys and girls as well as the associations with
psychological problems. In accordance with previous findings (Craig et al. 2009;
Petersen and Hyde 2009; Solberg and Olweus 2003), the gender differences were
small with respect to bullying and sexual harassment. Bullying was more

47
frequently reported by girls, and sexual harassment was slightly more common
among boys.

Against the background of previously found greater likelihood of girls reporting

experiences of sexual harassment (Gillander Gådin and Hammarström 2005;
Gruber and Fineran 2008; Hand and Sanchez 2000; American Association of
University Women 2001), the high prevalence among boys was somewhat
unexpected. At the same time, there is evidence of name-calling (mainly
homophobic) being particularly prevalent among boys (McMaster et al. 2002;
American Association of University Women 2001). As shown in Appendix 3, this
was also the case in the present study which might explain the high prevalence of
male experiences of sexual harassment among boys. Furthermore, previous
research indicates that there is a fine line between bullying and sexual harassment
with regard to understandings, conceptualisations and responses. That is, sexual
harassment might be perceived as bullying and acts of bullying might be perceived
as sexual harassment, by both adolescents and researchers. For example, in an
American study (Swearer et al. 2008), the homophobic name-calling of boys was
regarded as bullying and not sexual harassment. Moreover, it has been found that
male bullying of girls is predominately sexual in nature (Shute et al. 2008).

The mental health associations with bullying and sexual harassment confirm prior
research on younger adolescents (Gillander Gådin and Hammarström 2005;
Gobina et al. 2008; Gruber and Fineran 2008; Nansel et al. 2004). As expected, there
was a dose-response effect where the odds of reporting mental health problems
increased with the number of bullying and sexual harassment acts, especially
among girls and particularly among those attending vocational programmes.
These results are supported by prior research of more negative mental health
consequences of sexual harassment for girls than boys (Gillander Gådin and
Hammarström 2005; Gruber and Fineran 2008).

From a gender perspective, sexual harassment has been viewed as a crude way of
deploying gender, an exercise of power directed at the body and the sexuality of
the target, and it has been found to be mainly perpetrated by boys against girls and
other boys (Connell 2009; Fineran and Bennett 1999; McMaster et al. 2002). Hand
and Sanchez (2000) argue that, because of the structural, social and power-related
mechanisms of the asymmetric gender order, adolescent girls experience more
sexual harassment, particularly the most physical and intrusive forms, and report
greater negative behavioural, emotional and educational outcomes than boys
(Hand and Sanchez 2000). It is possible that this was also the case in the present
study because the associations between sexual harassment and mental health
problems were stronger among girls than boys. Nevertheless, although the
character of harassment may differ for girls and boys, bullying and sexual

48
harassment is controlling to boys as well. The results indicate, for instance, that the
perception of bullying, sexual harassment or racism as problems in school was
strongly associated with mental health problems among boys. Overall, this study
suggests that a hostile environment in school should be seen as a risk factor for
mental health problems in both boys and girls. This recognition of the contextual
aspects of violence is supported by an American study in which the perception of
possible victimisation was highly important in predicting psychological distress
(Dao et al. 2006). Moreover, to further understand the links between harassment
and mental health, it is of interest to explore by whom the girls and boys are
bullied and sexually harassed, for what purpose and in which context. The
findings call for a critical analysis of schools as potentially highly sexualised sites
in which gender hierarchies are being constructed and reconstructed through
bullying and sexual harassment (Dalley-Trim 2007). In addition, the processes of
normalisation of violence in school have to be recognised and challenged (Berman
et al. 2000). Name-calling is, for instance, not something that should be taken for
granted as a part of ‘being a boy’ and a means of constructing masculinity (see also
Eliasson 2007). Sexual harassment and bullying violate young peoples’ rights to a
safe school environment and their right to wellbeing (Witkowska and Menckel
2005).

The identified gender patterning of experiences of physical violence

(overrepresentation of boys) is consistent with previous research (Lawyer et al.
2006; Leonard et al. 2002). In accordance with existing evidence (Fredland et al.
2008; Hawton et al. 2002; Schraedley et al. 1999), the findings indicate that physical
violence should be considered a risk factor for various forms of mental health
problems in both boys and girls. However, there seems to be a tendency towards
stronger detrimental mental health associations of physical abuse in girls than in
boys, findings that are consistent with those from Thompson et al. (2004) and
Sundaram et al. (2004). One possible explanation of this could be that girls, to a
high degree, were offended by someone with whom they had a close relationship
and/or is potentially dependent upon, which has been found to be particularly
negative for mental health (Lawyer et al. 2006).

Apart from displaying prevalent gender differences in reports of perpetrator of

physical violence during the past 12 months, the findings also suggest that the
odds of reporting psychological distress differ among boys and girls depending on
the reported victim-perpetrator relationship of physical violence. No clear
conclusions on gender differences regarding whether the offender was known or
unknown to the victim could be drawn. The findings do, however, indicate that the
perpetrator being an unknown person increased the odds of reporting
psychological distress among boys, and the same for the category ‘known person’
among girls. According to Lawyer et al. (2006) more negative mental health

49
outcomes are likely to be reported by those who have been offended by a ‘non-
stranger’. Although the present study partly confirm their findings, a full
comparison is unfeasible because Lawyer et al. did not conduct the analysis
separately for boys and girls. Nevertheless, one of the key findings was that girls
reported being exposed to violence by their boyfriends and that it was strongly
associated with psychological distress. In addition to contributing new knowledge
on teen dating/intimate partner violence in Sweden, the present findings add to the
international research that suggest that partner violence within heterosexual dating
relationships is particularly negatively experienced by young females (Jackson et
al. 2000; Molidor and Tolman 1998). One possible explanation addressed is that
girls experience more severe partner violence than boys (Banister et al. 2003,
Molidor and Tolman 1998, Tolman et al. 2003). From a gender perspective, intimate
partner violence can be considered a means of dominance and control and,
according to research on the matter, there seems to exist a cultural acceptance for a
boy/man to use violence toward his girlfriend (Fredrickson and Roberts 1997;
Johnson et al. 2005). This highlights the need for an analysis in which gendered
power hierarchies (i.e., girls being collectively subordinated to boys as well as
power hierarchies among boys) are taken into account, especially given the
likelihood of more severe mental health consequences if the target is subordinate to
the offender (Banister et al. 2003). Moreover, another interpretation of the results is
that boys and girls experience violence and different environments. Exposure by
an unknown person is likely to occur in non-private arenas, whereas exposure by a
known person, especially family member or partner, plausibly takes place within
private home environment. Such circumstances might perhaps have an influence
on the psychological distress associations.

Overall, the findings suggest that being a boy implies a risk of experiencing
physical violence as well as a risk of being a perpetrator. These observations
should be interpreted in relation to theories on violence and the construction and
practice of hegemonic masculinity, i.e., how physical aggression and risk-taking
appears to play a central role in doing masculinity and how violent behaviour is
used to demonstrate power and to maintain hierarchies in male groups and over
girls (Connell 2002, 2005; Kenway and Fitzclarence 1997). Hence, if violence plays a
role in being ‘manly’, it likely contributes to boys both exercising and experiencing
physical violence to a greater extent than girls, which in turn imposes risk for
mental health problems among boys and girls. With regard to masculinity,
violence and health, Courtenay (2000) has recognised the emotional and
psychological costs of the stress and violence needed to maintain male hierarchies
among men. Apart from the mental health consequences of the insult that
victimisation implies, boys might also experience stressful pressure to adjust to
violent practices as well as fear of being targets of homophobic bullying if they do

50
not comply with such practices (Dalley-Trim 2007; Kenway and Fitzclarence 1997;
Phoenix et al. 2003).

However, although the most frequently reported perpetrators of physical violence

were male, it is worth noting that violence is not only perpetrated by men. Reports
of female perpetrators were not common but were, by no means absent,
particularly for girls. Research on the meaning of violence in constructions of
femininity is, however, scarce although it has been suggested that violent girls are
constructed as ‘bad girls’ crossing the boundaries of traditional notions of
femininity (Laidler and Hunt 2001). More research is needed to deepen the
understanding of the links between femininity, violence and mental health.

The gender patterning of experiences of sexual assault (overrepresentation of girls)

is consistent with past observations (Edgardh and Ormstad 2000; Fergusson et al.
2002; Romito and Grassi 2007). So are the associations with mental health problems
in both girls and boys (Ackard and Neumark-Sztainer 2003; Schraedley et al. 1999).
The high odds ratio among boys confirms the reports of Schraedley et al. (1999)
and (Haavet et al. 2004), which highlights the need to acknowledge sexual assault
against boys as an important risk factor for mental health problems. Schraedley et
al. (1999) argue that the weaker association between sexual assault and depression
among girls is due to better coping strategies because girls experience more
sexualised violence than boys. By their reasoning, they assume that the more
violence an individual is exposed to, the less consequences it might have. In
opposition to this argument, there is a vast amount of research confirming
profound negative mental health consequences of sexual assault in girls and
women (Fergusson et al. 2002; Jackson et al. 2000). Against this background, it was
somewhat unexpected that the association was weaker among girls than boys. This
might be due to the high prevalence of psychological distress also found in the
non-exposed group. Similar results were found by Schraedley (1999). However,
this does not diminish the severity of sexual abuse towards boys. As the findings
clearly displayed: the boys who reported experiences of being forced to have sex
reported worse mental health than the boys who had not.

Nevertheless, one should also keep in mind the considerable gender differences in
the experiences of sexual assault; girls were almost three times as likely to have
been forced to have sex as boys. Drawing on gender theory, sexualised violence
against girls can be seen as a consequence of objectifying attitudes toward girls,
which communicates that the bodies and sexuality of girls and women are objects
for the pleasure of men (Connell 2009; Fredrickson and Roberts 1997; Hand and
Sanchez 2000). Such a perspective is rarely employed in research on violence and
adolescent mental health. For example, in a recent qualitative study, both girls and
boys expressed awareness of increased sexual threats imposed on girls and how it

51
was likely to contribute to depression in girls (Wisdom et al. 2007). However,
rather than to discuss this in relation to demeaning values, male power, or the
objectification of girls, the authors argue that sexualised abuse is linked to the
bodily changes that girls undergo during puberty and that girls should learn how
to cope with sexualised harassment from boys. Through such reasoning, the
context, including gendered power dimensions, of violence is ignored and the
responsibility is placed on the girls. This example illustrates the need for a gender
analysis to better understand sexualised violence and the mental health
consequences of it.

The SES/social class patterning of experiences of violence as well as the gender-SES

interaction in associations with mental health problems are other important
observations. This has not has not been discussed in detail here but deserves great
attention in future research as well as in interventions.

Summary of the gender analysis

In this thesis, a gender analysis has been the main aspect of a public health
approach. The findings indicate that gender, in complex ways, could impart both
benefits and disadvantages in relation to mental health. The gender analysis
suggests that constructions and practices of gender as well as gendered power
structures influence the life circumstances of girls and boys and, thus, the kinds of
risk factors they encounter in their everyday life as well as the ways girls and boys
may react to such circumstances with respect to mental health. There seems to be a
mental health cost of distancing oneself from the dominant constructions of
masculinity and femininity, and there is a cost of adhering to them. Such
ambivalence and negotiations appear to be particularly negative for the mental
health of girls, for example by negotiating being both ‘‘bright’’ (i.e., succeeding
academically) and ‘‘beautiful’’ (succeeding in ‘‘doing girl’’) (Lucey et al. 2003;
Renold and Allan 2006). It is also important to recognise how the structural aspects
(e.g., the distribution of power, resources and values) influence the lives of boys
and girls of different socioeconomic status and, potentially, their mental health. In
contrast to the explanatory models based on sex-role and socialisation theory, the
present analysis has taken into account the constructions (or the ‘doing’) of gender,
gender as a social relation and a power structure. Such an approach is more fruitful
in providing the tools to understand the links between life circumstances and
mental health among both girls and boys. In sum, at the risk of oversimplifying,
the findings and the gender theoretical analysis suggest that gendered mechanisms
at the different levels in society influence the distribution of risk factors unevenly
among boys and girls, which could be a possible explanation for the gender
differences in reports of perceived stress, psychological distress and deliberate self-
harm.

52
Critical reflections on applying a gender analysis
Gender theories were intended to be used as tools to better understand the links
between life circumstances and adolescent mental health. Generally, researching
how boys and girls construct gender and how gendered and class-related power
relations frame the lives of young people is tremendously interesting in itself. To
then link this to the complex field of the social determinants of mental health has
been a challenge, especially with regard to the limited space provided in each
paper. It is, for example, difficult to grasp and illustrate the complexity of gender
relations, which may generate a tendency towards oversimplifications and the
focus on differences between boys and girls. Although the intention has been the
opposite, there is a risk of reproducing stereotypical images and positions.
Moreover, despite the strong arguments for structural influences and limitations in
the practice of gender, the emphasis on young peoples’ agency in practicing
gender might lead to an individualist ‘victim-blaming’ perspective. I strongly
oppose such an approach; as argued above, one must take into account the
structural influences on young peoples’ possibilities and life chances. Finally, and
perhaps against what one might expect, most research on gender and health is on
constructions of masculinity. The literature on femininity/ies and (mental) health is
scarce, particularly with respect to young people.

Methodological considerations
Multi-methods
The main focus of this thesis has been to explore which factors and circumstances
that are related to the mental health of adolescent boys and girls. This was
achieved by a combination of qualitative and quantitative methods. Employing
quantitative methods in addition to the qualitative approach enabled analyses of
prevalence, distribution, correlations and associations, which was a general
strength of using multi-methods. Although the qualitative and questionnaire study
fruitfully complemented each other, there are several methodological issues that
may have affected the results.

The qualitative study

The systematic yet reflexive process of gathering rich data and performing the
analysis served the study well. The proposed model (see Paper I) of factors and
circumstances related to adolescent mental health was constructed through a rich
material, interaction with the participants, closeness to data, conceptualisations of
‘what’s going on’, as well as theoretical interpretations.

With regard to scientific rigour, the overall criterion of credibility refers to the
trustworthiness of the collection as well as the analysis of data (Hamberg et al.

53
1994; Lincoln and Guba 1985). Aspects to be taken into account are, for example,
the constitution of and interaction within the focus groups. In accordance with the
suggestions from the literature (Morgan 1996; Renold and Allan 2006), self-
selected, single-sex focus groups facilitated open discussions. It was also observed
that the discussions in the gender-mixed groups were less relaxed than those in the
single sex groups. Focus groups also allowed for people to share their reflections
without referring to themselves and placing themselves in vulnerable positions.
Nevertheless, power relations and hierarchies within the groups could have
restrained some participants from sharing their experiences. Another possible
limitation associated with self-selected and single sex groups is a potential feeling
of familiarity that may ‘filter out’ issues that are either taken for granted or
perceived as too sensitive to discuss.

With respect to the size of the groups, the experience was in line with the
reasoning of Morgan (1996); small groups were appropriate given the somewhat
sensitive topics discussed. In comparison with groups of four or five participants,
the largest groups of eight individuals showed greater difficulties in the
interactions and in allowing all members to participate.

Actions were taken in data collection as well as in the analysis to reduce potential
researcher bias. First, the theoretical framework used in the interpretation of the
data has been clearly stated as was the structure of the stepwise analysis. Secondly,
I believe that my awareness of the ‘jargon’ and ability to adapt my language as
well as my experience of working with young people may have contributed to a
trustful atmosphere. Thirdly, the use of focus groups in itself probably reduced the
direct researcher-participant power imbalance. Taken together, the use of focus
groups served the study well. Individual interviews are an alternative way of
accessing deeper and more personal experiences (Morgan 1996), whereas
observations in schools may allow for studying the students’ practices, the
interactions between students, as well as the interactions between students and
teachers (see e.g., Ambjörnsson 2003).

The main strength of the qualitative study with respect to dependability is the
grounded theory design in which adaption to new inputs obtained during data
collection and analysis, is a central component (Hamberg et al. 1994). In addition,
meeting several of the groups a second time gave the participants and the
researcher the opportunity to follow up on the contents of the previous session as
well as to address additional topics. A strategy to further enhance the
confirmability of the study would have been to have had an observer present
during the focus groups and to use more of ‘cross reading’ between researchers in
the analysis process.

54
The criterion of transferability was taken into account when describing the settings
and methods used as well as in the presentation of the results. There are reasons to
believe that the findings could be transferrable to young people in similar contexts
given the variation in the sample. One issue to be considered is whether the results
and conclusions would be applicable in other settings, for example, a bigger city or
a society with a different school system.

The quantitative studies

The main strengths of the studies based on the quantitative material are the large
sample size and the relatively low drop-out rate which involves a high statistical
power with a low risk of the results being random findings. Another strength is the
link between the results of the focus groups and the content of the questionnaire.
However, there are some aspects to discuss with respect to design, procedure and
measures. For example, although the study is relying only on self-reports, this
should not be seen as a major limitation; the accuracy and reliability of self-reports
among adolescents have been confirmed in previous research (Riley 2004).

Despite the relatively high response rate there are some issues to be raised
regarding the sample and the response rate. The sample consisted only of students.
Probably, the findings would differ if the sample included young people who do
not attend school. There is, for example, a class pattern in upper secondary school
attendance. A majority of those, approximately 25 percent, who do not complete
upper secondary school, are of working-class backgrounds (The Swedish National
Agency for Education 2008). It has been found that both adverse life experiences
and mental health problems might be higher in non-attendees (Bridge et al. 2006;
Edgardh and Ormstad 2000). Thus, the findings might have underestimated
mental health problems as well as social-relationships problems, demands and
experiences of violence in the general young population. Moreover, with regards
to the possibilities of generalisation, there are good reasons to believe that the
findings are representative of, and can be generalised to, students in upper
secondary school/senior high school in areas outside of the big city regions in
Western countries.

Because of the anonymity of respondents, no detailed analysis of drop-outs was

possible due to the. However, the drop-outs consisted mainly of whole school
classes, and in some cases, approximately 50 percent of a school class, which might
be due to students filling in the questionnaire during half-class lessons. In only a
few occasions was it explicitly declared that respondents declined participation.
The response rate was also likely to have been affected by the short data-collection
period (approximately 2 weeks). It is possible that missing data arising from
students misunderstanding questions could have been reduced if research

55
assistants had been present in the class room to answer questions and provide
clarifications.

Given the cross-sectional design, one limitation of the three quantitative studies is
the question of cause and effect and the uncertainty in directions of relationships.
A student who is psychologically distressed is, for example, more likely to be
lonely or targets of bullying (Sweeting et al. 2006). The time frame of potential
predictors and identified outcomes are also problematic when examining
associations in cross-sectional data as one cannot discern when exposure and
outcome occurred. Nevertheless, cross-sectional results can be useful in inferring
pathways for causal relationships.

Aspects related to the questionnaire and specific measures may have affected the
results. Although efforts were made to keep the questionnaire short, missing data
might have occurred due to the length of the questionnaire (61 questions, of which
many were scales including a set of items).

The broad question on perceived stress might have rendered an overestimation of

perceived stress. On the other hand, in contrast to studies that measure stress by a
checklist of stressful events, the choice of a broad open-ended question on
perceived stress was deliberate in order for the respondents to specify what they
found stressful. Nevertheless, those items might not tap the full relevant range of
stressors or problems experienced by young people. The study did not, for
example, include specific questions on body image, financial opportunities and
anticipated plans about future studies and/or employment.

Although the measure of psychological distress is not a widely used validated

scale, it has similarities to other scales and was found to cover an underlying
construct in the factor and Rasch analyses. An alternative categorisation would
have been to compare the upper and lowest quartile of the sum score (see e.g.,
Hagquist 2007). Unfortunately, the sample size did not allow for such analysis.

Along the course of the study, questions have been raised by fellow researchers
and others as to whether measures of psychological distress and/or depressive- or
anxiety related symptoms adequately reflect boys and girls perceptions and
experiences. It is often argued that these examples of distress are appealing more
to girls’ lives and interpretations than boys’. As a consequence, it is argued, the use
of such outcomes would underestimate the problems experienced by boys, e.g.,
externalising symptoms (or an overestimation of girls’ problems). There are two
main arguments against this reasoning. Firstly, to my knowledge there is no
unequivocal scientific evidence that girls and boys interpret questions on
psychological distress/depression/anxiety differently. In addition, with few

56
exceptions, validations and evaluations of scales and measures of internalising as
well as externalising problems include both boys and girls. Secondly, the evidence
on gender patterns in internalising/externalising problems is inconsistent.
Generally, internalising problems such as psychological distress, depression and
anxiety, are more common in girls, whereas boys are said to be overrepresented
with regard to externalising problems, (e.g., anger, antisocial behaviour, or
attention problems) (Angold et al. 2002; Hankin et al. 1998; Rescorla et al. 2007).
However, research has also reported no gender difference in externalising
symptoms (Broberg et al. 2001), as well as the occurrence of more externalising
among girls than boys (Kapi et al. 2007b). The debate on the matter seems to mirror
stereotypical discourses and perceptions about gender among lay persons as well
as professionals and researchers. Furthermore, the questionnaire used in the
present study was validated through a ‘think aloud’ method in focus groups in
which both boys and girls declared that they would respond sincerely to questions
given that they were ensured anonymity.

As previously noted, the measure of deliberate self-harm concerned lifetime

experience, which perhaps was a too broad time span. There is, for example, a risk
of recall bias. Furthermore, apart from information about DSH during the past
year, it would have been of interest to have data on the methods used in self-
harming in order to more specifically discern acts of self-harm.

With respect to sexual harassment and bullying, the qualitative and quantitative
studies revealed somewhat different pictures. The measures of bullying and sexual
harassment can be problematic in terms of conceptualisations and definitions why
a combination of qualitative and quantitative understandings is valuable. More
research is needed on the topic. With regard to the bullying measure employed in
the present study, it did not cover overt physical aggression as in, for instance the
Olweus scale (Solberg and Olweus 2003). The comparability with other studies on
bullying may therefore be somewhat reduced.

Some considerations need to be made with respect to using the educational

programme as an indicator of socioeconomic status. Not all individuals attending
vocational programmes will necessarily be of a different socio-economic
background to all those attending academic programmes and vice versa. However,
at an aggregate level, and as a first step towards exploring social class patterning of
mental health problems, these educational programmes are, nevertheless,
considered to be suggestive indicators of social class (Hagquist 2007).

Finally, in the questionnaire as well as in the analysis of quantitative data, gender

was indicated by a binary variable which limited explorations of the heterogeneity
within the group of boys and girls. Given the theoretical framework in which

57
gender is considered social construction, relations and as being ‘done’ rather than
being in fixed categories, more diverse options for respondents to indicate gender
would have been preferred. Conducting analyses based on educational
programme within each gender category was one way of overcoming simplistic
generalisations of gender. Importantly, however, the use of focus groups
contributed to a deeper understanding of what gender and gendered life
circumstances can mean.

Implications and future research

The knowledge generated from this research can be applied on different levels.
Given the public health approach applied, possible implications of the findings are
presented in accordance with the three levels of social determinants of health
outlined in the background section (Figure 2). However, the likelihood of gender
and SES differences in mental health problems should be taken into account in
prevention and health promotion strategies at all levels. So should the call for a
greater awareness about gender relations and the gendered social circumstances
under which young people live. This includes challenging normative ideals and
attitudes at all levels as well as creating and implementing policies aimed at
reducing gender and class inequalities.

With respect to the levels of social networks and institutions, the findings highlight
the importance of the school environment in various ways. School-based
interventions should prioritise supportive peer and student-teacher relationships,
the prevention of bullying and sexual harassment and improved student-centred
influence and participation. Interventions targeted at academic pressure need to
acknowledge gender inequalities as well as constructions of masculinity,
femininity and schooling. A gender analysis is also important in the prevention of
sexual harassment and bullying. According to Swedish government legislation and
the national curriculum, all Swedish schools are required to work towards gender
equality through, for example, action plans against discrimination and harassment.
This work needs to be improved and a gender perspective is a necessity.
Furthermore, more effort is required to understand and counteract the processes in
which violence and harassment are normalised in school as well as in other
contexts (Berman et al. 2000). The high prevalence of psychological distress and
DSH among students in vocational programmes should also be recognised and
acted on.

Generally, health promotion programmes in schools need to be comprehensive; the

whole school should be involved and, importantly, the work must be sanctioned
by the head principal and be a part of the general school policy. Furthermore,

58
interventions should include staff education on gender issues and mental health, a
review of teaching material and a general overview of the curriculum from a
critical gender and class lens. Changes in the divisions of labour and distribution of
resources and power are also likely to be necessary. Throughout the process,
student participation is a key component; both school staff and students need to be
empowered in challenging harmful practices as well as in planning policies and
implementing actions. The extensive work within the ‘health-promoting schools’
has emphasised the health benefits of advanced possibilities for pupils to
participate in decision making (Clift and Brunn Jensen 2005). However, this work
has mainly focused on younger children than the age group covered in the present
study. More work is, thus, required for students in their late adolescence.

School-related interventions also include the improvement of the teacher training

programmes with respect to gender, class and mental health. Other potential
actions are the promotion of school counselling services and school-staff education
on adolescent mental health problems.

The strong associations between mental health problems and experiences of

different forms of violence highlight the need for joint action against violence and
harassment at all levels in society. For example, actions must be taken to fight the
normalisation of violence in youth and interventions need to acknowledge the
gendered experiences and responses to violence. Issues on dating violence should,
for instance, be recognised in relevant school subjects such as sex education and
social studies. In addition, school nurses and social workers should ask young
people about their experiences of violence and harassment. Furthermore, schools,
sport clubs and other institutions need to implement action plans against all types
of violence and harassment. On a structural level, the media a central role; there is
a strong cultural message that violence, aggression and risky behaviour is a part of
being manly. The legal system is also important to target. With regard to sexual
assault and rape, the Swedish laws should be changed. Instead of proving that the
victim did not consent to sex; an explicit consent should be in focus. Media and the
fashion industry have also a responsibility with regard to young peoples’
experiences of pressure to conform to ideals of body shapes and appearance.

Implications should not only concern young people. As noted by others (Wight et
al. 2006), interventions targeting only individual- or family-levels may be
inadequate. Hence, social policy and legislation should focus on reducing gender
and class inequalities in general. This includes, for example, reducing income
differences, ensuring more equitable distributions of recourses and power,
promoting better working conditions as well as reforms of the labour market.

59
Future research is needed to further explore the mental health implications of
responsibility taking, ‘joking’ and violence. It is also important to study what can
be done in school to reduce the pressures experienced. More research is needed on
dating violence in general and specifically on the links between sexual harassment
and dating violence and their consequences for mental health.

Future studies would benefit from a longitudinal design, or at least repeated

measures, to further understand the ways gendered life circumstances impact
adolescent mental health. Qualitative studies are also needed to gain a deeper
understanding of such processes. Importantly, intervention studies should be
prioritised. Furthermore, a salutogenic perspective would be of interest, that is, to
identify supportive factors and circumstances that influence mental health
positively.

With regard to statistical methods, multilevel analyses could be an option to

explore school and school class effects, whereas person-oriented approaches (e.g.,
latent class analysis and cluster analyses) could be used to study patterns in groups
of individuals on the basis of their related characteristics. Such analyses would be
useful in classifications based on characteristics other than sex as a way of avoiding
the dichotomous static perceptions of boys and girls.

A future challenge is to identify the mechanism of how the interaction of different

social structures (e.g., gender, class, ethnic background and sexual orientation)
influences adolescent mental health. Theoretically, models and conceptualisations
should be developed in order to bridge the gap between disciplines and to further
understand the ways that complex structural, organisational and individual
circumstances influence the mental health of young boys and girls.

60
CONCLUSIONS

Conclusions from the research questions and the gender analysis:

1. Young people understand mental health as an emotional, mainly negative,

experience.
2. Perceived stress, psychological distress and deliberate self-harm are
approximately twice as common among girls as boys. Reports of mental
health problems are generally more common among students attending
vocational educational programmes and among those whose both parents
do not have a full- or part-time job.
3. Supportive relationships with friends, family and teachers are of great
importance to positive mental health, whereas poor social relationships,
loneliness and lack of influence are potential risk factors for mental health
problems.
4. Perceived demands and responsibility taking regarding school work,
relationships, future plans, appearance and financial issues show strong
associations with mental health problems, particularly among girls,
regardless of social class.
5. Violence and harassment of different types are strongly related with
mental health problems. There are gendered patterns in experiences of
different types of violence and harassment as well as the victim-
perpetrator of physical violence. These diverging experiences appear to
influence the associations with mental health problems in boys and girls.

A gender analysis provides the tools to gain knowledge about the ways that boys’
and girls’ lives are shaped by gender relations at different levels in society. For
example, unequal power structures and the ways girls are expected to ‘do’ gender,
appear to place girls at greater risk of mental health problems. Hegemonic
constructions of masculinity and advantaged positions likely contribute to positive
mental health among boys but are also implying risk factors for poor mental
health, e.g., in terms of violence. A gender theoretical approach that takes social
class into account has the potential to contribute to a better understanding of the
relationships between life circumstances and the gender patterning of mental
health among adolescents.

61
ACKNOWLEDGEMENTS

First and foremost – All students, thank you! You and the school staff, particularly
Nancy Kostet, made this project possible and I owe you immense gratitude.

Warm and special thanks go to my supervisor Katja Gillander Gådin. Thank you
for your intense encouragement, your critical questions, your inspiration and your
trust in me. I am deeply grateful for having you as my supervisor and friend.
Please send my thanks to your family too.

Kenneth Asplund, co-supervisor, your calmness, positive mind and experience has
brought me down to earth many times. Thank you for your guidance and for the
intensity you have placed in convincing me to believe in my work.

Åsa Audulv, thank you for being my Ph.D. buddy from day one, the most clever
and supportive Ph.D. buddy ever. Thank you for all discussions during hours and
hours on trains, for being harsh when I have needed it and for giving me a
shoulder to lean on. This thesis and the time as a Ph.D. student would not have
been the same without you.

I am grateful to all fellow Ph.D. students at the Department of Health Sciences, and
especially Heidi Carlerby, for the care with which they have reviewed and
discussed my work and for being great colleagues and friends. A special thanks is
dedicated to Marianne Svedlund for her commitment in the Ph.D. seminars. I
would also like to acknowledge my friends and colleagues in the Health Care
Sciences Postgraduate School, in particular Malin Lövgren, Annmarie Wesley and
Emma Fransson. A number of other friends and colleagues have been with me
through this journey, thanks to Bodil Formark, Klara Svalin, Elisabet Ljungberg,
Johanna Sefyrin and colleagues in Sociology, Forum for Gender Studies and the
Challenging Gender project. Ann Öhman Umeå University, thank you for valuable
advice and helpful comments half way through this Ph.D. I would also like to
show my gratitude to Robert Young at MRC, Glasgow.

I am honored for being a part of the Public Health Sciences group at the
Department of Health Sciences; you are tremendously ambitious, knowledgeable
and optimistic people. Many thanks go to all colleagues at the Department of
Health Sciences, especially Annette Höglund for your warm heart and for refusing
to listen to my doubts. Thanks for pushing me. The same gratitude goes to Susanne
Strand and Lisbeth Kristiansen. I would like to acknowledge a special group of
colleagues: the ‘stats-people’. Azzam Khalaf, my teacher in biostatistics and
epidemiology at Malmö, thank you for still encouraging and assisting me. Anders
Knutsson, thank you for providing straightforward advice. I am indebted to Erling

62
Englund and Annika Tillander for always being willing to help out. Thank you for
sharing your competence and friendship. To all the above individuals, and to
several colleagues whose names I cannot continue listing and who have supported
and assisted me one way or another, I feel very much indebted.

To all friends and colleagues at the University of York, my deepest gratitude for
your hospitality, inspiring discussions and exciting adventures. I dedicate a special
thanks to Gabriele Griffin. You all made my stay unforgettable.

Emma Uprichard, I am deeply thankful for your endless trust in me and my

beautiful data. Your friendship and professional support has meant a great deal to
me, for that I am enormously grateful.

I am indebted to Raewyn Connell, The University of Sydney, for hosting me as a

visiting scholar, what an experience!

My beloved sisters Lilleanne, Pernilla and Matilda and your wonderful children,
thank you for broadening my horizons and reminding me of the valuable things in
life, laughs for example. Niklas, my brother, you are not with me but your spirit is.
You inspire me to never give up. Mum and dad, this is what came out of all
university years; no doctoral hat but a book, a book accomplished by the
stubbornness you have taught me. For that I am profoundly thankful.

All dear friends, thank you for enriching my life with love, joy, support and
inspiration during these years; Malin L, Sara H, Maria B, Marlene J, Elin T, Emma
F, Mattias A, Markus E, Karin L, Anna L, Niklas B, Janna W, Tony J, Jörgen P,
Henke L, Susanne L, Anna I, the ‘Ljusdal girls’ and many others. To a special
friend: Jessika Rylle Svensson, you make me believe I can do anything.

I am heartily thankful to The County Council and County Administrative Board of

Västernorrland for professional and financial support. I would also like to show
my gratitude to the foundations that have supported my work financially: Mid
Sweden University foundation for internationalisation, Zonta, Fredrika
Bremerförbundet, Land- och sjöfonden, Forum for Gender Studies, the Student
Union at Mid Sweden University and, especially, Health Care Sciences
Postgraduate School.

Most importantly, my partner Ann-Marie, thank you for being you. Thank you for
understanding my passion for research and for helping me to appreciate the
beautiful things in life. I deeply respect you for standing by my side; your support
has been invaluable, your love gives me strength. You were not in my life when I
started this journey. Now, we can go anywhere.

63
REFERENCES

Aalto-Setälä T, Poikolainen K, Tuulio-Henriksson A, Marttunen M, Lönnqvist J

(2002) Predictors of mental distress in early adulthood: a five-year follow-
up of 709 high-school students. Nord J Psychiatry 56: 121-25
Abada T, Hou F, Ram B (2008) The effects of harassment and victimization on self-
rated health and mental health among Canadian adolescents. Soc Sci Med
67: 557-567
Ackard DM, Neumark-Sztainer D (2003) Multiple sexual victimizations among
adolescent boys and girls: prevalence and associations with eating
behaviors and psychological health. J Child Sex Abus 12: 17-37
Adkins DE, Wang V, Elder GH, Jr. (2008) Stress processes and trajectories of
depressive symptoms in early life: Gendered development. Adv Life
Course Res 13: 107-136
Allgood-Merten B, Lewinsohn PM, Hops H (1990) Sex differences and adolescent
depression. J Abnorm Psychol 99: 55-63
Ambjörnsson F (2003) I en klass för sig: genus, klass och sexualitet bland
gymnasietjejer [In a class of its own: gender, class and sexuality among
high school girls. In Swedish] Ordfront, Stockholm
American Association of University Women (2001) Hostile hallways: Bullying,
teasing, and sexual harassment in school. American Association of
University Women, Washington, DC
Andrews G, Slade T (2001) Interpreting scores on the Kessler Psychological
Distress Scale (K10). Aust N Z J Public Health 25: 494-7
Aneshensel CS, Rutter CM, Lachenbruch PA (1991) Social Structure, Stress, and
Mental Health: Competing Conceptual and Analytic Models. Am Sociol
Rev 56: 166-178
Angold A, Costello EJ, Worthman CM (1998) Puberty and depression: the roles of
age, pubertal status and pubertal timing. Psychol Med 28: 51-61
Angold A, Erkanli A, Silberg J, Eaves L, Costello EJ (2002) Depression scale scores
in 8-17-year-olds: effects of age and gender. J Child Psychol Psychiatry 43:
1052-63
Armstrong C, Hill M, Secker J (2000) Young people's perceptions of mental health.
Children and Society 14: 60-72
Aubrey JS (2007) The Impact of Sexually Objectifying Media Exposure on Negative
Body Emotions and Sexual Self-Perceptions: Investigating the Mediating
Role of Body Self-Consciousness. Mass Comm Society 10: 1-23
Banister EM, Jakubec SL, Stein JA (2003) "Like, what am I supposed to do?":
adolescent girls' health concerns in their dating relationships. Can J Nurs
35: 16-33
Baum F (2003) The new public health 2edn. Oxford University Press, Oxford

64
Bengs C (2000) Looking Good: A Study of Gendered Body Ideals among Young
People. Umeå University, Umeå
Berman H, McKenna K, Arnold CT, Taylor G, MacQuarrie B (2000) Sexual
harassment: Everyday violence in the lives of girls and women. Advances
in Nursing Science 22: 32-46
Berntsson LT, Köhler L (2001) Long-term illness and psychosomatic complaints in
children aged 2-17 years in the five Nordic countries: comparison between
1984 and 1996. Eur J Public Health 11: 35-42
Bjärehed J, Lundh LG (2008) Deliberate self-harm in 14-year-old adolescents: how
frequent is it, and how is it associated with psychopathology, relationship
variables, and styles of emotional regulation? Cogn Behav Ther 37: 26-37
Bond TG, Fox CM (2007) Applying the Rasch Model: Fundamental Measurement
in the Human Sciences, 2 edn. Lawrence Erlbaum Associates, Mahwah,
USA
Bovier PA, Chamot E, Perneger TV (2004) Perceived stress, internal resources, and
social support as determinants of mental health among young adults. Qual
Life Res 13: 161-70
Brage D, Meredith W (1994) A causal model of adolescent depression. J Psychol
128: 455-68
Bridge JA, Goldstein TR, Brent DA (2006) Adolescent suicide and suicidal
behavior. J Child Psychol Psychiatry 47: 372-94
Broberg AG, Ekeroth K, Gustafsson PA, Hansson K, Hägglöf B, Ivarsson T, Larsson
B (2001) Self-reported competencies and problems among Swedish
adolescents: A normative study of the YSR. Eur Child Adolesc Psychiatry
10: 186-193
Brolin Låftman S, Östberg V (2006) The pros and cons of social relations: an
analysis of adolescents' health complaints. Soc Sci Med 63: 611-23
Brown GW, Harris T (1978) Social Origins of Depression: A Study of Psychiatric
Disorder in Women. Tavistock, London
Butler J (1990) Gender Trouble: Feminism and the Subversion of Identity
Routledge, New York
Byrne DG, Davenport SC, Mazanov J (2007) Profiles of adolescent stress: The
development of the adolescent stress questionnaire (ASQ). J Adolesc 30:
393-416
Charmaz K (2005) Grounded Theory in the 21st Century: Applications for
Advancing Social Justice Studies. In: Denzin NK, Lincoln YS (eds) The
Sage Handbook of Qualitative Research, 3rd edn. Sage, Thousand Oaks,
CA
Charmaz K (2006) Constructing Grounded Theory: A Practical Guide Through
Qualitative Analysis. SAGE, London

65
Clift S, Brunn Jensen B (2005) The Health Promoting School: International
Advances in Theory, Evaluation and Practice Danish University of
Education Press, Copenhagen
Collishaw S, Maughan B, Goodman R, Pickles A (2004) Time trends in adolescent
mental health. J Child Psychol Psychiatry 45: 1350-62
Compas BE, Davis GE, Forsythe CJ, Wagner BM (1987) Assessment of major and
daily stressful events during adolescence: The Adolescent Perceived
Events Scale. J Consult Clin Psychol 55: 534-41
Compas BE, Orosan PG, Grant KE (1993) Adolescent stress and coping:
Implications for psychopathology during adolescence. J Adolesc 16: 331-49
Connell R (2009) Gender in World Perspective, 2nd edn. Polity, Cambridge
Connell RW (1987) Gender and power: society, the person and sexual politics.
Stanford University Press, Stanford, Calif.
Connell RW (1996) Teaching the boys: new research on masculinity, and gender
strategies for schools. Teachers College Record 98: 206
Connell RW (2000) The men and the boys. Polity, Cambridge
Connell RW (2002) On hegemonic masculinity and violence: response to Jefferson
and Hall. Theor Crim 6: 89-99
Connell RW (2005) Masculinities, 2nd edn. University of California Press, Berkeley
Costello EJ, Foley DL, Angold A (2006) 10-year research update review: the
epidemiology of child and adolescent psychiatric disorders: II.
Developmental epidemiology. J Am Aca Child Adolesc Psychiatry 45: 8-25
Courtenay WH (2000) Constructions of masculinity and their influence on men's
well-being: a theory of gender and health. Soc Sci Med 50: 1385-1401
The County Administrative Board of Västernorrland (2009) Facts about
Västernorrland. The County Administrative Board of Västernorrland
Cowman S (1993) Triangulation: a means of reconciliation in nursing research. J
Adv Nurs 18: 788-92
Craig W, Harel-Fisch Y, Fogel-Grinvald H, Dostaler S, Hetland J, Simons-Morton B,
Molcho M, de Mato MG, Overpeck M, Due P, Pickett W (2009) A cross-
national profile of bullying and victimization among adolescents in 40
countries. Int J Public Health 54 Suppl 2: 216-24
Currie C, Gabhainn SN, Godeau E, Roberts C, Smith R, Currie D, Picket W, Richter
M, Morgan A, Barnekow V (2008) Inequalities in young people's health:
international report from the HBSC 2006/06 survey. Health Policy for
Children and Adolescents. No. 5. WHO Regional Office for Europe,
Copenhagen
Dahlgren G, Whitehead M (2006) Levelling up (part 2): a discussion paper on
European strategies for tackling social inequities in health. WHO Regional
Office for Europe Copenhagen
Dalley-Trim L (2007) 'The boys' present... Hegemonic masculinity: a performance
of multiple acts. Gen Educ 19: 199-217

66
Danielson M (2006) Svenska skolbarns hälsovanor 2005/2006. Grundrapport
[Health behaviour in school-aged children. A WHO collaborative study. In
Swedish]. Statens Folkhälsoinstitut [National Institute of Public Health],
Stockholm
Dao TK, Kerbs JJ, Rollin SA, Potts I, Gutierrez R, Choi K, Creason AH, Wolf A,
Prevatt F (2006) The association between bullying dynamics and
psychological distress. J Adolesc Health 39: 277-82
De Leo D, Heller TS (2004) Who are the kids who self-harm? An Australian self-
report school survey. Med J Aust 181: 140-4
Edgardh K, Ormstad K (2000) Prevalence and characteristics of sexual abuse in a
national sample of Swedish seventeen-year-old boys and girls. Acta
Paediatr 89: 310-9
Eliasson MA (2007) Verbal abuse in school: constructing gender and age in social
interaction. Karolinska Institute, Stockholm
Ellonen N, Kääriäinen J, Autio V (2008) Adolescent depression and school social
support: A multilevel analysis of a Finnish sample. J Comm Psychol 36:
552-567
Fergusson DM, Swain-Campbell NR, Horwood LJ (2002) Does sexual violence
contribute to elevated rates of anxiety and depression in females? Psychol
Med 32: 991-96
Fergusson DM, Woodward LJ (2002) Mental health, educational, and social role
outcomes of adolescents with depression. Arch Gen Psychiatry 59: 225-31
Fineran S, Bennett L (1999) Gender and power issues of peer sexual harassment
among teenagers. J Interpers Violence 14: 626-41
Fliege H, Lee JR, Grimm A, Klapp BF (2009) Risk factors and correlates of
deliberate self-harm behavior: a systematic review. J Psychosom Res 66:
477-93
Fombonne E (1998) Increased rates of psychosocial disorders in youth. Eur Arch
Psych Clin Neurosc 248: 14-21
Fredland NM, Campbell JC, Han H (2008) Effect of violence exposure on health
outcomes among young urban adolescents. Nurs Res 57: 157-65
Fredrickson BL, Roberts T-A (1997) Objectification Theory: Toward Understanding
Women's Lived Experiences and Mental Health Risks. Psychol Women Q
21: 173-206
Frosh S, Phoenix A, Pattman R (2002) Young masculinities: Understanding boys in
contemporary society. Palgrave, Basingstroke
Frost L (2003) Doing Bodies Differently? Gender, Youth, Appearance and Damage.
J Youth Studies 6: 53-70
Fröjd S, Marttunen M, Pelkonen M, von der Pahlen B, Kaltiala-Heino R (2006)
Perceived financial difficulties and maladjustment outcomes in
adolescence. Eur J Public Health 16: 542-8

67
Furlong A, Cartmel F, Biggart A (2006) Choice Biographies and Transitional
Linearity: Re-Conceptualising Modern Youth Transitions. Papers: Revista
de sociologia, no 79: 225-239
Ge X, Lorenz FO, Conger RD, Elder GH, Simons RL (1994) Trajectories of stressful
life events and depressive symptoms during adolescence. Dev Psychol 30:
467-83
Gillander Gådin K (2002) Does the psychosocial school environment matter for
health? a study of pupils in Swedish compulsory school from a gender
perspective Umeå University, Umeå
Gillander Gådin K, Hammarström A (2003) Do changes in the psychosocial school
environment influence pupils' health development? Results from a three-
year follow-up study. Scand J Public Health 31: 169-77
Gillander Gådin K, Hammarström A (2005) A possible contributor to the higher
degree of girls reporting psychological symptoms compared with boys in
grade nine? Eur J Public Health 15: 380-85
Gillander Gådin KG, Hammarström A (2000) School-related health: a cross-
sectional study among young boys and girls. Int J Health Serv 30: 797-820
Glass N, Fredland N, Campbell J, Yonas M, Sharps P, Kub J (2003) Adolescent
dating violence: prevalence, risk factors, health outcomes, and implications
for clinical practice. J Obstet Gynecol Neonatal Nurs 32: 227-38
Gobina I, Zaborskis A, Pudule I, Kalnins I, Villerusa A (2008) Bullying and
subjective health among adolescents at schools in Latvia and Lithuania. Int
J Public Health 53: 272-6
Goodman E, Huang B, Schafer-Kalkhoff T, Adler NE (2007) Perceived
socioeconomic status: a new type of identity that influences adolescents'
self-rated health. J Adolesc Health 41: 479-87
Goodman E, Huang B, Wade TJ, Kahn RS (2003a) A multilevel analysis of the
relation of socioeconomic status to adolescent depressive symptoms: does
school context matter? J Pediatr 143: 451-6
Goodman E, McEwen BS, Dolan LM, Schafer-Kalkhoff T, Adler NE (2005) Social
disadvantage and adolescent stress. J Adolesc Health 37: 484-492
Goodman E, Slap GB, Huang B (2003b) The public health impact of socioeconomic
status on adolescent depression and obesity. Am J Public Health 93: 1844-
50
Gratz KL, Conrad SD, Roemer L (2002) Risk factors for deliberate self-harm among
college students. Am J Orthopsychiatry 72: 128-40
Griffin JM, Fuhrer R, Stansfeld SA, Marmot M (2002) The importance of low
control at work and home on depression and anxiety: do these effects vary
by gender and social class? Soc Sci Med 54: 783-98
Gruber JE, Fineran S (2008) Comparing the impact of bullying and sexual
harassment victimization on the mental and physical health of adolescents.
Sex Roles 59: 1-13

68
Gunnell D, Shepherd M, Evans M (2000) Are recent increases in deliberate self-
harm associated with changes in socio-economic conditions? An ecological
analysis of patterns of deliberate self-harm in Bristol 1972-3 and 1995-6.
Psychol Med 30: 1197-203
Haavet OR, Straand J, Saugstad OD, Grunfeld B (2004) Illness and exposure to
negative life experiences in adolescence: two sides of the same coin? A
study of 15-year-olds in Oslo, Norway. Acta Paediatr 93: 405-11
Hagquist C (2009) Psychosomatic health problems among adolescents in Sweden--
are the time trends gender related? Eur J Public Health 19: 331-6
Hagquist C (2010) Discrepant Trends in Mental Health Complaints Among
Younger and Older Adolescents in Sweden: An Analysis of WHO Data
1985–2005. J Adolesc Health 46: 258-64
Hagquist C, Forsberg E (2007) Ung i Värmland 1988-2005. Rapport 2007:24. [Young
in Värmland. In Swedish]. Karlstad University, Faculty of Social and Life
Sciences, Karlstad
Hagquist CE (2007) Health inequalities among adolescents: the impact of academic
orientation and parents' education. Eur J Public Health 17: 21-6
Hamberg K, Johansson E, Lindgren G, Westman G (1994) Scientific rigour in
qualitative research--examples from a study of women's health in family
practice. Fam Pract 11: 176-81
Hammarström A (2002) What could a gender perspective mean in medical and
public-health research? In: Wamala SP, Lynch J (eds) Gender and Social
Inequities in Health. Studentlitteratur, Lund
Hammarström A, Ripper M (1999) What could a feminist perspective on power
bring into public health? Scand J Public Health 27: 286-9
Hand JZ, Sanchez L (2000) Badgering or bantering? Gender differences in
experience of, and reactions to, sexual harassment among U. S. high school
students. Gender Soc 14: 718-46
Hankin BL, Abramson LY, Moffitt TE, Silva PA, McGee R, Angell KE (1998)
Development of depression from preadolescence to young adulthood:
emerging gender differences in a 10-year longitudinal study. J Abnorm
Psychol 107: 128-40
Hankin BL, Mermelstein R, Roesch L (2007) Sex differences in adolescent
depression: stress exposure and reactivity models. Child Dev 78: 279-95
Hanson RF (2002) Adolescent dating violence: prevalence and psychological
outcomes. Child Abuse Negl 26: 449-53
Haraldsson K, Lindgren EC, Hildingh C, Marklund B (2010) What makes the
everyday life of Swedish adolescent girls less stressful: a qualitative
analysis. Health Promot Int 25: 192-9
Hawton K, Harriss L, Hodder K, Simkin S, Gunnell D (2001) The influence of the
economic and social environment on deliberate self-harm and suicide: an
ecological and person-based study. Psychol Med 31: 827-36

69
Hawton K, Rodham K, Evans E, Weatherall R (2002) Deliberate self harm in
adolescents: self report survey in schools in England. BMJ 325: 1207-11
Hazel NA, Hammen C, Brennan PA, Najman J (2008) Early childhood adversity
and adolescent depression: the mediating role of continued stress. Psychol
Med 38: 581-9
Heinrich LM, Gullone E (2006) The clinical significance of loneliness: A literature
review. Clin Psychol Rev 26: 695-718
Helweg-Larsen K, Sundaram V, Curtis T, Larsen HB (2004) The Danish Youth
Survey 2002: asking young people about sensitive issues. Int J Circumpolar
Health 63 Suppl 2: 147-52
Hetherington JA, Stoppard JM (2002) The theme of disconnection in adolescent
girls' understanding of depression. J Adolesc 25: 619-29
Hjern A, Alfven G, Ostberg V (2008) School stressors, psychological complaints
and psychosomatic pain. Acta Paediatr 97: 112-7
Horwitz AV, Scheid TL (1999) A handbook for the study of mental health : social
contexts, theories, and systems. Cambridge University Press, New York
Jackson C (2002) "Laddishness" as a Self-Worth Protection Strategy. Gen Educ 14:
37-51
Jackson SM, Cram F, Seymour FW (2000) Violence and Sexual Coercion in High
School Students' Dating Relationships. J Fam Violence 15: 23-36
Johansson A, Brunnberg E, Eriksson C (2007) Adolscent girls' and boys'
perceptions of mental health. J Youth Studies 10: 183-202
Johnson SB, Frattaroli S, Campbell J, Wright J, Pearson-Fields AS, Cheng TL (2005)
"I know what love means." Gender-based violence in the lives of urban
adolescents. J Women's Health 14: 172-9
Jonsson JO, Östberg V, Brolin Låftman S, Evertsson M (2001) Barns och ungdomars
välfärd, Kommittén Välfärdsbokslut, SOU 2001:55. [Child and adolescent
welfare. In Swedish]. Stockholm: Fritzes
Kaltiala-Heino R, Rimpelä M, Rantanen P, Rimpelä A (2000) Bullying at school: an
indicator of adolescents at risk for mental disorders. J Adolesc 23: 661-74
Kapi A, Veltsista A, Kavadias G, Lekea V, Bakoula C (2007a) Social determinants of
self-reported emotional and behavioral problems in Greek adolescents. Soc
Psychiatry Psychiatr Epidemiol 42: 594-8
Kapi A, Veltsista A, Sovio U, Järvelin M-R, Bakoula C (2007b) Comparison of self-
reported emotional and behavioural problems in adolescents from Greece
and Finland. Acta Paediatr 96: 1174-1179
Kaplan A, Maehr ML (1999) Achievement goals and student well-being. Contemp
Educ Psychol 24: 330-358
Kemper TD (1991) Predicting emotions from social relations. Soc Psychol Q 54: 330-
342
Kenway J, Fitzclarence L (1997) Masculinity, Violence and Schooling: challenging
"poisonous pedagogies". Gen Educ 9: 117-34

70
Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SL, Walters EE,
Zaslavsky AM (2002) Short screening scales to monitor population
prevalences and trends in non-specific psychological distress. Psychol Med
32: 959-76
Kimmel MS (2008) The gendered society 3rd edn. Oxford University Press, Oxford
Kitzinger J (1994) The Methodology of Focus Groups: the importance of interaction
between research participants. Soc Health Ill 16: 103-21
Kitzinger J (1995) Qualitative research. Introducing focus groups. Bmj 311: 299-302
Kline P (2000) Handbook of Psychological Testing. Routledge, London and New
York
Kolip P, Schmidt B (1999) Gender and health in adolescence. WHO, Regional
Office for Europe
Konu A, Lintonen T (2006) Theory-based survey analysis of well-being in
secondary schools in Finland. Health Promot Int 21: 27-36
Kraaij V, Garnefski N, de Wilde EJ, Dijkstra A, Gebhardt W, Maes S, ter Doest L
(2003) Negative life events and depressive symptoms in late adolescence:
bonding and cognitive coping as vulnerability factors? J Youth Adolesc 32:
185-93
Laidler KJ, Hunt G (2001) Accomplishing Femininity among the Girls in the Gang.
Br J Criminol 41: 656-678
Lawyer SR, Ruggiero KJ, Resnick HS, Kilpatrick DG, Saunders BE (2006) Mental
health correlates of the victim-perpetrator relationship among
interpersonally victimized adolescents. J Interpers Violence 21: 1333-53
Laye-Gindhu A, Schonert-Reichl KA (2005) Nonsuicidal Self-Harm among
Community Adolescents: Understanding the "Whats" and "Whys" of Self-
Harm. J Youth Adolesc 34: 447-457
Leonard KE, Quigley BM, Collins RL (2002) Physical Aggression in the Lives of
Young Adults: Prevalence, Location, and Severity among College and
Community Samples. J Interpers Violence 17: 533-550
Lewinsohn PM, Gotlib IH, Lewinsohn M, Seeley JR, Allen NB (1998) Gender
differences in anxiety disorders and anxiety symptoms in adolescents. J
Abnorm Psychol 107: 109-17
Lincoln Y, Guba E (1985) Naturalistic Inquiry. Sage, Beverly Hills
Lowenstein LF (2005) Youths who intentionally practise self-harm. Review of the
recent research 2001-2004. Int J Adolesc Med Health 17: 225-230
Lucey H, Melody J, Walkerdine V (2003) Uneasy Hybrids: Psychosocial Aspects of
Becoming Educationally Successful for Working-Class Young Women.
Gen Educ 15: 285-99
Lynch J, Kaplan G (2000) Socioeconomic Position. In: Berkman LF, Kawachi I (eds)
Social Epidemiology. Oxford University Press, New York

71
McLaughlin KA, Hatzenbuehler ML (2009) Mechanisms Linking Stressful Life
Events and Mental Health Problems in a Prospective, Community-Based
Sample of Adolescents. J Adolesc Health 44: 153-60
Mac an Ghaill M (1994) The Making of Men: Masculinities, Sexualities and
Schooling. Open University Press, Buckingham
Mac an Ghaill M (1996) 'What about the Boys?': Schooling, Class and Crisis
Masculinity. Sociol Rev 44: 381-397
Madge N, Hewitt A, Hawton K, de Wilde EJ, Corcoran P, Fekete S, van Heeringen
K, De Leo D, Ystgaard M (2008) Deliberate self-harm within an
international community sample of young people: comparative findings
from the Child & Adolescent Self-harm in Europe (CASE) Study. J Child
Psychol Psychiatry 49: 667-77
Mahadevan S, Hawton K, Casey D (2010) Deliberate self-harm in Oxford
University students, 1993-2005: a descriptive and case-control study. Soc
Psychiatry Psychiatr Epidemiol 45: 211-9
Marmot M (2007) Achieving health equity: from root causes to fair outcomes.
Lancet 370: 1153-63
McMaster LE, Connolly J, Pepler D, Craig WM (2002) Peer to peer sexual
harassment in early adolescence: a developmental perspective. Dev
Psychopathol 14: 91-105
Meadows SO, Brown JS, Elder GH, Jr. (2006) Depressive Symptoms, Stress, and
Support: Gendered Trajectories from Adolescence to Young Adulthood. J
Youth Adolesc 35: 93-103
Michaud PA, Fombonne E (2005) Common mental health problems. BMJ 330: 835-8
Modin B, Östberg V (2009) School climate and psychosomatic health: A multilevel
analysis. Sch Eff Sch Improv 20: 433-455
Molidor C, Tolman RM (1998) Gender and contextual factors in adolescent dating
violence. Violence Against Women 4: 180-194
Morgan DL (1996) Focus Groups. Ann Rev Sociol 22: 129-52
Murberg TA, Bru E (2004) School-Related Stress and Psychosomatic Symptoms
Among Norwegian Adolescents. School Psychol Int 25: 317-332
Nansel TR, Craig W, Overpeck MD, Saluja G, Ruan WJ (2004) Cross-national
consistency in the relationship between bullying behaviors and
psychosocial adjustment. Arch Pediatr Adolesc Med 158: 730-6
Nilsson KW, Leppert J, Simonsson B, Starrin B (2010) Sense of coherence and
psychological well-being: improvement with age. J Epidemiol Community
Health 64: 347-52
Nixon MK, Cloutier P, Jansson SM (2008) Nonsuicidal self-harm in youth: a
population-based survey. Can Med Assoc J 178: 306-12
Nolen-Hoeksema S, Girgus JS (1994) The emergence of gender differences in
depression during adolescence. Psychol Bull 115: 424-43

72
Nolen-Hoeksema S, Larson J, Grayson C (1999) Explaining the gender difference in
depressive symptoms. J Pers Soc Psychol 77: 1061-72
Ollfors M, Andersson SI (2007) Ability of Stress, Sense of Control, and Self-
Theories to Predict Swedish High School Students' Final Grades. Edu Res
Eval 13: 143-169
Paechter C (2006) Masculine Femininities/Feminine Masculinities: Power, Identities
and Gender. Gen Educ 18: 253-263
Paechter C (2007) Being boys, being girls: learning masculinities and femininities
Open University Press, Maidenhead
Patel V, Flisher AJ, Hetrick S, McGorry P (2007) Mental health of young people: a
global public-health challenge. Lancet 369: 1302-13
Patton MQ (2002) Qualitative Research & Evaluation Methods, 3rd edn. Sage,
Thousand Oaks, CA
Petersen JL, Hyde JS (2009) A longitudinal investigation of peer sexual harassment
victimization in adolescence. J Adolesc 32: 1173-1188
Phoenix A, Frosh S, Pattman R (2003) Producing contradictory masculine subject
positions: Narratives of threat, homophobia and bullying in 11-14 year old
boys. J Soc Issues. Special Issue: Youth perspectives on violence and
injustice 59: 179-195
Piccinelli M, Wilkinson G (2000) Gender differences in depression: critical review.
Br J Psychiatry 177: 486-492
Pickett KE, Wilkinson RG (2009) Greater equality and better health. BMJ 339: b4320
Plug W, Zeijl E, Du Bois-Reymond M (2003) Young People's Perceptions on Youth
and Adulthood. A Longitudinal Study from the Netherlands. J Youth
Studies 6: 127-144
Polce-Lynch M, Myers BJ, Kliewer W, Kilmartin C (2001) Adolescent self-esteem
and gender : Exploring relations to sexual harassment, body image, media
influence, and emotional expression. J Youth Adolesc 30: 225-44
Pollack WS (2006) The "war" for boys: Hearing "real boys'" voices, healing their
pain. Prof Psychol - Res Pr 37: 190-195
Portzky G, De Wilde EJ, van Heeringen K (2008) Deliberate self-harm in young
people: differences in prevalence and risk factors between the Netherlands
and Belgium. Eur Child Adolesc Psychiatry 17: 179-86
Powers RS, Reiser C (2005) Gender and Self-Perceptions of Social Power. Soc Behav
Pers 33: 553-567
Presser S, Couper MP, Lessler JT, Martin E, Rothgeb JM, Singer E (2004) Methods
for Testing and Evaluating Survey Questions. Publ Opinon Q 68: 109-130
Priess HA, Lindberg SM, Hyde JS (2009) Adolescent gender-role identity and
mental health: gender intensification revisited. Child Dev 80: 1531-44
Renold E (2004) 'Other' boys: negotiating non-hegemonic masculinities in the
primary school. Gen Educ 16: 247-265

73
Renold E, Allan A (2006) Bright and Beautiful: High achieving girls, ambivalent
femininities, and the feminization of success in the primary school.
Discourse: Studies in the Cultural Politics of Education 27: 457-473
Rescorla L, Achenbach TM, Ivanova MY, Dumenci L, Almqvist F, Bilenberg N,
Bird H, Broberg A, Dobrean A, Dopfner M, Erol N, Forns M, Hannesdottir
H, Kanbayashi Y, Lambert MC, Leung P, Minaei A, Mulatu MS, Novik TS,
Oh KJ, Roussos A, Sawyer M, Simsek Z, Steinhausen HC, Weintraub S,
Metzke CW, Wolanczyk T, Zilber N, Zukauskiene R, Verhulst F (2007)
Epidemiological comparisons of problems and positive qualities reported
by adolescents in 24 countries. J Consult Clin Psychol 75: 351-8
Riley AW (2004) Evidence that school-age children can self-report on their health.
Amb Pediatr 4: 371-6
Romito P, Grassi M (2007) Does violence affect one gender more than the other?
The mental health impact of violence among male and female university
students. Soc Sci Med 65: 1222-34
Rothman KJ (2002) Epidemiology: an introduction Oxford University Press, New
York
Rudolph KD (2002) Gender differences in emotional responses to interpersonal
stress during adolescence. J Adolesc Health 30: 3-13
Rutter M, Smith DJ (1995) Psychosocial disorders in young people: time trends and
their causes. Wiley for Academia Europaea, Chichester
Saab H, Klinger D (2010) School differences in adolescent health and wellbeing:
findings from the Canadian Health Behaviour in School-aged Children
Study. Soc Sci Med 70: 850-8
Sawyer MG, Miller-Lewis LR, Clark JJ (2007) The mental health of 13-17 year-olds
in Australia: Findings from the National Survey of Mental Health and
Well-Being. J Youth Adolesc 36: 185-194
Schraedley PK, Gotlib IH, Hayward C (1999) Gender differences in correlates of
depressive symptoms in adolescents. J Adolesc Health 25: 98-108
Secker J, Armstrong C, Hill M (1999) Young people's understanding of mental
illness. Health Educ Res 14: 729-39
Sen G, Östlin P (2007) Unequal, Unfair, Ineffective and Inefficient Gender Inequity
in Health: Why it exists and how we can change it. Final Report to the
WHO Commission on Social Determinants of Health. Karolinska Institute,
Stockholm
Shields SA (2008) Gender: an intersectionality perspective. Sex Roles 59: 301-311
Shute R, Owens L, Slee P (2008) Everyday victimization of adolescent girls by boys:
Sexual harassment, bullying or aggression? Sex Roles 58: 477-489
Siegel JM, Yancey AK, Aneshensel CS, Schuler R (1999) Body image, perceived
pubertal timing, and adolescent mental health. J Adolesc Health 25: 155-65

74
Simovska V (2004) Student participation: a democratic education perspective--
experience from the health-promoting schools in Macedonia. Health Educ
Res 19: 198-207
Skeggs B (1997) Formations of class and gender: becoming respectable. Sage,
London
Solberg ME, Olweus D (2003) Prevalence estimation of school bullying with the
Olweus Bully/Victim Questionnaire. Aggr Behav 29: 239-268
Statistics Sweden (2009). Statistics Sweden, Stockholm
Statistics Sweden (2010) Barns levnadsförhållanden [Living Conditions Survey of
Children. www.scb.se/LE106].
Stoppard JM (2000) Understanding Depression: Feminist Social Constructionist
Approaches. Routledge, London
Strauss A, Corbin J (1998) Basics of Qualitative Research: Techniques and
Procedures for Developing Grounded Theory. Sage Publications,
Thousand Oaks, CA
Stuart H (2006) Psychosocial risk clustering in high school students. Soc Psychiatry
Psychiatr Epidemiol 41: 498-507
Sundaram V, Helweg-Larsen K, Laursen B, Bjerregaard P (2004) Physical violence,
self rated health, and morbidity: is gender significant for victimisation? J
Epidemiol Community Health 58: 65-70
Swearer SM, Turner RK, Givens JE, Pollack WS (2008) "You're so gay!": Do
different forms of bullying matter for adolescent males? School Psychol
Rev 37: 160-173
The Swedish National Agency for Education (2008) Studieresultat i
gymnasieskolan: en statistisk beskrivning av ofullständiga
gymnasiestudier [Study results in upper secondary school: statistical
descriptions of uncompleted upper secondary education. In Swedish]. The
Swedish National Agency for Education, Stockholm
The Swedish National Agency for Education (2007) Attityder till skolan 2006:
Elevernas och lärarnas attityder till skolan [Attitudes towards school 2006:
Pupils' and teachers' attitudes towards school. In Swedish]. The Swedish
National Agency for Education, Stockholm
Sweeting H, Young R, West P (2009) GHQ increases among Scottish 15 year olds
1987-2006. Soc Psychiatry Psychiatr Epidemiol 44: 579-86
Sweeting H, Young R, West P, Der G (2006) Peer victimization and depression in
early-mid adolescence: a longitudinal study. Br J Edu Psychol 76: 577-94
Thompson MP, Kingree JB, Desai S (2004) Gender differences in long-term health
consequences of physical abuse of children: data from a nationally
representative survey. Am J Public Health 94: 599-604
Tolman DL, Impett EA, Tracy AJ, Michael A (2006) Looking good, sounding good:
femininity ideology and adolescent girls' mental health. Psychol Women
Quart 30: 85-95

75
Tolman DL, Spencer R, Rosen-Reynoso M, Porche MV (2003) Sowing the Seeds of
Violence in Heterosexual Relationships: Early Adolescents Narrate
Compulsory Heterosexuality. J Soc Issues 59: 159-178
Torsheim T, Ravens-Sieberer U, Hetland J, Valimaa R, Danielson M, Overpeck M
(2006) Cross-national variation of gender differences in adolescent
subjective health in Europe and North America. Soc Sci Med 62: 815-27
Torsheim T, Wold B (2001) School-related stress, support, and subjective health
complaints among early adolescents: a multilevel approach. J Adolesc 24:
701-13
Turner RJ, Avison WR (2003) Status Variations in Stress Exposure: Implications for
the Interpretation of Research on Race, Socioeconomic Status, and Gender.
J Health Soc Behav 44: 488-505
Wagner BM, Compas BE (1990) Gender, instrumentality, and expressivity:
moderators of the relation between stress and psychological symptoms
during adolescence. Am J Commun Psychol 18: 383-406
Walby S (1990) Theorizing Patriarchy. Blackwell, Oxford
Walkerdine V, Lucey H, Melody J (2001) Growing up girl: Psychosocial
explorations of gender and class. Palgrave Macmillan, New York
Watts RH, Borders LD (2005) Boys' Perceptions of the Male Role: Understanding
Gender Role Conflict in Adolescent Males. J Men's Studies 13: 267-280
West C, Zimmerman DH (1987) Doing Gender. Gender Soc 1: 125-51
West P, Sweeting H (2003) Fifteen, female and stressed: changing patterns of
psychological distress over time. J Child Psychol Psychiatry 44: 399-411
West P, Sweeting H (2004) Evidence on equalisation in health in youth from the
West of Scotland. Soc Sci Med 59: 13-27
West P, Sweeting H, Young R, Robins M (2006) A Material Paradox: Socioeconomic
Status, Young People's Disposable Income and Consumer Culture. J Youth
Studies 9: 437-462
Westberg A (2004) Forever Young? Young People's Conception of Adulthood: The
Swedish Case. J Youth Studies 7: 35-53
WHO (2005) Child and adolescent mental health policies and plans. World Health
Organization, Geneva
WHO (2007) Mental health: strengthening mental health promotion. World Health
Organisation. www.who.int/mediacentre/factsheets/fs220/en/
WHO (2010) Child and adolescent mental health.
http://www.who.int/mental_health/prevention/childado/en/. WHO
Wichström L (1999) The emergence of gender difference in depressed mood during
adolescence: the role of intensified gender socialization. Dev Psychol 35:
232-245
Wight RG, Botticello AL, Aneshensel CS (2006) Socioeconomic Context, Social
Support, and Adolescent Mental Health: A Multilevel Investigation. J
Youth Adolesc 35: 115-126

76
Wisdom JP, Rees AM, Riley KJ, Weis TR (2007) Adolescents' perceptions of the
gendered context of depression: "Tough" boys and objectified girls. J
Mental Health Counseling 29: 144-162
Witkowska E, Menckel E (2005) Perceptions of sexual harassment in Swedish high
schools: experiences and school-environment problems. Eur J Public
Health 15: 78-85
Young R, van Beinum M, Sweeting H, West P (2007) Young people who self-harm.
Br J Psychiatry 191: 44-9
Ystgaard M (1997) Life stress, social support and psychological distress in late
adolescence. Soc Psychiatry Psychiatr Epidemiol 32: 277-83
Ystgaard M, Arensman E, Hawton K, Madge N, van Heeringen K, Hewitt A, de
Wilde EJ, De Leo D, Fekete S (2009) Deliberate self-harm in adolescents:
comparison between those who receive help following self-harm and those
who do not. J Adolesc 32: 875-91
Zubrick SR, Silburn SR, Burton P, Blair E (2000) Mental health disorders in children
and young people: scope, cause and prevention. Austr NZ J Psychiat 34:
570-8
Zøllner L, Jensen B (2010) Sårbarhed og (mis)trivsel blandt unge [Vulnerability and
(poor) well-being among adolescents. In Danish]. Center for
Selvmordsforskning, Odense

77
APPENDICIES

Appendix 1. Interview guide – an example

In bold: main structure of the focus group discussions.

In italics: examples of probes and topics introduced by the interviewer when
needed.

What do you think of

when you hear the word
‘Mental health’? What
words would you use?

How?

School?
What do you think is
important for mental health
and mental ill health among Friends?
young people?

For girls?
<please
explain more< Future?
Leisure time? For boys?

Partner?

78
Appendix 2. Examples of questions in the questionnaire

Psychological distress (items 2, 3, 4, 6, 8, 10)

36. Hur ofta har du under de tre senaste månaderna känt dig:
Sätt ett kryss på varje rad! Alltid Ofta Ibland Sällan Aldrig
Glad och uppåt     
Nervös     
Ängslig/orolig     
Nedstämd/deppig     
Pigg     
Irriterad eller på dåligt humör     
Avslappnad och lugn     
Värdelös     
Att du har haft kontroll över ditt liv     
Uppgiven     
Slutkörd     
Betydelsefull     

Deliberate self-harm (items 2 and 4)

Här kommer några frågor om att skada sig själv.

Det handlar alltså INTE om skador som du råkat ut för genom en olyckshändelse.

44. Har du någon gång:

Ja, Ja, några Ja, Nej,
Sätt ett kryss på varje rad!
flera gånger någon aldrig
gånger gång
Tänkt på att du skulle vilja skada dig själv
genom att t. ex. skära, rispa, bränna eller sticka    
dig?
Skadat dig själv genom att t ex skära, rispa,
   
bränna eller sticka dig?
Skadat dig själv så mycket att du behövt
   
uppsöka skolsyster eller annan sjukvård?
Överdoserat läkemedel eller annat preparat i
   
syfte att skada dig själv?

79
Bullying and sexual harassment

Vi kommer nu att fråga om mobbning, hot, våld och annan kränkande behandling.
Om du har varit med om någonting som vi frågar om så kanske du tycker att det
är jobbigt att svara. Sist i enkäten finns kontaktuppgifter till ställen som du kan
vända dig till om du känner att du behöver prata med någon. Kom ihåg att våld,
hot och kränkningar alltid är fel och är brottsligt enligt lag. Du kan alltså alltid
anmäla om du har blivit illa behandlad.

47. Har något av detta hänt dig under de senaste tolv månaderna i skolan?
Ja, Ja, Ja, Nej,
Sätt ett kryss på varje rad! flera några någon aldrig
gånger gånger gång
Att andra personer har frusit ut dig    
Att någon gett dig ovälkomna kommentarer om ditt
   
utseende eller kropp
Att någon kallat dig ‛hora‛, ‛bög‛, ‛fitta‛ eller andra
   
former av könsord
Att någon hållit fast eller trängt dig    
Att andra personer har ljugit eller spridit falska
   
rykten om dig
Att någon tafsat på dig eller tvingat dig att ta på
   
honom/henne på ett sexuellt sätt
Att någon har utsatt dig för rasistiska ord eller
   
handlingar
Att någon sagt nedsättande saker om ditt kön eller
   
sexualitet

80
Appendix 3. Examples of responses on specific questions

Reports (percentage) of items included in the measure of psychological distress

(always or often during the past 3 months).
Items in measure of psychological distress Boys Girls
(%) (%)
Nervous 14.2 20.3 ***
Irritable 18.5 28.4***
Worthless 9.4 19.2***
Resigned 11.0 14.4*
Depressed/low 16.7 29.1***
Worried/anxious 13.5 27.1***
Chi-Square test. *p<0.05; **p<0.01***p<0.001

Reports (percentage) of items included in measure of deliberate self-harm (DSH),

(ever in life).
Items in measure of deliberate self-harm Boys Girls
(%) (%)
DSH by cutting, scratching, burning 9.7 21.6 ***
DSH by overdose of medicine 4.7 6.0
Chi-Square test. *p<0.05; **p<0.01***p<0.001

Reports (percentage) of items included in the measure of bullying.

Items in measure of bullying Boys Girls
(%) (%)
Been socially excluded 22.4 31.2***
Experienced somebody spreading false rumours about you 28.4 39.2***
Been exposed to racist comments or actions 12.0*** 4.8
Chi-Square test. *p<0.05; **p<0.01***p<0.001

Reports (percentage) of items included in the measure of sexual harassment.

Items in measure of bullying Boys Girls
(%) (%)
Received unwelcomed comments on body or appearance 28.5 29.2
Been called ‘whore’, ‘fag’, ‘cunt’ or other ‘four-letter’ words 36.5*** 23.5
Been pawed or forced to touch somebody in a sexual way 8.5 9.0
Received degrading comments about your gender or sexuality 9.0 14.1***
Been grabbed or shouldered/cornered 20.3*** 13.4
Chi-Square test. *p<0.05; **p<0.01***p<0.001

81
Appendix 4. Overview of interaction effects

Overview of interaction effects between violence variables and educational programme

(vocational) and parental employment status (one or both parents not employed).
Significant interaction effects are indicated by asterisks.

Boys Girls
Stress PD DSH Stress PD DSH
Voa PnEb Vo PnE Vo PnE Vo PnE Vo PnE Vo PnE
Bullying - - - - - - ** - - - - -
Sexual harassment - - - - - - ** - - * * *
Physical violence past *** - - - - - - - - - * ***
12 months
Physical violence ever - - - - - - * - - ** * *
Sexual assault - - - - - - ** - - * * -
*p<0.05; **p<0.01***p<0.001
a Vocational educational programme

b One or both parents not currently employed

82