MENTAL HEALTH LITERACY OF PORTUGUESE ADOLESCENTS AND YOUTH ABOUT ALCOHOL ABUSE

Characterize the mental health literacy of adolescents and young people about alcohol abuse, in the various components of the concept. Exploratory descriptive study, through the application of the instrument QuALiSMental to a representative sample of 4938 adolescents and young adults aged between 14 and 24 years, attending schools in the 3rd cycle of basic and secondary education of the central region of Portugal.The recognition of the vignette of alcohol abuse by the participants is high (72.4%), although it is also identified as alcoholism (70.3%), which indicates the perception of the problem as serious. Participants have modest levels of literacy in the remaining components, preferring informal sources of help.Therefore, we conclude that there is a need to implement school programs that promote mental health literacy, to promote the adoption of healthy behaviors in young people, which transfer them into adulthood. 1 Ph.D Adjunct Professor Nursing School of Coimbra Health Sciences Research Unit in: Nursing Coimbra AC Portugal. E-mail: luisloureiro@esenfc.pt 2 Ph.D Nursing School of Coimbra Health Sciences Research Unit in: Nursing Coimbra AC Portugal E-mail: tbarroso@esenfc.pt 3 Ph.D Nursing School of Coimbra Health Sciences Research Unitin: Nursing Coimbra -E-mail: acmendes@esenfc.pt 4 Ph.D Nursing School of Coimbra Health Sciences Research Unit in: Nursing Coimbra Portugal. E-mail: demar7@gmail.com 5 Ph.D ISPA Lisbon Portugal. E-mail: raragao@clinipinel.com 6 Nurse Nursing School of Coimbra Coimbra Portugal. E-mail: nrafael@esenfc.pt RESEARCH Literacia em saúde mental de adolescentes e jovens portugueses sobre abuso de álcool Esc Anna Nery (print)2013 Jul-Sep; 17 (3):474 481 Luís Manuel de Jesus Loureiro1, Teresa Maria Mendes Dinis de Andrade Barroso2, Aida Maria de Oliveira Cruz Mendes3, Manuel Alves Rodrigues4, Rui Aragão Aleixo Neves Oliveira5, Nuno Rafael Neves de Oliveira6 Instrucción en salud mental de adolescentes y jóvenes portugueses sobre el abuso del alcohol Mental health; Health Education; Alcoholism; Adolescent.


INTRODUCTION
Alcohol is the most widely consumed psychoactive substance nowadays, including among adolescents and young 1 .The first experiences of consume usually occurs during adolescence, with estimated start from the age of 12, observing both excessive and even abuse consumption before 18 years old, with half of young people having their first episode of drunkenness before this age 2,3 .
In Portugal, the studies conducted in the last decade, in 2003, 2007 and 2011 respectively, with samples of adolescents and young people with ages between 13 and 18 revealed that the alcohol consumption tends to increase linearly with age, and is larger among males 3 .
Although many times those experiences of consumption are socially accepted and culturally justified, studies indicate that alcohol should not be consumed before the age of 18, because the liver is not prepared to metabolize alcohol and the brain is still developing/in maturation 4,5 .
Alcohol-related harms resulting from episodes of drunkenness and excessive consumption are known: unprotected sex, violence, driving under the influence of alcohol and school absenteeism, among others.Moreover, the fact that adolescence and youth are periods considered critical in the life cycle characterized by significant changes and transitions and in which problems such as alcohol abuse and excessive consumption can have profound impact on the lives and on mental health of individuals, compromising their standard of development and potentiate dependency situations in the future 5 .
In this regard different types of interventions in the context of health education have been developed in order to prevent early alcohol consumption and its inappropriate use, warning of the risks associated with consumption, consequences and individual and collective effects 6 .Some authors suggest that interventions, when anchored in the concept of mental health literacy, understood as the knowledge and beliefs about mental disorders that allow their recognition, prevention and/or management, can be effective because they imply knowledge focused on action in favor of health the individual or their pairs 7,8 .
The mental health literacy concept involves a number of components that are: a) the recognition of mental disorders in order to promote and help seeking b) knowledge about the professionals and treatments available, c) knowledge on the effectiveness of self-help strategies, d) knowledge and skills to provide support and first aid to others, and) knowledge of how to prevent mental disorders 8 .
Studies show that low levels of mental health literacy in its different components, for example, associating depression and alcohol consumption, emerge as barriers to professional help seeking, either by its absence or for its postponement and may result on the worsening of symp-toms, and possible evolution for dependence situations 9 .Social stigma is also pointed out as a barrier to help seeking, for example leading the individual to hide the signs, or even as a consequence of low levels of literacy [10][11][12] .
Therefore mental health literacy of young people is considered a key principle for the planning and development of health education programs, with particular focus in the school context, where individuals spend most of their time.The education system must also promote health and well-being promotion and the education and civic participation of individuals, a process that supports the acquisition of skills and learning in order to promote the autonomy of individuals, empowering them for action in favor of their own health 7 .
The scientific literature focused on mental health literacy components in terms of abusive consumption, or alcoholism, specifically in samples of adolescents and young adults does not exist.However, there are studies that use the same data collection an instrument, in which is assessed mental health literacy concerning depression associating it with alcohol abuse.
The results of those studies reveal more appropriate levels of mental health literacy in the component knowledge about the effectiveness of self-help strategies, compared to more modest levels in the remaining components.For example, approximately 50% of adolescents and young people recognize and identify situations of alcohol abuse associated with depression, roughly 80% indicating intent to ask for help in similar situations and tend to value the sources of informal help (friends and close family members) compared to formal help (health professionals) 9,13,14 .
In Portugal is explicitly mentioned by documents such as the Mental Health National Plan 2007-2016 15 or even in School Health Program 16 that not only there are no studies but also that school-based interventions are needed, aimed at promoting health and preventing mental illness, by increasing mental health literacy, linking different sectors, such as education and health.
Given these findings we developed the present study to characterize the mental health literacy of young people in relation to alcohol abuse in the components of the recognition of disorders, knowledge of professionals and treatments available, effectiveness of self-help strategies, skills to provide support and first aid to others and ways to prevent this disorder.

METHODOLOGY
This is a descriptive exploratory study with quantitative approach carried out in the central region of mainland Portugal, from a representative sample of adolescents and young people with ages between 14 and 24 years, attending the 3 rd Cycle of basic and secondary education (7 th to Loureiro LMJ, Barroso TMMDA, Mendes AMOC, Rodrigues MA, Oliveira RAAN, Oliveira NRN Mental health literacy 12 th grade), of 50 schools that are framed in the Regional Direction of Education -Centre (DREC).Data were collected between the months of November 2011 and May 2012, having been used cluster sampling.
As instrument of data collection, we used the Questionnaire of Mental Health Literacy Assessment -QuAL-iSMental 17 .This questionnaire consists of a 1 st part that includes instructions for completion and socio-demographic questions (gender, age, residence, district and parents qualifications) and different sections relating to each component of mental health literacy.
Following the 1 st part, a vignette is presented describing a case of alcohol abuse (according to the diagnostic criteria for alcohol abuse in DSM-IV-TR 18

of a young man named Jorge with 16 years, as presented below and then used to evaluate all components:
Jorge is a 16 years old boy who attends 11th grade.In the last year, he started to drink alcohol and got drunk in every party he went.His parents are worried about him because he has been declining his academic performance, missing school due to hangovers and his parents were called to school because he appeared drunk in a class.In the last party, his friends called 112 because he was unconscious.
The questionnaire was administered in the classroom, in group sessions, supervised by a team member and a class teacher.The time of response was between 40 to 50 minutes.
Data were inserted and processed in the software IBM-SPSS 20.0.Since this is a descriptive exploratory study, we calculated the appropriate summary statistics and the absolute and percentage frequencies in order to meet the objectives of the study, using the procedure table for multiple responses.
The instrument for data collection was submitted to the General Directorate for Innovation and Curriculum Development of the Ministry of Education of the Portuguese Government (case no.º 0252500001) and to the Ethics Committee of the Health Sciences Research Unit -Nursing (UICISA-E) of the Nursing School of Coimbra (No.: P58-12/2011).In both cases the opinion was positive, having it been approved and the application authorized.Given the characteristics of the sample (mostly minors), the instrument was accompanied by an informed consent form to be signed by parents/guardians, or, in cases where young people were aged > 18 years, an own consent form.

RESULTS
4938 adolescents and young Portuguese participated in the study, 43.3% males and 56.7% of females, with ages between 14 and 24 years (mean age of 16.75 years and a standard deviation of 1.62 years), as can be seen in Table 1.Educational attainment of parents shows a very similar distribution (Table 1).For both, the qualifications are concentrated mostly in the first 4 levels of education (Basic Education -1 st Cycle (former 4 th grade); Basic Education -2 nd Cycle (Preparatory Education -former 6 th grade); Basic Education -3 rd cycle (general course of the lyceum -former 9th grade), Secondary Education (lyceum complementary course)), with approximately 50.0% having completed the 3rd cycle of Basic Education (24.1% of fathers and 24.9% of mothers) and Secondary Education (24.1% of fathers and 24.5% of mothers).
Since this is a tool that analyzes the different components of mental health literacy, it was decided to provide separate results for each component.

Alcohol abuse recognition
Regarding the recognition of the situation of substance abuse, the most marked option was substance abuse (72.4%) followed by alcoholism (70.3%), age crisis (21.9%) and psychological/mental/emotional problems with 13.8%.All the other categories have relatively low values.

Recognition of professional help and available treatments
For the different people and professionals who can help in the situation presented, we can observe (Table 3) that the family doctor (77.8%), the psychologist (76,8%) and nurses (54.6%) are considered useful by a considerable majority of the sample.However, most young people find useful a significant friend (81.3%) and a close relative (75.2%).
It is also notorious the ambivalence regarding the help of professionals, being the most striking the social worker (66.1%), the teacher (57.0%), the psychiatrist (45.0%) and the nurse (39.7%).
In what concerns medications/products (Table 3) it should be highlight the high percentages of unawareness with a response interval ranging from 51.7% for teas (e.g.: chamomile or St. John's wort) and 62.6% to antipsychotics.

Recognition of the effectiveness of self-help strategies
Regarding the activities that may help Jorge (Table 3), participants consider helpful becoming more physically active (79.4%),receiving therapy with a spe-

Knowledge and skills to provide support and first aid to others
At the knowledge and skills to provide support level (Table 3), participants considered as useful, first, listen to his problems in an understanding way (90.1%),second, suggest he seek professional help (76.2%) and also encourage him to become more physically active (74.7%).
To suggest he have a few drinks to forget his troubles (84.3%), not acknowledging his problem, ignoring him until he gets over it (80.3%)and ask him whether he is feeling suicidal (46.9%) are considered harmful by most of the sample.

Knowledge of how to prevent mental disorders
In the last component (Table 4), knowledge about how to prevent mental disorders, most teenagers and young value, with the exception of having a religious or spiritual belief, all other activities, highlighting the never drinking alcohol (85.6%), not using drugs (82.4%) and keeping regular contact with family (80.9%).

DISCUSSION
The recognition of disorders is referred in literature as a prerequisite to professional help seeking, and this recognition when is done early can decrease the time elapse that mediates the onset of signs and symptoms and the access to health care, avoiding the exacerbation of problems and improving health outcomes individually and in the community 8,10 .
The results of this study show that the recognition of alcohol abuse by adolescents and youth is complex.On one hand, the majority of adolescents recognize the vignette as alcohol abuse, but roughly the same percentage labels the situation as alcoholism.The overvaluation of the situation reported in the vignette, as being alcoholism, may be salubrious, since the situation is perceived as more serious.However, the label alcoholism is used here improperly suggesting lack of knowledge of young people about alcoholism as an addiction.
However, if we analyze the clinical expressions that are used in everyday life by people in general, we can understand the trivialization of the use of the term "alcoholic" in reference to someone with problems related to alcohol consumption, and consequently label the situation in the vignette as alcoholism 11 .In any case, the classification of the situation as alcoholism may reveal that young people do not know what is alcoholism and what it implies 5 .It should be noted, therefore, that the perception that the situation is serious, whether being a problem of alcohol abuse and/or alcoholism, may be a favorable factor in the assessment of risk perception in relation to alcohol consumption.
It should also be noted that alcohol abuse is perceived as one of the most stigmatizing mental disorders and that implies greater social distance 11,12 .
This result for alcoholism deserves also an observation, because if more than 2/3 endorses it, and alcohol is the substance more present and consumed in recreational settings, although not all young people consume, we have a set of young people who may consider their peers as alcoholics 14 .
To associate the alcohol abuse behavior with a temporary crisis age, a much shared vision on our society, can mean both depreciation of the alcohol-related harms and even act as a barrier to help seeking, and to give aid to others 5,14 .

Mental health literacy
When we mention that alcohol consumption tends to be socially accepted and culturally justified, since the first experiences often occur at early ages, this perception that this is a temporary crisis or normal for age is commonly shared by parents and children, and can become a barrier in implementing prevention programs 10 .This question leads us to the necessity of legislation norms, as restrictive measure to help delay the onset of alcohol consumption.In Portugal, the minimum legal age to purchase alcohol is 16 years of age for beer and wine and 18 years for other alcoholic beverage.
Regarding the component of knowledge of people who can help and medicines/products, it is observed that adolescents and young favor the informal help (friends and family), along with the general practitioner, psychologist and even the nurse 9,13,14 .The valorization of informal sources is relevant because most of the time is by the suggestion of friends and family that young people seek help, reinforcing the importance of integrate on prevention programs the family and significant people 8 .
The valorization of the general practitioner as the principal help source is relevant, as the primary health care is the first health service available to young people.However, young people are the ones who have less contact with the health services 13,14 .
The fact that a substantial percentage of young people do not know about the usefulness of the teacher to give support or even consider this professional harmful it is worrying, as teachers are the professionals who spend more time with young people.It is possible that adolescents and young people consider that sharing the problem with the teacher can have an impact on their academic achievement or be associated with problems of anonymity and confidentiality 10 .
In terms of medicaments/products it is mentioned in the literature that adolescents and young people tend to have for most mental disorders a negative view of psychopharmacology, not knowing what are those medicaments as overvaluing the side effects, such as "zombie effect", weight gain and addiction 12 .In this study approximately 1/4 of the sample consider the use of psychopharmacology as harmful.
The results also indicate clearly that young people are unaware of the usefulness of medicaments, possibly because they do not know what they are or suspect they do not prevent the alcohol consumption 13,14 .It is noteworthy that this negative view of medicaments can to some extent enhance the non-adherence to treatment when prescribed by a health professional 8 .
A valorization of everyday products and that do not require a prescription is noted, such as teas and vitamins, yet there is no empirical evidence of their effectiveness, although it is associated with these products a widespread belief that they can help solve the problems 13,14 .It is also noteworthy that these products can be easily bought, not involving contact with a health professional.
In terms of self-help interventions and strategies, it should be highlighted the fact that young people consider that the continued consumption of alcohol and the use of tobacco as a form of relaxation, are harmful and can exacerbate the existing problem, as noted in other studies 14 .There are studies that present as useful the interventions/ strategies that are based on physical exercise, therapy with a specialist and even participation in a self-help group 13,14 .Consulting a website with information about the problem is considered useful to 3/5 of the participants.
These results indicate that a substantial portion of young people are aware of what are the useful strategies of self-help 13,14 .This knowledge may be the result not only of the information that comes in the contexts of education /training, as well as of the awareness and health promotion actions held within the school health, adding to those the social marketing done by advocacy organizations and institutions associated with alcoholism 8 .Still, a considerable number of individuals expressed ignorance about the usefulness of most strategies, not knowing if they are going to use them in a similar situation, which is very worrying, because in the early stages of the problem these strategies are useful.
About knowledge and skills to provide first aid and support to others young people elect attentive and comprehensive listening as the attitude most useful in an alcohol abuse situation, as well as the suggestion of seeking professional help and monitoring, which comes in accordance with the guidelines of mental health first aid 8 .
Tell the young person who abuses alcohol to get his/her act together or keep him/her busy to do not think of problems are actions considered helpful for more than 50% of the participants.This result is worrying because it can reassure the person but in the medium-long term these strategies may delay the search for help.
Ask a person who abuses alcohol if has suicidal thoughts is considered by nearly half of young people as harmful.This result can be explained by the fact that people think, wrongly, that the simple question can turn on the thoughts of suicide 8 .
The last component, knowledge about how to prevent mental disorders, is referred in literature as a field of study in mental health literacy that needs more investment in research 8 .Nevertheless, the results suggest that adolescents and young people have the idea that it is possible to prevent mental disorders, including alcohol abuse.
Religious and spiritual beliefs are not considered useful as a way of preventing mental disorders.

CONCLUSION
The results of this groundbreaking study, as there are no studies that simultaneously evaluate this specific issue with this approach and using this instrument, show that the level of mental health literacy of adolescents and young Portuguese about alcohol abuse is moderate in the components of the concept.This data becomes worrying when it is known that the first experiences of drinking occur during adolescence and youth, which are transition phases with significance in the context of individual's lives of, in which the body is in the process of maturation, which may threaten the development and well-being of individuals.
It is therefore urgent the need to develop programs aimed at increasing mental health literacy of adolescents and young people, as those are also privileged periods for the acquisition of knowledge and the adoption of behaviors that transit to adulthood.
Schools are the privileged places for the implementation of programs, not only because they are the places where young people spend most of their time and privileged spaces for the acquisition of health promoting knowledge and skills.Although the mental health literacy is a recent concept, it implies an action-oriented knowledge to improve the health of young people and their peers.

Table 1 .
Distribution of percentage frequencies of the participants on the socio-demographic variables (N = 4938)

Table 2 .
Percentage of respondents endorsing each category to describe the problem shown in the vignette describing a case of alcohol abuse (N = 4938)

Table 3 .
Percentage of respondents endorsing various potential types of help (N = 4938)

Table 4 .
Percentage of respondents endorsing each item on beliefs about prevention (N = 4938)