Rethinking Mental Health Wellness Among Adolescents: An Integrative Review Protocol of Mental Health Components

Background: Adolescence have been overlooked in global public health initiatives as this period is generally considered to be the healthiest in an individual’s life course. However, the growth of the global adolescent population along and their changing health proles have called attention to the diverse health needs of adolescents. However, the increased attention toward adolescent health has accentuated existing gaps as global health reports have emphasised that there is a continued need for valid and reliable health data. In this context, evidence has shown that mental health issues constitute one of the greatest burdens of disease for adolescents. The paucity of research on adolescent mental health and wellbeing may be related to the lack of validated instruments. This integrative review aims to unpack the meaning of mental health wellness among adolescents and its associated constructs by analysing and synthesising peer-reviewed empirical and theoretical research on adolescent mental health. In doing this, we will develop a working denition of adolescent mental health wellness that can be used to develop an instrument aimed at measuring adolescent mental health wellness. Methods: The integrative review is guided by the ve steps described by Whittemore and Kna. A comprehensive search strategy which will include carefully selected terms that correspond to the domains of interest (mental health wellness) will be used to search for relevant literature on electronic databases, grey literature and government or non-governmental organisations (NGO) websites. Studies will be included if they describe and/or dene general mental health wellbeing in adolescent populations aged 10-19. The screening and reporting of the review will be conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data from the integrative review will be analysed using narrative framework synthesis for qualitative and quantitative studies Conclusion: This integrative review aims to search for and synthesise current research regarding adolescent mental health wellbeing to identify how wellbeing is being described and conceptualised. We aim to identify gaps and to contribute to a more comprehensive denition of mental health wellness which can aid in the development of an age- and culturally appropriate measure of adolescent mental health wellness


Background
Signi cant advances in health care have resulted in an overall decline in child mortality rates globally and more children are surviving to reach adolescence [1]. In 2016, adolescents (10-19 years) were estimated at 1.2 billion (18%) of the world population, making them the largest population of adolescents in history [1,2]. Adolescents have been largely overlooked in global health and social policies, because this period is generally considered to be the healthiest in an individual's life-course [1], and the unique health problems associated with adolescence have been misconstrued or ignored in favour of more pressing public health concerns [3]. However, changing health pro les of adolescents in both developed and developing countries have called attention to the diverse health needs of adolescents. According to the World Health Organization (WHO), more than 1.1 million adolescents died in 2016 -mostly from preventable or treatable causes [4]. Therefore, the considerable gains from global investments in child and maternal health programmes would yield fewer long term bene ts without simultaneous investments in adolescent health [5,6].
In this context, perspectives on adolescent health have shifted to recognise that adolescence represents a unique and formative developmental phase which is central in the development of capabilities related to health and wellbeing [6][7][8]. According to the life course approach, all stages of an individual's life are intricately intertwined and interconnected with each other, as well as other people in society and with past and future generations of their families [9]. In other words, evidence has shown that early life experiences, including events experienced in pre-conception, play a role in determining the developmental origins and trajectories of health and wellbeing or disease across an individual's life course [9]. From this perspective, it is understood that health and wellbeing of individuals, as well as communities, depend on interactions oscillating between multiple risk and protective factors throughout one's life. Based on this, early and appropriate interventions during child and adolescent years are shown to be the most effective prevention strategies to promote optimal public health and human development [5,6,8]. Additionally, following the life course approach, it is argued that these early investments in child and adolescent health will yield a triple dividend as they will grow into healthier adults who can contribute positively to society, as well as the health and development of the next generation [9].
In response to changing adolescent health pro les, the prioritisation of adolescent health has become an increasingly prominent issue on global health agenda as seen in the Sustainable Developmental Goals (SDGs) [10], the Global Strategy for Women's, Children's and Adolescents' Health [11], the Global Accelerated Action for the Health of Adolescents (AA-HA!) [3], the Lancet Commission on Adolescent Health and Well-being [1], and the South African National Department of Health's National Adolescent and Youth Health Policy [12]. Furthermore, adolescents were included in the UNICEF's Countdown to 2030 initiative, which previously focused on tracking child and maternal health in countries with the highest burden of child and maternal mortality [13]. However, the increased attention toward adolescent health has accentuated existing gaps as reports from the abovementioned initiatives have emphasised that there is a continued need for valid and reliable health data to drive accountability, identify priority areas and monitor progress in adolescent health [1,3,14]. To ensure a healthy and sustainable future for the world's adolescents, special attention needs to be paid to understanding all aspects of adolescent health and development in context.
Globally, mental health issues constitute one of the greatest burdens of disease for adolescents. According to the WHO, in 2016 mental health conditions accounted for 16% of the global burden of disease and injury for adolescents, with depression being identi ed one of the leading causes of illness and disability among adolescents, suicide noted as the second leading cause of death in adolescents and self-harm the third [4,15]. UNICEF propagates that half of all lifetime mental disorders have onset during adolescence [16]. The recent inclusion of adolescence on the global health agenda as a target group for intervention represents a key step toward reducing the global burden of disease attributed to mental health disorders and reducing preventable deaths. However, due to the previous neglect of mental health as a public health issue, efforts to address adolescent mental health are met with various challenges Currently, there is a lack of data concerning mental health conditions among adolescents, especially those in low and -middle-income countries (LMICs) [17]. The lack of a body of quality evidence can affect the way adolescents are represented in national policies, as well as the ways in which government and healthcare o cials respond to treatment and prevention. According to WHO, a 2014 review of health policy documents from 109 countries showed that 84% have given some attention to adolescents, with three-quarters of them addressing sexual and reproductive health; one-third addressing tobacco and alcohol use, and one-quarter focusing on mental health [2]. In LMICs, efforts regarding the promotion, prevention and treatment of child and adolescent mental health (CAMH) are hindered by a lack of speci c CAMH policies, resources and have fewer child and adolescent psychiatrists and other mental health professionals [18,19]. Furthermore, studies from developed countries have suggested that while CAMH services and policies are in place, there is a lack of mental health service uptake among children and adolescents due to various attitudinal, stigma-related, and structural barriers to accessing mental health services [20]. These challenges and barriers to CAMH in both LMICs and higher-income countries are particularly apparent among adolescents living with a chronic order or disease. Mental health conditions are increasingly recognised in children and adolescents with chronic conditions. Studies have shown that living with a chronic health condition is associated with increased risk of developing comorbid physical and mental health problems, which in turn in uence treatment adherence and quality of life [21][22][23].
Another recurring obstacle for integrating mental health into global public health initiatives and frameworks is the lack of consensus of a de nition of mental health [24]. Currently, the term 'mental health' is often used as a euphemism to refer to mental illness. This use re ects in the literature as the majority of adolescent mental health research adopts the dominant pathological view of health by focusing on mental health disorders such as psychiatric disorders, general mental health disorders, emotional and behavioural problems and psychological distress [17]. For example, Duffus et al. [21] observed that adolescents (aged 11-17 years) with type 1 diabetes presented with higher anxiety and depressive scores than their peers without a chronic disease. Research focused on exploring mental health among ALHIV have found similar results. A study conducted by Sherr et al. [25] found that that behaviourally infected ALHIV were more likely to be depressed, anxious and report internalised stigma than perinatally infected ALHIV, who were also found to be more adherent to antiretroviral therapy (ART). Similarly, global health initiatives such as AAH-HA! focus majorly on the burden of disease of mental disorders by reporting on self-harm, depressive disorders, childhood behavioural disorders and anxiety [3].
This dominant pathological view of mental health persists despite the contributions of positive health and well-being research [24]. In research and measurement, it is imperative to consider both mental health wellness and mental illness, as social scientists have argued that being free of mental illness does not constitute positive mental health [26]. Adolescents in particular experience multiple physical, social and emotional changes, which can positively or negatively impact their mental well-being. Therefore, interventions at this stage are crucial as research shows that providing psychosocial support and mental health promotion, such as psycho-education and community empowerment, facilitates the development of mental health wellness (positive mental health) which is protective against psychopathology (mental illness) [15,26]. As such, mental health should be viewed as more than the absence of mental illness [27].
According to Vreeman, McCoy and Lee [17], the paucity of research on adolescent mental health and wellbeing may be related to the lack of validated instruments to measure mental health in all its facets. Therefore, it may be necessary to reconsider how mental health is conceptualised. WHO has adopted the complete state model to de ne mental health as 'a state of wellness in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community' [28].
Despite the growth of wellbeing research in recent decades, the question of how wellbeing should be de ned remains largely unresolved [29]. Consequently, this has given rise to broad and ambiguous de nitions of wellbeing. The problem concerning the de nition of wellbeing is not new, as Ryff argued early on that, there is a "particular neglect in the task of de ning psychological wellbeing" [30]. As previously mentioned, there is a need to develop accurate and culturally appropriate measures of psychological wellbeing to support research endeavours that aim to improve adolescent mental health. Therefore, there is a greater necessity to clarify what is being measured, and how the resulting data from the measure should be interpreted to undertake fair and valid assessments. As such, developing a de nition of mental health wellbeing should encompass more than the description of wellbeing itself (as is the case with current de nitions) to a clear and de nite statement of the exact meaning of the construct.
To this end, this integrative review aims to unpack the meaning of mental health wellness among adolescents and its associated constructs by analysing and synthesising peer-reviewed empirical and theoretical research on adolescent mental health. In doing this, we will develop a working de nition of adolescent mental health wellness that can be used to develop an instrument aimed at measuring adolescent mental health wellness.

Methodology
The integrative review has been identi ed as a unique tool in healthcare for synthesizing investigations available on a given topic or phenomena and for directing practise based on scienti c knowledge [31]. The existing body of literature on mental health among adolescents is varied and complex as there are many concepts associated with mental health research ranging from positive aspects such as 'resilience' and 'self-e cacy' to negative aspects such as 'depression' and 'anxiety'. As such, it is not possible for one study to capture all the dimensions associated with mental health. However, by adopting the integrative review method, we will be able to include the various sources and methodologies used in research to summarise existing empirical and theoretical literature associated with mental health concepts to better understand and conceptualise mental health wellness among adolescents. The integrative review method proposed by Whittemore and Kna [32,33] will be used: 1) problem identi cation; 2) literature search; 3) data evaluation; 4) data analysis and 5) presentation of the integrative review.

Problem Identi cation
The problem identi cation stage is a crucial rst step in an integrative review. Therefore, we aim to approach this as a phase in itself. This means, going beyond the initial research questions to fully develop a framework of the problem and all its related variables. In this section, we describe some approaches we will use to identify the problem which the integrative review will address. As previously mentioned, our interest lies in understanding how mental health wellness is conceptualised among adolescents, to aid in the development of a mental health wellness instrument for ALHIV. Based on our initial reading of the literature, we have identi ed two recurring issues in this regard; rstly, research suggests that there is a lack of validated mental health instruments for adolescents; and secondly, despite a growing body of research, the question of how wellbeing should be de ned remains largely an unresolved issue. Based on this, we have proposed to following to research questions to aid us in identifying the problem; 1. How is the concept of mental health wellbeing de ned in research involving adolescents?

What indicators of mental health wellbeing are being explored/investigated in research?
These two questions allow is to investigate how research has approached the study of mental health wellbeing, what variables were of interest and how these were de ned. To answer these questions, we will follow an iterative approach to gather and assess the available information to present a clear identi cation of the problem and all the variables of interest. To this end we are currently conducting a systematic review of mental health instruments used in research with adolescent populations [34].
Understanding how mental health wellbeing has been de ned in research is an important part of our problem identi cation, as it will show us what theories and/or de nitions of mental health are dominant and which are missing. As Dodge et al. [29] argued, current de nitions of wellbeing are more descriptive in the sense that they describe aspects of wellbeing rather than the construct itself. This lack of de nition poses a problem in measurement development as the de nition of a construct ultimately in uences how it is being measured and how the resulting data should be interpreted. Therefore, to further aid our problem identi cation, we will compare the data from the systematic review with data from qualitative interviews exploring mental health wellbeing among ALHIV. This information will be used to identify the problem of the integrative review ( gure 1). Using the information from the problem identi cation phase, we will move on to the second phase to conduct a literature search of mental health concepts used in research with adolescent populations.

Literature Search
A comprehensive search strategy which will include carefully selected terms that correspond to the domains of interest (mental health wellness) will be used to search for relevant literature on electronic databases, grey literature and government or non-governmental organisations (NGO) websites. A systematic database search will be performed using Ebscohost (Psycharticles, Academic Search Premier, SocIndex), Educational Resource Information Center (ERIC), Medical Literature Analysis Retrieval System Online (MEDLINE) and Sabinet. The list of initial keywords have been identi ed for the search strategy: "((adolescen* OR teenage* OR young people OR youth) [AND] ("psychological wellbeing" OR "mental health wellbeing" OR "mental health wellness"). As the integrative review allows for a more iterative process, the list of keywords will be modi ed as the initial search reveals more relevant and re ned search terms.

Inclusion and Exclusion Criteria
Studies will be included if they describe and/or de ne mental health wellbeing in adolescent populations. As the interest lies in conceptualising mental health wellness for adolescents, only studies dealing with general mental health and wellbeing will be included. In other words, studies focused on mental disorders or mental illnesses among adolescents will be excluded. For the purpose of this review, studies will be included for all adolescents aged 10-19 who have not been diagnosed with a mental illness or disorder.
Eligible studies will include qualitative, quantitative and mixed-method studies published from 2000-2020.

Study Selection
The PICOT mnemonics (Table 1.) for reviews will be used to guide study selection. The above-mentioned criteria and search strategy will be used to search the databases. The screening and reporting of the review will be conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-P) guideline and checklist [35]. The number of hits for each database will be recorded and the citations will be exported to Mendeley citation software. Following this, two reviewers will screen all the titles and abstracts to assess which articles are appropriate for inclusion. The full-text articles of the included abstracts will be downloaded and reviewed again to determine which articles should be included for the nal assessment [36,37]. Any discrepancies between the two reviewers will be resolved by a third party. Additionally, based on the information retrieved from the screening, the researcher may modify the search to include other relevant sources.

Data Evaluation
In this integrative review, the primary sources will include both empirical and theoretical literature -which increases the complexity of evaluating the quality of the included sources [33]. According to Whittmore and Kna [33], integrative reviews using diverse sampling frames may adopt an approach to data evaluation that is similarly used in historical research. In this case, the authenticity, methodological quality, informational value and representativeness of the available sources should be discussed in the nal report. To minimise bias, the two reviewers will utilise two existing quality criteria instruments to evaluate the different types of data [33]. Firstly, the Mixed Methods Appraisal Tool (MMAT) will be used to assess the methodological quality of the studies as it allows for summarising the overall quality across a range of study designs [38]. Secondly, the SFS scoring system version E (Appendix A) will be used to assess the quality of the methodologies of the included articles [39]. The SFS scoring system version E is appropriate as it allows for screening of both quantitative and qualitative research and allows for the appraisal of the de nitions of constructs being investigates [39] Data Analysis Once the selection of included articles has been nalised, we will extract the relevant data into a Microsoft Excel document to organise the information and prepare for the data synthesis. The Excel sheet will include information regarding the purpose of the study, study characteristics, results, and appraisal of the study as well as any other supporting information. All data will be cross-checked for quality purposes.
Data from the integrative review will be analysed using narrative framework synthesis for qualitative and quantitative studies. Framework synthesis begins with a tentative framework that can either be borrowed from previous studies or can be developed from key concepts [33]. With framework synthesis, the included studies are coded according to the developing framework in an iterative process until the body of evidence can be presented coherently.
In the nal stage, the ndings from the review will be discussed and presented in either tabular or diagrammatic form. Additionally, the limitations of the review will be discussed as well as recommendations for future research.

Discussion
This integrative review aims to search for and synthesise current literature and research regarding adolescent mental health wellbeing to identify the ways in which wellbeing is being described and conceptualised. The purpose of this is to identify gaps and to contribute to a more comprehensive de nition of mental health wellness which can aid in the development of an age-and culturally appropriate measure of adolescent mental health wellness. Such measures are much-needed in adolescent health research as it may be used to better understand the mental health needs of adolescents, as well as contribute to the development of interventions and programmes aimed at improving psychological wellbeing and/or wellness among adolescents.

Strengths And Limitations
According to our knowledge, this protocol describes the rst integrative review to investigate and describe how mental health wellbeing is de ned in research among adolescents. Understanding how mental health wellbeing among adolescents has been conceptualised is necessary to identify what are the strengths and limitations of such de nitions. This will allow us to rethink what mental health wellness means to adolescents and how this can and should be measured in research. A limitation of this study is related to the search strategy, notably around the time span (2000-2020) and the identi cation of grey literature, as not all possible sources of literature may be accessed.   Authors' contributions ZO conceived the idea, developed the research question and study methods and contributed meaningfully to the drafting and editing; she also approved the nal manuscript. BvW aided in developing the research question and study methods, contributed meaningfully to the drafting and editing, and approved the nal manuscript.

Figure 1
Steps followed to identify problem for integrative review

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download. IntegrativeReviewAppendices.docx