Mental health profiles of Finnish adolescents before and after the peak of the COVID-19 pandemic

This is a sel -a chi ed e sion o an o iginal a icle. This e sion may di e om he o iginal in pagina ion and ypog aphic de ails. Au ho (s): Ti le: Yea : Ve sion: Copy igh : Righ s: Righ s u l: Please ci e he o iginal e sion: CC BY 4.0 h ps://c ea i ecommons.o g/licenses/by/4.0/ Men al heal h p o iles o Finnish adolescen s be o e and a e he peak o he COVID-19 pandemic © The Au ho (s) 2023 Published e sion Gus a sson, Jasmine; Lyy a, Nelli; Jasinskaja-Lah i, Inga; Simonsen, Nina; Lah i, Hen i; Kulmala, Ma kus; Ojala, K is iina; Paakka i, Leena Gus a sson, J., Lyy a, N., Jasinskaja-Lah i, I., Simonsen, N., Lah i, H., Kulmala, M., Ojala, K., & Paakka i, L. (2023). Men al heal h p o iles o Finnish adolescen s be o e and a e he peak o he COVID-19 pandemic. Child and Adolescen Psychia y and Men al Heal h, 17, A icle 54. h ps://doi.o g/10.1186/s13034-023-00591-1 2023 Gus a ssone al. Child and Adolescen Psychia y and Men al Heal h (2023) 17:54 h ps://doi.o g/10.1186/s13034-023-00591-1 RESEARCH Open Access © The Au ho (s) 2023. Open Access This a icle is licensed unde a C ea i e Commons A ibu ion 4.0 In e na ional License, which pe mi s use, sha ing, adap a ion, dis ibu ion and ep oduc ion in any medium o o ma , as long as you gi e app op ia e c edi o he o iginal au ho (s) and he sou ce, p o ide a link o he C ea i e Commons licence, and indica e i changes we e made. The images o o he hi d pa y ma e ial in his a icle a e included in he a icle’s C ea i e Commons licence, unless indica ed o he wise in a c edi line o he ma e ial. I ma e ial is no included in he a icle’s C ea i e Commons licence and you in ended use is no pe mi ed by s a u o y egula ion o exceeds he pe mi ed use, you will need o ob ain pe mission di ec ly om he copy igh holde . To iew a copy o his licence, isi h p:// c ea i eco mmons. o g/ licen ses/ by/4. 0/. The C ea i e Commons Public Domain Dedica ion wai e (h p:// c ea i eco mmons. o g/ publi cdoma in/ ze o/1. 0/) applies o he da a made a ailable in his a icle, unless o he wise s a ed in a c edi line o he da a. Child and Adolescen Psychia y and Men al Heal h Men al heal h p o iles o Finnish adolescen s be o eanda e hepeak o  heCOVID-19 pandemic Jasmine Gus a sson1,2,3*, Nelli Lyy a1, Inga Jasinskaja‑Lah i2, Nina Simonsen3,4, Hen i Lah i1, Ma kus Kulmala1, K is iina Ojala1 and Leena Paakka i1 Abs ac Backg ound The COVID‑19 pandemic has had implica ions o adolescen s’ in e pe sonal ela ionships, communi‑ ca ion pa e ns, educa ion, ec ea ional ac i i ies and well‑being. An unde s anding o he impac o he pandemic on hei men al heal h is c ucial in measu es o p omo e he pos ‑pandemic eco e y. Using a pe son‑cen e ed app oach, he cu en s udy aimed o iden i y men al heal h p o iles in wo c oss‑sec ional samples o Finnish adoles‑ cen s be o e and a e he peak o he pandemic, and o examine how socio‑demog aphic and psychosocial ac o s, academic expec a ions, heal h li e acy, and sel ‑ a ed heal h a e associa ed wi h he eme ging p o iles. Me hods and indings Su ey da a om he Heal h Beha iou in School‑aged Child en (HBSC) s udy conduc ed in Finland in 2018 (N = 3498, age M = 13.44) and 2022 (N = 3838, age M = 13.21) we e analyzed. A ou ‑p o ile model using clus e analysis was selec ed o bo h samples. In Sample 1, he iden i ied p o iles we e (1) “Good men al heal h”, (2) “Mixed psychosocial heal h”, (3) “Soma ically challenged”, and (4) “Poo men al heal h”. In Sample 2, he iden i ied p o iles we e (1) “Good men al heal h”, (2) “Mixed psychosoma ic heal h”, (3) “Poo men al heal h and low loneliness”, and (4) “Poo men al heal h and high loneliness”. The esul s o he mixed e ec mul inomial logis ic eg ession analy‑ sis showed ha in bo h samples, being a gi l and epo ing lowe ma e nal moni o ing; lowe amily, pee , and eache suppo ; highe in ensi y o online communica ion; a less posi i e home a mosphe e and school clima e; and poo sel ‑ a ed heal h we e mos s ongly linked o belonging o a poo e men al heal h p o ile. In addi ion, in Sample 2, low subjec i e heal h li e acy was a key ac o associa ed wi h poo e men al heal h p o iles, and eache suppo was mo e impo an han be o e COVID. Conclusions The cu en s udy s esses he impo ance o iden i ying hose ulne able o de eloping poo men al heal h. To maximize pos ‑pandemic eco e y, he ole o schools, especially eache suppo and heal h li e acy, along wi h he ac o s ha emained impo an o e ime should be aken in o accoun in public heal h and heal h p omo‑ ion in e en ions. Keywo ds Men al heal h, Social ela ionships, Adolescence, COVID‑19 pandemic, Clus e analysis *Co espondence: Jasmine Gus a sson jasmine.g.gus a sson@helsinki. i Full lis o au ho in o ma ion is a ailable a he end o he a icle Page 2 o 33 Gus a ssone al. Child and Adolescen Psychia y and Men al Heal h (2023) 17:54 In oduc ion Resea ch du ing he COVID-19 pandemic has aised conce ns o e he poo men al heal h o child en and adolescen s. Acco ding o se e al e iews and me a-anal- yses, he men al heal h o you hs has de e io a ed du ing he pandemic [1–4], pa icula ly in e ms o inc eased anxie y and dep ession symp oms. Fo example, he me a-analysis by Panda e al. [2] ound ha du ing he 1yea o he pandemic, be ween 31 and 42% o child en and adolescen s expe ienced men al heal h p oblems such as anxie y, dep ession, and i i abili y. In addi ion, a popula ion-based longi udinal s udy in Ge many [5] ound ha adolescen s’ psychosoma ic complain s we e mo e p e alen du ing he pandemic compa ed o he p e-pandemic pe iod: 23% o adolescen s epo ed eel- ing low weekly be o e he pandemic, as compa ed wi h 34–43% in h ee wa es du ing he i s and second yea o he pandemic. As he pandemic has impac ed di e en popula ion g oups unequally [6], including adolescen s [7, 8], i is impo an o iden i y he cha ac e is ics o he g oups a pa icula isk o men al heal h p oblems and hose who a e mo e esilien o he ad e se impac o he pandemic. The de e io a ion o adolescen s’ men al heal h could be pa ly explained by he di e en measu es imple- men ed o educe he sp ead o he COVID-19 i us, such as social dis ancing, home qua an ines, and emo e schooling. Many o hese measu es es ic ed con ac wi h o he people, bo h pee s and adul s ou side he home, as well as social suppo (e.g., pe cep ions o ha - ing someone who lis ens and encou ages when needed) [9], esul ing in de imen al e ec s on adolescen s’ abil- i y o ul ill hei social needs and de elopmen al asks [10]. Gi en ha social suppo may se e as a bu e ing mechanism be ween s ess ul e en s like he COVID-19 pandemic and poo men al heal h [11], adolescen s wi h limi ed social suppo may ha e been especially ulne - able o he nega i e impac s o he pandemic. I has also been sugges ed ha he e ec s o social dis ancing migh ex end beyond he pandemic [12], and ha he dynamic o suppo i e ela ionships migh ha e changed du ing his ime pe iod [13]. The e ec s o he pandemic du ing adolescence a e no limi ed o pee ela ionships, hey may also ha e an impac on he quali y o ela ionships be ween pa en s and hei child en [14], which in u n can con ibu e o he o e all heal h o adolescen s [15]. Du ing he pan- demic, adolescen s ha e epo ed lowe le els o pa en- al suppo han 6mon hs be o e he lockdown [16]. Fu he mo e, Magson e al. [17] obse ed ha abou a qua e o adolescen s epo ed mo e equen con lic s wi h hei pa en s du ing he pandemic, which in u n was associa ed wi h lowe li e sa is ac ion. Families ha e also aced inancial ha dships du ing he pandemic, wi h pa en s om low-income and lowe -middle class amilies being a g ea e isk o educed income and job loss [18]. This could ha e a ec ed he heal h o you hs, as associa ions be ween low socioeconomic s a us and child men al heal h p oblems ha e ecei ed much sup- po ( o e iew, see Reiss [19]. Simul aneously, many adolescen s ha e had less oppo uni ies o in e ac wi h classma es and eache s. This is conce ning, as eache s and he class oom en i onmen ha e shown o play a i al ole in suppo ing he well-being o young people [20, 21]. Since he COVID-19 pandemic began, adoles- cen s ha e epo ed a dec ease in communica ion wi h eache s and less emo ional suppo om eache s (e.g., eache s lis ening o wo ies and conce ns wi h less ca e), as measu ed du ing he all o 2020 [22]. How- e e , one s udy [23] has ound ha connec edness wi h school pee s did no p edic men al heal h among chil- d en and ea ly adolescen s du ing he pandemic in he sp ing and summe o 2020. This could possibly be due o he ac ha ela ionships wi h o he sou ces (e.g., amily) may ha e played a mo e impo an ole when access o classma es and eache s was limi ed. New oppo uni ies o in e ac and ob ain social sup- po ha e also a isen du ing he pandemic, wi h many adolescen s spending mo e ime wi h hei iends online in spaces such as social media o compensa e o he loss o ace- o- ace social in e ac ions [24]. Tu ning o social media o alk wi h o he s can be one way o coping wi h he c isis [25]. Howe e , sys ema ic e iews, along wi h c oss-na ional and single coun y s udies, ha e indica ed p oblema ic social media use, including addic ion-like symp oms (e.g., con lic wi h amily and displacemen o o he ac i i ies due o social media use [26]), o associ- a e wi h a mul i ude o psychological p oblems such as dep essi e symp oma ology [27–30]. Mo eo e , i has been sugges ed ha digi ally media ed social in e ac ions a e no he same as ace- o- ace expe iences, as spending mo e i ual ime wi h iends du ing he pandemic has been associa ed wi h highe le els o dep ession among adolescen s [31]. A he beginning o he pandemic, educa ion p ac- ices changed, and online educa ion inc eased. This may ha e a ec ed adolescen s’ school engagemen and mo i a ion, wi h e idence showing lowe lea ning concen a ion, engagemen , and abili y o lea n du ing online classes han in class oom lea ning [32]. These expe iences, in u n, migh ha e an impac on adoles- cen s’ plans o u u e educa ion, which ha e also been linked o heal h. Fo example, lowe educa ional expec- a ions (e.g., expec ing an educa ion lowe han uni e - si y) ha e been associa ed wi h poo e men al heal h in Page 3 o 33 Gus a ssone al. Child and Adolescen Psychia y and Men al Heal h (2023) 17:54 e ms o highe le els o ex e nalizing p oblems (e.g., hype ac i i y) among you hs [33]. In addi ion o di e en psychosocial asse s, o he indi idual asse s, such as heal h li e acy, could also se e as a bu e ing mechanism agains he nega i e e ec s o he pandemic on adolescen s’ men al heal h. Du ing he pandemic, he ole o heal h li e acy as a se o compe encies (e.g., knowledge on heal h issues and an abili y o seek and assess in o ma ion) neces- sa y o p omo ing and sus aining one’s heal h and ha o o he s [34] has g own in impo ance. I has been impo an o ollowing sa e y egula ions, o seeking imely help and o inding alid heal h in o ma ion om among he massi e low o in o ma ion o di e - en quali y p o ided on he in e ne in pa icula . Low heal h li e acy has been linked wi h no only di icul ies in unde s anding COVID-19 in o ma ion and in ec- ion p e en ion beha io s, bu also wi h poo e men al heal h [35]. Al eady be o e he pandemic, low heal h li e acy was ecognized as an independen explana o y ac o in men al heal h a iance (e.g., eeling low) [36]. The pandemic has also had ad e se e ec s on adoles- cen s’ sel - a ed heal h, ha is, a pe son’s o e all heal h s a us [37], especially among hose wi h limi ed social suppo [38]. This is dis u bing, gi en ha poo e sel - a ed heal h du ing adolescence has been linked o heal h p oblems in adul hood [39] and has shown o be a obus p edic o o mo ali y [40]. Acco ding o p e- pandemic esea ch, associa ions be ween highe s ess caused by unce ain y and poo e sel - a ed heal h ha e also been obse ed [41], whe eas be e sel - a ed heal h has been linked o be e men al heal h in e ms o lowe anxie y [42] and highe esilience [43], ha is, he abili y o main ain one’s men al heal h when ac- ing ad e si y [44]. Fo hese easons, sel - a ed heal h could be an impo an ac o in how adolescen s eac o adap o he s esso s caused by he pandemic. The di e en e ec s o he pandemic on di e en indi iduals may also be due o hei socio-demog aphic cha ac e is ics. A as body o esea ch has shown ha gi ls al eady epo ed poo e men al heal h in e ms o dep ession han boys p io o he pandemic ( o a me a-analysis, see Salk e  al. [45]). P e-pandemic esea ch [46, 47] has also linked o he cha ac e is ics o young people, such as olde age and immig an s a- us, o poo e men al heal h (e.g., dep ession, anxie y). S udies conduc ed in di e en pa s o he wo ld ha e shown ha you hs li ing in u ban a eas end o epo sligh ly poo e well-being han hose li ing in u al a eas [48, 49], al hough coun y-speci ic di e ences exis . These indi iduals may be pa icula ly ulne able o he ad e se e ec s o he pandemic. The pandemic in heFinnish con ex Beginning in mid-Ma ch 2020, Finnish schools we e closed na ionwide o abou wo mon hs [50]. Du ing all 2020 and sp ing 2021, educa ion was empo a ily con- duc ed in he o m o dis ance lea ning in some egions, especially uppe educa ion [51]. F om all 2021 un il sp ing 2022, Finnish comp ehensi e schools emained ully open. Since he onse o he COVID-19 pandemic, leisu e cen e s and spo s acili ies ha e closed se e al imes, wi h closu es las ing a ew weeks o se e al mon hs [52, 53]. Mos spo s acili ies ha e emained open since Feb ua y 2022 [54]. As in many coun ies, men al heal h p oblems ha e inc eased among Finnish adolescen s du - ing he pandemic. In sp ing 2021, sa is ac ion wi h li e had dec eased, while anxie y, dep ession and eelings o loneliness had inc eased om 2019 [55, 56]. Howe e , i should be no ed ha al eady du ing he las wo decades p io o he pandemic, Finnish adolescen s’ psychologi- cal and soma ic heal h complain s (e.g., dep ession and headaches) had inc eased [57]. In sum, he pandemic has a ec ed he li es o you hs and hei amilies in many ways. Unde s anding he implica ions o he COVID-19 pandemic o he men al heal h o you hs and he po en ial isk and p o ec i e ac- o s is c ucial o measu es o p omo e pos -pandemic eco e y. To da e, mos s udies examining he impac o he pandemic on he men al heal h o adolescen s ha e ocused on he p e alence o symp oms o dep ession o anxie y and used a iable-cen e ed app oaches aimed a p edic ing hei di e en men al heal h ou comes, wi h indings la gely elying on da a collec ed du ing he 1yea o he pandemic. The men al heal h ou comes o su i o s o he pandemic may be highly indi idual and linked o di e en psychosocial and heal h asse s o esou ces, including p ima y and ins i u ionalized sup- po sys ems such as amilies and school. To show his di e si y o men al heal h eac ions and o iden i y ul- ne abili ies o he pandemic, in his s udy, we adop ed a pe son-cen e ed app oach, ha is, s a is ical echniques ha iden i y g oups o indi iduals who sha e pa icula cha ac e is ics ha a e simila wi hin g oups bu di e - en be ween g oups [58]. D awing on wo la ge da a se s o epea ed c oss-sec ional design— he i s a 2yea s p io o COVID-19 and he second a 2yea s a e he beginning o he pandemic— he cu en s udy aimed o iden i y men al heal h p o iles among Finnish adoles- cen s be o e (2018) and a e he peak o he pandemic (2022), and hen o analyze which socio-demog aphic, psychosocial, and o he heal h- ela ed ac o s cha ac e - ize adolescen s who a e a isk and hose who a e mo e esilien o he de imen al impac o he pandemic on men al heal h. Page 4 o 33 Gus a ssone al. Child and Adolescen Psychia y and Men al Heal h (2023) 17:54 The speci ic aims o his s udy we e: 1) To iden i y men al heal h p o iles (psychological complain s, soma ic complain s, li e sa is ac ion, pe - cei ed loneliness, and p oblema ic social media use) among Finnish adolescen s be o e and a e he peak o he COVID-19 pandemic 2) To examine how socio-demog aphic cha ac e is- ics (gende , age, language o ins uc ion, immi- g an backg ound, amily a luence, amily s uc u e, u ban/ u al esidence), psychosocial ac o s (pe - cei ed social suppo , pe cei ed home a mosphe e, pa en al moni o ing, pe cep ions o school clima e, in ensi y o online communica ion), educa ional expec a ions, heal h li e acy, and sel - a ed heal h a e associa ed wi h he heal h p o iles be o e and a e he peak o he pandemic. Me hods Pa icipan s andp ocedu e Da a we e collec ed om wo c oss‐sec ional samples o Finnish adolescen s in he 5 h, 7 h, and 9 h g ades in 2018 (N = 3498) and 2022 (N = 3838), as pa o he Heal h Beha iou in School-aged Child en (HBSC) s udy. The HBSC s udy is ca ied ou in collabo a ion wi h he Wo ld Heal h O ganiza ion (WHO) Regional O ice o Eu ope. Samples we e d awn using a clus e sampling me hod, wi h schools as he p ima y sampling uni . The sampling was adjus ed o p o ince, municipali y, and school size. The collec ion o da a ollowed he p o o- col o he in e na ional HBSC s udy, ensu ing esponsi- ble conduc o esea ch [59]. The esponden s answe ed he online su eys du ing he school day in he sp ing semes e . Pa icipa ion was olun a y and no pe sonally iden i iable in o ma ion was collec ed. The su eys we e app o ed by he E hical Commi ee o he Uni e si y o Jy askyla. Measu es Table 1 p esen s he s udy a iables. Men al heal h indica o s we e psychological complain s, soma ic complain s, li e sa is ac ion, pe cei ed loneliness, and p oblema ic social media use. In o ma ion on socio- demog aphic cha ac e is ics (immig an backg ound, amily a luence, amily s uc u e, u ban/ u al esidence), psychosocial ac o s (pe cei ed social suppo , pe cei ed home a mosphe e, pa en al moni o ing, pe cep ions o school clima e, in ensi y o online communica ion), educa ional expec a ions, heal h li e acy, and sel - a ed heal h was also collec ed. The adolescen s also epo ed hei gende (1 = Boy, 2 = Gi l). G ade le el consis ed o he ollowing ca ego ies: 1 = 5 h g ade (age M = 11.39 in Sample 1/11.38 in Sample 2), 2 = 7 h g ade (age M = 13.37 in Sample 1/13.52 in Sample 2), and 3 = 9 h g ade (age M = 15.33 in Sample 1/15.37 in Sample 2). The language o ins uc ion, which pa ly se ed as an indica- o o g oup s a us, was based on he eaching language o he schools (1 = Finnish, 2 = Swedish), as Finland is a bilingual coun y wi h wo o icial languages, Finnish being he mo he ongue o he majo i y and Swedish ha o he linguis ic mino i y. A de ailed desc ip ion o he ins umen s o he HBSC su ey can be ound in he HBSC S udy P o ocol by Inchley e al. [59]. S a is ical analysis Di e ences be ween he key a iables in Samples 1 and 2 we e analyzed using Chi-squa e es s and independen - es s, wi h Bon e oni-co ec ed p- alues o mul iple es ing. Co ela ions we e calcula ed using Spea man’s ank co ela ion, and di e ences be ween he co ela- ions o samples we e compa ed using Fishe - o-z ans o ma ions. Men al heal h p o iles, based on i e indica o s (i.e., psychological complain s, soma ic com- plain s, li e sa is ac ion, pe cei ed loneliness, and p ob- lema ic social media use), we e iden i ied sepa a ely o Samples 1 and 2 using he SPSS TwoS ep Clus e ing algo i hm. This explo a o y me hod iden i ies subg oups o adolescen s based on simila i ies in hei cha ac e - is ics. The numbe o clus e s we e allowed o be au o- ma ically es ima ed by he analysis me hod on he basis o he Bayesian in o ma ion c i e ion (BIC), and a ious ixed numbe s o clus e s we e also es ed. Missing da a we e handled using lis wise dele ion, and di e ences in socio-demog aphic cha ac e is ics be ween included and excluded cases we e examined u he using Chi-squa e es , analysis o a iance (ANOVA), pos -hoc ANOVA analysis wi h Bon e oni co ec ion, and Gene alized lin- ea mixed models wi h mul inomial logis ic eg ession. The inal clus e solu ion was de e mined on he basis o clus e quali y (silhoue e coe icien ), size, and in e - p e abili y. The Chi-squa e es , ANOVA, and pos -hoc ANOVA analysis wi h Bon e oni co ec ion we e used o compa e he clus e s. The clus e s we e named on he basis o he in e p e a ion o he mos no able cha ac e - is ics ha made up he p o iles. Gene alized linea mixed models wi h mul inomial logis ic eg ession we e pe o med sepa a ely o he wo samples, o assess he associa ions be ween independ- en a iables and men al heal h p o iles, using he “Good men al heal h” p o ile as he e e ence ca ego y. A mul i- le el analysis wi h “school” included as a andom e ec was chosen on he basis o he s uc u e o he da a, as he adolescen s we e nes ed wi hin schools. No mul icol- linea i y was de ec ed among he independen a iables (Va iance In la ion Fac o (VIF) < 2 in bo h samples). Page 5 o 33 Gus a ssone al. Child and Adolescen Psychia y and Men al Heal h (2023) 17:54 Table 1 Measu es used in he s udy Va iable and i ems Response op ions Coding Scale used/adap ed om C onbach’s alpha Sample 1 Sample 2 Men al heal h indica o s Psychological complain s How o en ha e you expe ienced hese symp oms o e he las six mon hs? Abou e e y day Mo e han once a week Abou e e y week Abou e e y mon h Ra ely o ne e Numbe o complain s (1 = 0, 2 = 1–2, 3 = 3–4) expe ienced wice a week o mo e o en HBSC symp oms checklis [60]. The meas‑ u e has p o en alidi y [60]0.83 0.82 Soma ic complain s How o en ha e you expe ienced hese symp oms o e he las six mon hs? Abou e e y day Mo e han once a week Abou e e y week Abou e e y mon h Ra ely o ne e Numbe o complain s (1 = 0, 2 = 1–2, 3 = 3–4) expe ienced wice a week o mo e o en HBSC symp oms checklis [60]. The meas‑ u e has p o en alidi y [60]0.75 0.76 Li e sa is ac ion Adolescen s we e asked o a e how sa is ied hey we e wi h hei li es on a isual scale 10 The bes possible li e—0 The wo s possible li e The scale was e e sed and used as a con inuous scale (0–10) Can il ladde [61]. The measu e has shown good es – e es eliabili y and con e gen alidi y [62] Pe cei ed loneliness Do you e e eel lonely? (Sample 1) Yes, e y o en Yes, qui e o en Some imes No 1 = Low loneliness (No / Some imes), 2 = High loneliness (Yes, qui e o en / Yes, e y o en) How o en ha e you el lonely du ing he las 12 mon hs? (Sample 2) Ne e Ra ely Some imes Mos o he ime Always 1 = Low loneliness (Ne e / Ra ely / Some imes), 2 = High loneliness (Mos o he ime /Always) Page 6 o 33 Gus a ssone al. Child and Adolescen Psychia y and Men al Heal h (2023) 17:54 Table 1 (con inued) Va iable and i ems Response op ions Coding Scale used/adap ed om C onbach’s alpha Sample 1 Sample 2 P oblema ic social media use Du ing he pas yea , ha e you No Yes All yes‑ esponses we e summed ( ange 0–9) and ecoded in o h ee g oups: no ma i e use s (0 o 1 yes‑ esponses), isky use s (2 o 5 yes‑ esponses), and p oblema ic use s (6 o 9 yes‑ esponses) [30, 63] Social Media Diso de Scale [26]. The measu e has p o en alidi y [63]0.82 0.82 Regula ly no iced ha you can only hink abou he momen ha you will be able o use social media again? Regula ly el dissa is ied because you wan ed o spend mo e ime on social media? O en been in a bad mood because you couldn’ use social media? T ied o spend less ime on social media bu ailed? Regula ly neglec ed doing o he hings (e.g., hobbies, spo s) because you wan ed o use social media? Regula ly a gued wi h o he s abou you own social media usage? Regula ly lied o you pa en s o iends abou how much ime you spend on social media? O en used social media o escape om unpleasan eelings? Ac ually ough wi h you pa en s o siblings because o you social media usage? Psychosocial ac o s Pe cei ed home a mosphe e How would you a e he a mos‑ phe e in you home? Ve y good Qui e good Nei he good no bad Qui e bad Ve y bad The scale was e e sed and used as a con inuous a iable Simonsen e al. [64]; Suominen e al. [65] Pa en al moni o ing Ma e nal moni o ing (6 i ems)aB own [66] 0.86 0.86 Page 7 o 33 Gus a ssone al. Child and Adolescen Psychia y and Men al Heal h (2023) 17:54 Table 1 (con inued) Va iable and i ems Response op ions Coding Scale used/adap ed om C onbach’s alpha Sample 1 Sample 2 Pa e nal moni o ing (6 i ems)aB own [66] 0.89 0.90 How much does you mo he / a he eally know abou She/he knows a lo She/he knows some hing She/he knows no hing I ha e no mo he , o I do no see he I ha e no a he , o I do no see him The las wo esponse op ions we e omi ‑ ed. Mean sco es we e calcula ed o bo h subscales Who you iends a e How you spend you money Whe e you spend you ime a e school Whe e you a e in he e enings Wha you do in you ee ime Wha you do on he in e ne Family suppo My amily eally ies o help me Ve y s ongly disag ee (1)—Ve y s ongly ag ee (7) I ems we e compu ed in o a mean sco e Mul i‑dimensional Scale o Pe cei ed Social Suppo [67]. The measu e has p o en alidi y [68] 0.97 0.96 I ge he help and emo ional sup‑ po I need om my amily I can alk abou my p oblems wi h my amily My amily is willing o help me in decision‑making Pee suppo My iends eally y o help me Ve y s ongly disag ee (1)— Ve y s ongly ag ee (7) I ems we e compu ed in o a mean sco e Mul i‑dimensional Scale o Pe cei ed Social Suppo [67]. The measu e has p o en alidi y [68] 0.96 0.96 I can coun on my iends when some hing goes w ong I ha e iends wi h whom I can sha e my joys and so ows I can alk abou my p oblems wi h my iends Page 8 o 33 Gus a ssone al. Child and Adolescen Psychia y and Men al Heal h (2023) 17:54 Table 1 (con inued) Va iable and i ems Response op ions Coding Scale used/adap ed om C onbach’s alpha Sample 1 Sample 2 Teache suppo I eel ha my eache s accep me as I am Comple ely ag ee Ag ee Nei he ag ee no disag ee Disag ee Comple ely disag ee I ems we e e e sed and compu ed in o a mean sco e Teache and Classma e Suppo Scale [69]. The measu e has p o en alidi y [70]0.87 0.88 I eel ha my eache s ca e abou me as a pe son I us my eache s a lo Classma e suppo The pupils in my class ge on well wi h each o he Comple ely ag ee Ag ee Nei he ag ee no disag ee Disag ee Comple ely disag ee I ems we e e e sed and compu ed in o a mean sco e Teache and Classma e Suppo Scale [69]. The measu e has p o en alidi y [70]0.81 0.84 Mos pupils in my class a e kind and help ul O he pupils accep me he way I am School clima e I eel sa e in his school Comple ely ag ee Ag ee Nei he ag ee no disag ee Disag ee Comple ely disag ee I ems we e e e sed and compu ed in o a mean sco e The School Clima e Index [71] 0.81 0.86 I eel like I belong in his school In ensi y o online communica ion How o en do you in e ac wi h he ollowing people ia he in e ne ? I don’ know/Doesn’ conce n me Ne e o ha dly e e A leas e e y week Daily o almos daily Se e al imes a day Almos all he ime The i s esponse op ion was omi ed. Following p e ious esea ch [72, 73], all i ems we e calcula ed in o a mean sco e EU Kids Online Su ey [74] 0.71 0.74 Close iend(s) F iends om a la ge iend g oup People ha you ha e me on he in e ne O he people (e.g., pa en s, siblings, classma es, eache s) Page 15 o 33 Gus a ssone al. Child and Adolescen Psychia y and Men al Heal h (2023) 17:54 In his sample (n = 2981), ou p o iles we e obse ed: (1) “Good men al heal h” (37%, n = 1103), (2) “Mixed psy- chosoma ic heal h” (17%, n = 499), 3) “Poo men al heal h and low loneliness” (34%, n = 1011), and 4) “Poo men al heal h and high loneliness” (12%, n = 368). The silhoue e coe icien was 0.40, indica ing ai clus e quali y. No a- bly, he dis ibu ion o men al heal h indica o s in he di e en p o iles was qui e simila o one p o ile in bo h samples (i.e., “Good men al heal h”). Howe e , he p o- po ion o adolescen s belonging o his p o ile di e ed in he wo samples, wi h ewe adolescen s belonging o his p o ile in Sample 2 (2022) han in Sample 1 (2018) (p = 0.001). Adolescen s in he “Good men al heal h” p o ile epo ed low p e alence o psychological and soma ic complain s. The mean alue o li e sa is ac ion (M = 8.19) was he highes in his p o ile, and all adolescen s epo ed low loneliness (100%). The majo i y we e no - ma i e social media use s (71%). In he “Mixed psychosoma ic heal h” p o ile, he majo - i y expe ienced one o wo equen psychological (72%) o soma ic complain s (56%). Thei mean alue o li e sa is ac ion (M = 7.77) was mode a e, and all he adoles- cen s epo ed low loneliness (100%). This was he only p o ile in which all he adolescen s we e no ma i e social media use s (100%). In he “Poo men al heal h and low loneliness” p o ile, mos adolescen s epo ed expe iencing one o wo (46%) o h ee o ou (41%) equen psychological complain s. Almos 60 pe cen expe ienced a leas one o wo soma ic complain s equen ly. The mean alue o li e sa - is ac ion (M = 7.07) was low. All he adolescen s epo ed low loneliness (100%). This p o ile had he highes pe - cen age o isky social media use s (66%), and oughly one i h we e p oblema ic social media use s (22%). Table 2 (con inued) Sample 1 (2018), N = 3498 Sample 2 (2022), N = 3838 Signi icance % (n)/M (SD) % (n)/M (SD) O he heal h‑ ela ed ac o s Academic educa ional expec a ionsc ( s. oca ional) 64.71 (704) 58.47 (518) χ2= 8.07, p =0.005 Heal h li e acybχ2= 15.00, p = 0.005 Low 10.2 (238) 8.8 (208) p > 0.05d Mode a e 55.5 (1301) 61.1 (1446) p <0.001d High 34.3 (805) 30.2 (714) p = 0.002d Sel ‑ a ed heal h x= 31.36, p < 0.001 Poo 2.4 (84) 2.1 (79) p > 0.05d Fai 13.9 (479) 12.9 (487) p > 0.05d Good 60.1 (2074) 55.7 (2106) p < 0.001d Excellen 23.6 (813) 29.4 (1111) p < 0.001d Chi-squa e es o pe cen age compa ison and independen - es o mean compa ison. Sco es anged om 10 o 19 o age, 0 o 10 o li e sa is ac ion, 1 o 5 o home a mosphe e, 1 o 3 o pa en al moni o ing, 1 o 7 o amily and pee suppo , 1 o 5 o eache and classma e suppo , 1 o 5 o school clima e, and 1 o 5 o in ensi y o online communica ion.Bold alues deno e s a is ical signi icance a Numbe o complain s expe ienced mo e han once a week b Only assessed among 7 h and 9 h g ade adolescen s (sample 1, n = 2457, sample 2, n = 2406) c Only assessed among 9 h g ade adolescen s (sample 1, n = 1176, sample 2, n = 993) d Bon e oni-co ec ed p- alues o mul iple es ing Table 3 Co ela ions o men al heal h indica o s in bo h samples Spea man’s ank co ela ion a Highe alues indica e poo e men al heal h b Highe alues indica e highe li e sa is ac ion ** p < 0.001 1234 Sample 1 (2018) 1 Psychological complain sa– 2 Soma ic complain sa0.45** – 3 Li e sa is ac ionb− 0.40** − 0.26** – 4 Pe cei ed lonelinessa0.37** 0.22** − 0.33** – 5 P oblema ic social media usea0.26** 0.18** − 0.22** 0.17** Sample 2 (2022) 1 Psychological complain sa– 2 Soma ic complain sa0.51** – 3 Li e sa is ac ionb− 0.46** − 0.33** – 4 Pe cei ed lonelinessa0.31** 0.25** − 0.32** – 5 P oblema ic social media usea0.33** 0.23** − 0.28** 0.19** Page 16 o 33 Gus a ssone al. Child and Adolescen Psychia y and Men al Heal h (2023) 17:54 The “Poo men al heal h and high loneliness” p o ile was he only p o ile wi h adolescen s who epo ed high loneliness (99%) in Sample 2. This p o ile had he high- es pe cen age o adolescen s epo ing h ee o ou e- quen psychological (59%) o soma ic complain s (25%). The mean alue o li e sa is ac ion (M = 5.74) was he lowes in his p o ile. The majo i y we e isky (52%) o p oblema ic (20%) social media use s. Socio‑demog aphic desc ip ion o men al heal h p o iles Tables 6, 7 p esen desc ip i e esul s om he Chi- squa e es and pos hoc ANOVA, showing he cha ac- e is ics o adolescen s in each p o ile. The “Good men al heal h” p o ile in bo h samples con ained mo e boys han gi ls, whe eas he o he h ee p o iles con ained mo e gi ls han boys. The “Soma ically challenged” p o ile in Sample 1, and he “Poo men al heal h and low lone- liness” and “Mixed psychosoma ic heal h” p o iles in Sample 2 had a highe p opo ion o adolescen s whose language o ins uc ion was Swedish han he “Good men al heal h” p o iles. The “Poo men al heal h” p o ile in Sample 1 and he “Poo men al heal h and high lone- liness” p o ile in Sample 2 had a highe p opo ion o i s -gene a ion immig an s and adolescen s li ing in a single-pa en amily o a s ep amily han he “Good men- al heal h” p o iles. Fac o s associa ed wi hmen al heal h p o iles Table8 p esen s he esul s om he mixed e ec mul i- nomial logis ic eg ession analysis, showing associa ions be ween socio-demog aphic cha ac e is ics, psychoso- cial ac o s, educa ional expec a ions, heal h li e acy, sel - a ed heal h, and men al heal h p o iles, showing he “Good men al heal h” p o ile as he e e ence ca ego y in bo h samples. Table 4 Men al heal h p o iles in sample 1 (2018) Chi-squa e es o pe cen age compa ison and Pos -hoc ANOVA o mean compa ison ( wo- ailed) a Numbe o complain s expe ienced mo e han once a week b P o iles di e ed signi ican ly (p <0.001) using Bon e oni-co ec ed pai wise compa isons c P o iles di e ed signi ican ly (p = 0.042) using Bon e oni-co ec ed pai wise compa isons All P o ile 1 P o ile2 P o ile 3 P o ile 4 P o ile compa ison n = 3149 “Good men al heal h” (43.7%, n = 1375) “Mixed psychosocial heal h” (19.9%, n = 628) “Soma ically challenged” (15.0%, n = 471) “Poo men al heal h” (21.4%, n = 675) O e all p‑ alue Pai wise compa ison %/M (SD) %/M (SD) %/M (SD) %/M (SD) %/M (SD) χ2/F Sample 1 (2018) Men al heal h indica o s Psychological complain sa2747.51 < 0.001 0 57.5 100.0 8.1 49.0 22.8 All p o iles di e b 1–2 27.7 74.4 51.0 24.4 2, 3, 4 di e b 3–4 14.8 17.5 52.7 2, 4 di e b Soma ic complain sa2919.90 < 0.001 0 69.5 100.0 100.0 27.3 1 = 2, 4 di e sb 1–2 26.5 100.0 53.8 3, 4 di e b 3–4 4.1 19.0 Li e sa is ac ion 7.74 (1.77) 8.44 (1.15) 7.48 (1.59) 7.92 (1.28) 6.42 (2.37) 251.64 < 0.001 All p o iles di e b High loneliness ( s. low) 14.5 0.0 26.4 0.0 43.0 827.20 < 0.001 1 = 3, 2b, 4 di e b P oblema ic social media use 1363.10 < 0.001 No ma i e use 56.1 72.4 55.6 58.2 21.8 2 = 3, o he s di e b Risky use 34.3 27.6 44.4 41.8 33.3 2 = 3, o he s di e c P oblema ic use 9.6 44.9 Page 17 o 33 Gus a ssone al. Child and Adolescen Psychia y and Men al Heal h (2023) 17:54 Sample 1 (2018) A e adjus men o all a iables (model adjus ed b–d), in 2018, adolescen s belonging o any o he o he h ee p o iles han he “Good men al heal h” p o ile we e mo e likely o be gi ls, and o epo a highe in ensi y o online communica ion. In addi ion, hey we e less likely o epo excellen sel - a ed heal h han poo sel - a ed heal h. Those belonging o he “Mixed psychosocial heal h” p o ile we e also mo e likely o epo lowe ma e nal moni o ing, lowe pee suppo , and a less posi i e home a mosphe e and school clima e, and o ha e academic educa ional expec a ions, and we e less likely o li e in an u ban esidence han hose in he “Good men al heal h” p o ile. Those belonging o he “Soma ically challenged” p o- ile we e also mo e likely o be in he 7 h g ade, o ha e Swedish as opposed o Finnish as hei language o ins uc ion, and o epo highe pee suppo and lowe classma e suppo , and we e less likely o epo medium amily a luence han low amily a luence han hose in he “Good men al heal h” p o ile. Those belonging o he “Poo men al heal h” p o ile we e mo e likely o epo lowe ma e nal moni o ing, lowe amily suppo , lowe eache suppo , and a less posi i e home a mosphe e and school clima e, and we e less likely o li e in an u ban esidence han hose in he “Good men al heal h” p o ile. A e adjus men o all a iables, amily s uc u e, immig an backg ound, pa e nal moni o ing and heal h li e acy we e no associa ed wi h p o ile membe ship (p > 0.05). Fo he school-le el a iance in he models, see Addi- ional ile1: TableS4. Table 5 Men al heal h p o iles in Sample 2 (2022) Chi-squa e es o pe cen age compa ison and Pos -hoc ANOVA o mean compa ison ( wo- ailed) a Numbe o complain s expe ienced mo e han once a week b P o iles di e ed signi ican ly (p < 0.001) using Bon e oni-co ec ed pai wise compa isons c P o iles di e ed signi ican ly (p = 0.015) using Bon e oni-co ec ed pai wise compa isons d P o iles di e ed signi ican ly (p = 0.004) using Bon e oni-co ec ed pai wise compa isons All P o ile 1 P o ile 2 P o ile 3 P o ile 4 P o ile compa ison n = 2981 “Good men al heal h” (37.0%, n = 1103) “Mixed psychosoma ic heal h” (16.7%, n = 499) “Poo men al heal hand low loneliness” (33.9%, n = 1011) “Poo men al heal h and high loneliness” (12.3%, n = 368) O e all p‑ alue Pai wise compa ison %/M (SD) %/M (SD) %/M (SD) %/M (SD) %/M (SD) χ2/F Sample 2 (2022) Men al heal h indica o s Psychological complain sa2453.62 < 0.001 0 48.1 100.0 27.7 13.9 14.1 3 = 4, o he s di e b 1–2 30.9 72.3 45.5 27.2 2, 3, 4 di e b 3–4 21.0 40.6 58.7 3, 4 di e b Soma ic complain sa1264.00 < 0.001 0 62.1 100.0 44.3 40.4 32.1 2 = 3, o he s di e c 1–2 30.6 55.7 46.9 43.5 3 = 4, 2 di e sd 3–4 7.3 12.8 24.5 3, 4 di e b Li e sa is ac ion 7.44 (1.66) 8.19 (1.00) 7.77 (1.32) 7.07 (1.58) 5.74 (2.24) 293.31 < 0.001 All p o iles di e b High loneliness ( s. low) 12.2 0.0 0.0 0.0 98.9 2944.09 < 0.001 1 = 2 = 3, 4 di e sb P oblema ic social media use 1437.46 < 0.001 No ma i e use 50.2 70.5 100.0 11.8 27.4 All p o iles di e b Risky use 39.9 29.5 66.4 52.4 All p o iles di e b P oblema ic use 9.9 21.9 20.1 3 = 4 Page 18 o 33 Gus a ssone al. Child and Adolescen Psychia y and Men al Heal h (2023) 17:54 Sample 2 (2022) A e adjus men o all a iables (model adjus ed b–d), in 2022, adolescen s belonging o any o he o he h ee p o iles han he “Good men al heal h” p o ile we e mo e likely o be gi ls, and o epo lowe eache suppo . Those belonging o he “Mixed psychosoma ic heal h” p o ile we e also mo e likely o ha e Swedish as hei a numbe o complain s expe ienced mo e han once a week. Sample 2 (2022)Sample 1 (2018) Psychological complain s a 0 Somac complain s a 0 Pe cei ed loneliness Low P oblemac social media use No ma e use Risky use Li e sas acon “Good men al heal h” (P o ile 1) Psychological complain s a 0 1-2 Somac complain s a 1-2 Pe cei ed loneliness Low P oblemac social media use No ma e use Risky use Li e sas acon “Poo men al heal h” (P o ile 4) Psychological complain s a 0 1-2 3-4 Somac complain s a 0 1-2 3-4 Pe cei ed loneliness Low High P oblemac social media use No ma e use Risky use P oblemac use Li e sas acon “Poo men al heal h and high loneliness” (P o ile 4) Psychological complain sa 0 Somac complain s a 0 Pe cei ed loneliness Low P oblemac social media use No ma e use Risky use Li e sas acon Psychological complain s a 0 1-2 Somac complain s a 0 1-2 Pe cei ed loneliness Low P oblemac social media use No ma e use Li e sas acon Li e sas acon Li e sas acon Psychological complain s a 0 1-2 3-4 Psychological complain s a 0 1-2 3-4 Somac complain s a 0 1-2 3-4 Somac complain s a 0 1-2 3-4 Pe cei ed loneliness Low Pe cei ed loneliness Low High P oblemac social media use No ma e use Risky use P oblemac use P oblemac social media use No ma e use Risky use P oblemac use “Poo men al heal h and low loneliness” (P o ile 3) “Mixed psychosomac heal h” (P o ile 2) “Good men al heal h” (P o ile 1) “Somacally challenged” (P o ile 3) “Mixed psychosocial heal h” (P o ile 2) Psychological complain s a 0 1-2 3-4 Somac complain s a 0 Pe cei ed loneliness Low High P oblemac social media use No ma e use Risky use Li e sas acon Fig. 1 S acked ba plo s and box plo s showing dis ibu ion o men al heal h indica o s in each p o ile in bo h samples Page 19 o 33 Gus a ssone al. Child and Adolescen Psychia y and Men al Heal h (2023) 17:54 Table 6 Di e ences be ween p o iles in e ms o socio‑demog aphic, psychosocial, and o he heal h‑ ela ed ac o s in Sample 1 (2018) All P o ile 1 P o ile 2 P o ile 3 P o ile 4 P o ile compa ison n = 974– 3149 “Good men al heal h” (n = 386– 1375) “Mixed psychosocial heal h” (n = 195– 628) “Soma ically challenged” (n = 148–471) “Poo men al heal h” (n = 245– 675) O e all p‑ alue Pai wise compa ison %/M (SD)%/M (SD) %/M (SD) %/M (SD) %/M (SD) χ2/F Sample 1 (2018) Socio‑demog aphic cha ac e is ics Gende , emale ( s. male) 51.2 39.7 56.1 58.6 65.1 140.79 < 0.001 1 and 2c, 1 and 3c, 1 and 4c, 2 and 4d di e G ade 48.46 < 0.001 5 h 30.4 35.9 30.4 25.1 23.0 1 and 3c, 1 and 4c, 2 and 4e di e 7 h 36.5 34.4 36.8 41.0 37.5 No di e ences 9 h 33.1 29.7 32.8 34.0 39.6 1 and 4c di e Language o ins uc‑ ion, Swedish ( s. Finnish) 19.4 16.9 21.5 24.2 19.3 14.00 0.003 1 and 3c di e Rela i e amily a luence 20.83 0.002 Low 17.1 15.6 19.1 18.3 17.8 No di e ences Medium 57.0 60.9 55.4 50.5 54.8 1 and 3c, 1 and 4e di e High 25.9 23.5 25.5 31.2 27.4 1 and 3d di e Family s uc u e 36.14 < 0.001 Nuclea amily 74.7 79.2 73.5 73.4 67.2 1 and 2e, 1 and 4c di e Single‑pa en amily 13.4 11.0 14.8 13.2 17.2 1 and 4c di e S ep‑ amily 11.9 9.7 11.7 13.4 15.6 1 and 4c di e U ban esidence ( s. u al) 54.9 59.4 50.7 51.7 51.9 19.93 < 0.001 1 and 2d, 1 and 3e, 1 and 4d di e Immig an back‑ g ound 18.62 0.005 Fi s ‑gene a ion immig an 4.3 3.3 3.1 4.7 7.0 1 and 4c, 2 and 4e di e Second‑gene a‑ ion immig an 7.1 7.1 6.5 7.5 7.2 No di e ences Na i e (non‑ immig an ) 88.7 89.6 90.5 87.7 85.8 No di e ences Psychosocial ac o s Pe cei ed home a mosphe e 4.32 (0.78) 4.55 (0.59) 4.23 (0.73) 4.40 (0.67) 3.90 (0.99) 122.94 < 0.001 All p o iles di e c Pa en al moni o inga Ma e nal moni‑ o ing 2.44 (0.45) 2.53 (0.40) 2.41 (0.44) 2.48 (0.42) 2.28 (0.50) 36.07 < 0.001 1 and 2c, 1 and 4c, 2 and 4c, 3 and 4c di e Pa e nal moni o ‑ ing 2.24 (0.53) 2.36 (0.50) 2.23 (0.52) 2.24 (0.51) 2.04 (0.56) 37.07 < 0.001 1 and 2c, 1 and 3d, 1 and 4c, 2 and 4c, 3 and 4c di e Family suppo 5.70 (1.63) 6.05 (1.53) 5.57 (1.52) 5.89 (1.40) 4.99 (1.83) 71.63 < 0.001 1 and 2c, 1 and 4c, 2 and 3d, 2 and 4c, 3 and 4c di e Page 20 o 33 Gus a ssone al. Child and Adolescen Psychia y and Men al Heal h (2023) 17:54 Chi-squa e es o pe cen age compa ison and Pos -hoc ANOVA o mean compa ison ( wo- ailed) a Answe ed only by 7 h and 9 h g ade adolescen s (n = 2191) b Answe ed only by 9 h g ade adolescen s (n = 1041) c P o iles di e ed signi ican ly (p < 0.001) when Bon e oni-co ec ed pai wise compa isons we e used d P o iles di e ed signi ican ly (p < 0.01) when Bon e oni-co ec ed pai wise compa isons we e used e P o iles di e ed signi ican ly (p < 0.05) when Bon e oni-co ec ed pai wise compa isons we e used Table 6 (con inued) All P o ile 1 P o ile 2 P o ile 3 P o ile 4 P o ile compa ison n = 974– 3149 “Good men al heal h” (n = 386– 1375) “Mixed psychosocial heal h” (n = 195– 628) “Soma ically challenged” (n = 148–471) “Poo men al heal h” (n = 245– 675) O e all p‑ alue Pai wise compa ison %/M (SD)%/M (SD) %/M (SD) %/M (SD) %/M (SD) χ2/F Pee suppo 5.47 (1.64) 5.63 (1.55) 5.23 (1.67) 5.78 (1.40) 5.14 (1.85) 24.20 < 0.001 1 and 2c, 1 and 4c, 2 and 3c, 3 and 4c di e Teache suppo 3.85 (0.93) 4.11 (0.77) 3.81 (0.89) 3.85 (0.88) 3.37 (1.10) 105.28 < 0.001 1 and 2c, 1 and 3c, 1 and 4c, 2 and 4c, 3 and 4c di e Classma e suppo 3.90 (0.77) 4.09 (0.65) 3.79 (0.76) 3.87 (0.71) 3.62 (0.92) 66.89 < 0.001 1 and 4c, 1 and 2c, 1 and 3c, 2 and 4c, 3 and 4c di e Pe cei ed school clima e 4.15 (0.86) 4.43 (0.67) 4.04 (0.85) 4.19 (0.71) 3.66 (1.06) 140.30 < 0.001 1 and 2c, 1 and 3c, 1 and 4c, 2 and 3e, 2 and 4c, 3 and 4c di e In ensi y o online communi‑ ca ion 3.02 (0.85) 2.92 (0.79) 2.97 (0.85) 3.08 (0.80) 3.22 (0.96) 19.64 < 0.001 1 and 2d, 1 and 4c, 2 and 4c, 3 and 4e di e O he heal h‑ ela ed ac o s Academic educa‑ ional expec a ionsb ( s. oca ional) 67.2 65.5 75.4 71.6 60.8 12.26 0.007 2 and 4d di e Heal h li e acya96.91 < 0.001 Low 9.2 5.7 8.0 7.1 17.6 1 and 4c, 2 and 4c, 3 and 4c di e Mode a e 56.2 52.0 64.4 55.1 57.1 1 and 2c di e High 34.6 42.3 27.6 37.8 25.3 1 and 2c, 1 and 4c, 2 and 3e, 3 and 4d di e Sel ‑ a ed heal h 412.48 < 0.001 Poo 2.2 0.2 1.1 1.3 7.9 1 and 2e, 1 and 3e, 1 and 4c, 2 and 4c, 3 and 4c di e Fai 14.0 6.4 17.0 12.3 27.9 1 and 2c, 1 and 3c, 1 and 4c, 2 and 4c, 3 and 4c di e Good 60.5 59.8 66.0 68.2 51.5 1 and 3d, 1 and 4d, 2 and 4c, 3 and 4c di e Excellen 23.3 33.5 15.9 18.3 12.8 1 and 2c, 1 and 3c, 1 and 4c di e Page 21 o 33 Gus a ssone al. Child and Adolescen Psychia y and Men al Heal h (2023) 17:54 Table 7 Di e ences be ween p o iles in e ms o socio‑demog aphic, psychosocial, and o he heal h‑ ela ed ac o s in Sample 2 (2022) All P o ile 1 P o ile 2 P o ile 3 P o ile 4 P o ile compa ison n = 738–2981 “Good men al heal h” (n = 232– 1103) “Mixed psychosoma ic heal h” (n = 124–499) “Poo men al heal h and low loneliness” (n = 254–1011) “Poo men al heal h and high loneliness” (n = 128–368) O e all p‑ alue Pai wise compa ison %/M (SD) %/M (SD) %/M (SD) %/M (SD) %/M (SD) χ2/F Sample 2 (2022) Socio‑demog aphic cha ac e is ics Gende , emale ( s. male) 54.7 39.6 51.6 65.3 75.3 209.56 < 0.001 1 and 2c, 1 and 3c, 1 and 4c, 2 and 3c, 2 and 4c, 3 and 4d di e G ade 85.70 < 0.001 5 h 36.7 44.3 40.5 32.0 21.2 1 and 3c, 1 and 4c, 2 and 3d, 2 and 4c, 3 and 4d di e 7 h 36.2 33.2 32.5 39.7 40.5 1 and 3e, 2 and 3e di e 9 h 27.2 22.5 27.1 28.3 38.3 1 and 3e, 1 and 4c, 2 and 4d, 3 and 4d di e Language o ins uc‑ ion, Swedish ( s. Finnish) 35.3 30.3 39.7 40.4 30.2 31.94 < 0.001 1 and 2d, 1 and 3c, 2 and 4e, 3 and 4d di e Rela i e amily a lu‑ ence 22.76 < 0.001 Low 16.8 17.8 14.0 14.8 23.4 2 and 4d, 3 and 4d di e Medium 56.4 57.4 59.1 55.4 52.2 No di e ences High 26.8 24.8 26.9 29.8 24.5 No di e ences Family s uc u e 40.23 < 0.001 Nuclea amily 69.6 73.9 72.8 67.4 58.2 1 and 3d, 1 and 4c, 2 and 4c, 3 and 4e di e Single‑pa en amily 20.4 18.8 15.8 21.8 27.7 1 and 4d, 2 and 3e, 2 and 4c di e S ep‑ amily 10.0 7.3 11.4 10.8 14.0 1 and 3e, 1 and 4d di e U ban esidence ( s. u al) 57.2 57.8 53.1 57.7 59.8 4.62 0.202 No di e ences Immig an back‑ g ound 37.01 < 0.001 Fi s ‑gene a ion immig an 3.4 3.0 3.7 2.5 6.5 1 and 4e, 3 and 4d di e Second‑gene a ion immig an 6.3 6.0 3.9 6.1 11.6 1 and 4d, 2 and 4c, 3 and 4d di e Na i e (non‑immi‑ g an ) 90.3 91.1 92.4 91.5 81.9 1 and 4c, 2 and 4c, 3 and 4c di e Psychosocial ac o s Pe cei ed home a mosphe e 4.28 (0.80) 4.57 (0.59) 4.45 (0.65) 4.11 (0.80) 3.69 (1.05) 156.82 < 0.001 1 and 2e, 1 and 3c, 1 and 4c, 2 and 3c, 2 and 4c, 3 and 4 c di e Pa en al moni o inga Ma e nal moni‑ o ing 2.49 (0.44) 2.59 (0.39) 2.56 (0.40) 2.39 (0.44) 2.31 (0.51) 63.09 < 0.001 1 and 3c, 1 and 4c, 2 and 3c, 2 and 4c, 3 and 4e di e Pa e nal moni o ‑ ing 2.30 (0.55) 2.45 (0.50) 2.41 (0.49) 2.18 (0.54) 1.99 (0.62) 86.44 < 0.001 1 and 3c, 1 and 4c, 2 and 3c, 2 and 4c, 3 and 4c di e Page 22 o 33 Gus a ssone al. Child and Adolescen Psychia y and Men al Heal h (2023) 17:54 Chi-squa e es o pe cen age compa ison and Pos -hoc ANOVA o mean compa ison ( wo- ailed) a Answe ed only by 7 h and 9 h g ade adolescen s (n = 1888) b Answe ed only by 9 h g ade adolescen s (n = 810) c P o iles di e ed signi ican ly (p < 0.001) when Bon e oni-co ec ed pai wise compa isons we e used d P o iles di e ed signi ican ly (p < 0.01) when Bon e oni-co ec ed pai wise compa isons we e used e P o iles di e ed signi ican ly (p < 0.05) when Bon e oni-co ec ed pai wise compa isons we e used Table 7 (con inued) All P o ile 1 P o ile 2 P o ile 3 P o ile 4 P o ile compa ison n = 738–2981 “Good men al heal h” (n = 232– 1103) “Mixed psychosoma ic heal h” (n = 124–499) “Poo men al heal h and low loneliness” (n = 254–1011) “Poo men al heal h and high loneliness” (n = 128–368) O e all p‑ alue Pai wise compa ison %/M (SD) %/M (SD) %/M (SD) %/M (SD) %/M (SD) χ2/F Family suppo 5.54 (1.64) 6.07 (1.40) 5.80 (1.50) 5.31 (1.56) 4.24 (1.83) 144.41 < 0.001 1 and 2d, 1 and 3c, 1 and 4c, 2 and 3c, 2 and 4c, 3 and 4c di e Pee suppo 5.42 (1.63) 5.70 (1.47) 5.54 (1.56) 5.43 (1.55) 4.36 (1.95) 68.01 < 0.001 1 and 3c, 1 and 4c, 2 and 4c, 3 and 4c di e Teache suppo 3.93 (0.92) 4.24 (0.75) 3.96 (0.92) 3.81 (0.86) 3.26 (1.11) 124.80 < 0.001 1 and 2c, 1 and 3c, 1 and 4c, 2 and 3e, 2 and 4c, 3 and 4c di e Classma e suppo 3.76 (0.84) 4.02 (0.70) 3.88 (0.74) 3.64 (0.85) 3.14 (0.97) 121.72 < 0.001 1 and 2d, 1 and 3c, 1 and 4, 2 and 3c, 2 and 4c, 3 and 4c di e Pe cei ed school clima e 3.92 (0.94) 4.27 (0.74) 4.05 (0.83) 3.77 (0.91) 3.10 (1.13) 179.77 < 0.001 1 and 2c, 1 and 3c, 1 and 4c, 2 and 3c, 2 and 4c, 3 and 4c di e In ensi y o online communi‑ ca ion 3.03 (0.94) 2.93 (0.94) 3.04 (0.90) 3.14 (0.93) 2.98 (1.03) 8.31 < 0.001 1 and 3c di e O he heal h‑ ela ed ac o s Academic educa ional expec a ionsb ( s. oca ional) 62.9 69.0 62.9 61.0 55.5 7.07 0.070 No di e ences Heal h li e acya56.54 < 0.001 Low 8.0 4.2 4.0 9.1 17.3 1 and 3d, 1 and 4c, 2 and 3e, 2 and 4c, 3 and 4d di e Mode a e 62.2 63.4 62.0 63.0 58.1 No di e ences High 29.8 32.4 34.0 27.9 24.6 No di e ences Sel ‑ a ed heal h 355.37 < 0.001 Poo 1.9 0.4 0.8 2.3 7.1 1 and 3d, 1 and 4c, 2 and 4c, 3 and 4c di e Fai 13.9 5.2 8.4 19.8 31.3 1 and 3c, 1 and 4c, 2 and 3c, 2 and 4c, 3 and 4c di e Good 59.7 59.1 65.7 60.7 50.8 1 and 4e, 2 and 4c, 3 and 4d di e Excellen 24.5 35.4 25.1 17.2 10.9 1 and 2c, 1 and 3c, 1 and 4c, 2 and 3d, 2 and 4c, 3 and 4e di e Page 23 o 33 Gus a ssone al. Child and Adolescen Psychia y and Men al Heal h (2023) 17:54 Table 8 C ude and adjus ed OR be ween key a iables and men al heal h p o iles in Sample 1 (2018) and Sample 2 (2022) Va iable Sample 1 (2018) P o ile ( e e ence: p o ile 1—“Good men al heal h”) Sample 2 (2022) P o ile ( e e ence: p o ile 1— “Good men al heal h”) P o ile 2—“Mixed psychosocial heal h” P o ile 3—“Soma ically challenged” P o ile 4—“Poo men al heal h” P o ile 2—“Mixed psychosoma ic heal h” P o ile 3—“Poo men al heal h and low loneliness” P o ile 4—“Poo men al heal h and high loneliness” OR (CI 95%) p‑ alue OR (CI 95%) p‑ alue OR (CI 95%) p‑ alue OR (CI 95%) p‑ alue OR (CI 95%) p‑ alue OR (CI 95%) p‑ alue Socio‑demog aphic cha ac e is ics Gende , emale ( e . male) C ude 1.95 (1.61–2.36) <0.001 2.16 (1.74–2.67) <0.001 2.84 (2.34–3.45) < 0.001 1.64 (1.32–2.04) < 0.001 2.93 (2.44–3.51) < 0.001 4.49 (3.42–5.89) < 0.001 Adjus eda1.94 (1.59–2.36) < 0.001 2.11 (1.69–2.63) < 0.001 2.94 (2.40–3.57) < 0.001 1.61 (1.28–2.02) < 0.001 3.11 (2.56–3.77) < 0.001 5.69 (4.18–7.76) < 0.001 Adjus edb1.81 (1.45–2.27) < 0.001 1.82 (1.42–2.33) < 0.001 2.53 (1.98–3.25) < 0.001 1.46 (1.13–1.90) 0.004 2.49 (1.98–3.14) < 0.001 4.87 (3.25–7.28) <0.001 G ade ( e . 5) 7 h C ude 1.22 (0.96‑ 1.54) 0.108 1.71 (1.32–2.22) < 0.001 1.70 (1.33–2.16) < 0.001 1.08 (0.82–1.41) 0.600 1.56 (1.24–1.97) < 0.001 2.69 (1.91–3.79) < 0.001 Adjus eda1.21 (0.95–1.55) 0.127 1.67 (1.27–2.21) <0.001 1.58 (1.22–2.04) < 0.001 1.20 (0.90–1.60) 0.206 1.55 (1.21–1.99) < 0.001 2.86 (1.97–4.13) <0.001 Adjus edb0.89 (0.68–1.18) 0.428 1.39 (1.02–1.89) 0.036 0.84 (0.61–1.14) 0.254 1.06 (0.77–1.46) 0.730 1.18 (0.89–1.57) 0.246 1.79 (1.11–2.90) 0.017 9 h C ude 1.28 (1.01–1.63) 0.044 1.64 (1.25–2.15) < 0.001 2.08 (1.63–2.64) <0.001 1.32 (0.99–1.78) 0.062 1.62 (1.25–2.09) <0.001 3.65 (2.55–5.21) < 0.001 Adjus eda1.30 (1.01–1.67) 0.040 1.63 (1.22–2.16) <0.001 2.02 (1.56–2.60) < 0.001 1.35 (0.99–1.83) 0.056 1.58 (1.20–2.07) < 0.001 3.56 (2.42–5.23) <0.001 Adjus edb0.90 (0.68–1.20) 0.470 1.28 (0.93–1.76) 0.130 0.91 (0.67–1.23) 0.530 0.99 (0.70–1.40) 0.968 0.99 (0.73–1.34) 0.944 1.81 (1.10–2.98) 0.020 Language o ins uc ion, Swedish ( e . Finnish) C ude 1.30 (0.99–1.69) 0.056 1.57 (1.21–2.02) <0.001 1.10 (0.84–1.43) 0.495 1.52 (1.17–1.95) < 0.001 1.40 (1.11–1.77) 0.005 1.02 (0.71–1.47) 0.914 Adjus eda1.21 (0.90–1.63) 0.197 1.45 (1.09–1.93) 0.011 0.98 (0.73–1.32) 0.904 1.48 (1.11–1.96) 0.007 1.63 (1.27–2.11) <0.001 1.12 (0.78–1.60) 0.540 Adjus edb1.17 (0.84–1.61) 0.356 1.46 (1.06–2.01) 0.019 0.91 (0.65–1.29) 0.611 1.73 (1.27–2.35) <0.001 1.83 (1.39–2.41) < 0.001 1.20 (0.75–1.94) 0.447 Rela i e amily a luence ( e . low) Medium C ude 0.74 (0.57–0.95) 0.020 0.71 (0.53–0.94) 0.019 0.79 (0.61–1.02) 0.067 1.26 (0.93–1.72) 0.142 1.11 (0.87–1.43) 0.390 0.67 (0.49–0.91) 0.011 Adjus eda0.73 (0.55–0.96) 0.025 0.65 (0.48–0.89) 0.007 0.88 (0.66–1.17) 0.370 1.26 (0.90–1.77) 0.180 1.15 (0.87–1.52) 0.335 0.92 (0.63–1.34) 0.680 Adjus edb0.84 (0.62–1.13) 0.249 0.69 (0.50–0.96) 0.027 0.93 (0.67–1.30) 0.672 1.41 (0.95–2.08) 0.088 1.19 (0.86–1.65) 0.297 1.57 (0.94–2.64) 0.085 High C ude 0.88 (0.65–1.18) 0.394 1.13 (0.82–1.55) 0.448 1.02 (0.76–1.36) 0.899 1.35 (0.95–1.91) 0.093 1.35 (1.02–1.78) 0.033 0.72 (0.50–1.03) 0.071 Adjus eda0.84 (0.61–1.16) 0.285 0.99 (0.71–1.40) 0.971 1.13 (0.82–1.57) 0.457 1.22 (0.83–1.79) 0.306 1.33 (0.97–1.81) 0.075 0.91 (0.60–1.40) 0.683 Adjus edb0.97 (0.69–1.37) 0.865 0.97 (0.67–1.41) 0.889 1.17 (0.80–1.71) 0.419 1.31 (0.85–2.03) 0.218 1.23 (0.85–1.77) 0.277 1.34 (0.75–2.39) 0.317 Family s uc u e ( e . nuclea amily) Single‑pa en amily C ude 1.44 (1.09–1.92) 0.011 1.30 (0.94–1.79) 0.113 1.82 (1.39–2.39) <0.001 0.87 (0.64–1.18) 0.362 1.38 (1.09–1.75) 0.007 1.85 (1.35–2.53) <0.001 Adjus eda1.35 (1.00–1.83) 0.050 1.23 (0.88–1.73) 0.224 1.78 (1.33–2.38) <0.001 0.99 (0.72–1.37) 0.947 1.50 (1.16–1.93) 0.002 1.70 (1.21–2.40) 0.002 Adjus edb1.20 (0.86–1.67) 0.286 1.10 (0.76–1.60) 0.609 1.34 (0.95–1.90) 0.097 0.91 (0.63–1.32) 0.623 1.40 (1.04–1.89) 0.028 1.46 (0.94–2.28) 0.096 S ep‑ amily C ude 1.30 (0.96–1.77) 0.096 1.50 (1.08–2.08) 0.015 1.90 (1.43–2.52) <0.001 1.60 (1.09–2.34) 0.015 1.71 (1.23–2.37) <0.001 2.54 (1.68–3.83) < 0.001 Adjus eda1.33 (0.97–1.82) 0.080 1.42 (1.01–1.99) 0.045 1.87 (1.39–2.51) < 0.001 1.71 (1.16–2.52) 0.007 1.79 (1.27–2.51) < 0.001 2.47 (1.59–3.83) <0.001 Adjus edb1.19 (0.85–1.66) 0.323 1.40 (0.98–2.00) 0.066 1.40 (0.99–1.99) 0.056 1.39 (0.90–2.13) 0.136 1.27 (0.86–1.87) 0.238 1.50 (0.87–2.59) 0.149 U ban esidence ( e . u al) C ude 0.71 (0.58–0.87) <0.001 0.73 (0.59–0.91) 0.004 0.75 (0.62–0.91) 0.004 0.81 (0.64–1.03) 0.085 0.99 (0.81–1.21) 0.923 1.14 (0.86–1.53) 0.361 Adjus eda0.73 (0.59–0.91) 0.004 0.84 (0.67–1.06) 0.148 0.72 (0.58–0.89) 0.003 0.88 (0.68–1.13) 0.318 1.03 (0.83–1.29) 0.770 0.96 (0.71–1.30) 0.796 Adjus edb0.74 (0.59–0.94) 0.012 0.86 (0.67–1‑11) 0.253 0.74 (0.58–0.95) 0.019 0.94 (0.72–1.24) 0.678 1.15 (0.90–1.47) 0.270 1.03 (0.70–1.54) 0.868 Page 24 o 33 Gus a ssone al. Child and Adolescen Psychia y and Men al Heal h (2023) 17:54 Table 8 (con inued) Va iable Sample 1 (2018) P o ile ( e e ence: p o ile 1—“Good men al heal h”) Sample 2 (2022) P o ile ( e e ence: p o ile 1— “Good men al heal h”) P o ile 2—“Mixed psychosocial heal h” P o ile 3—“Soma ically challenged” P o ile 4—“Poo men al heal h” P o ile 2—“Mixed psychosoma ic heal h” P o ile 3—“Poo men al heal h and low loneliness” P o ile 4—“Poo men al heal h and high loneliness” OR (CI 95%) p‑ alue OR (CI 95%) p‑ alue OR (CI 95%) p‑ alue OR (CI 95%) p‑ alue OR (CI 95%) p‑ alue OR (CI 95%) p‑ alue Immig an backg ound ( e . na i e) Fi s ‑gene a ion immig an C ude 0.91 (0.53–1.57) 0.730 1.45 (0.86–2.44) 0.167 2.19 (1.44–3.34) < 0.001 1.19 (0.66–2.15) 0.563 0.79 (0.46–1.35) 0.385 2.47 (1.40–4.35) 0.002 Adjus eda0.92 (0.52–1.63) 0.782 1.26 (0.72–2.21) 0.423 1.56 (0.95–2.55) 0.079 1.21 (0.64–2.29) 0.550 0.80 (0.44–1.46) 0.475 1.89 (0.94–3.78) 0.072 Adjus edb0.86 (0.46–1.59) 0.620 0.80 (0.40–1.58) 0.513 1.36 (0.75–2.45) 0.314 1.15 (0.57–2.32) 0.696 0.66 (0.33–1.32) 0.237 1.26 (0.51–3.14) 0.615 Second‑gene a ion immig an C ude 0.91 (0.62–1.33) 0.614 1.09 (0.73–1.63) 0.675 1.07 (0.74–1.53) 0.732 0.65 (0.38–1.11) 0.115 1.01 (0.69–1.46) 0.972 2.03 (1.32–3.12) 0.001 Adjus eda0.87 (0.58–1.31) 0.510 1.14 (0.75–1.72) 0.545 1.03 (0.70–1.52) 0.883 0.68 (0.39–1.19) 0.175 1.00 (0.66–1.51) 0.993 1.88 (1.14–3.09) 0.013 Adjus edb0.77 (0.50–1.19) 0.236 1.11 (0.71–1.74) 0.648 0.75 (0.47–1.20) 0.228 0.49 (0.26–0.94) 0.033 0.85 (0.53–1.36) 0.497 1.10 (0.57–2.09) 0.784 Psychosocial ac o s Pe cei ed home a mosphe e C ude 0.50 (0.44–0.58) < 0.001 0.69 (0.58–0.81) <0.001 0.32 (0.28–0.37) < 0.001 0.74 (0.63–0.88) < 0.001 0.40 (0.35–0.46) < 0.001 0.24 (0.20–0.28) < 0.001 Adjus eda0.51 (0.44–0.59) <0.001 0.76 (0.64–0.90) 0.002 0.36 (0.31–0.42) < 0.001 0.76 (0.64–0.92) 0.004 0.42 (0.36–0.49) < 0.001 0.26 (0.22–0.32) <0.001 Adjus edb0.64 (0.54–0.77) < 0.001 0.98 (0.80–1.20) 0.833 0.56 (0.47–0.67) < 0.001 0.99 (0.79–1.25) 0.955 0.60 (0.49–0.72) <0.001 0.60 (0.46–0.77) < 0.001 Pa en al moni o ing Ma e nal moni‑ o ing C ude10.52 (0.39–0.68) < 0.001 0.76 (0.57–1.03) 0.078 0.29 (0.23–0.37) < 0.001 0.78 (0.56–1.10) 0.154 0.40 (0.30–0.52) < 0.001 0.27 (0.20–0.38) <0 .001 Adjus eda1 0.40 (0.30–0.54) < 0.001 0.60 (0.44–0.83) 0.002 0.21 (0.16–0.28) < 0.001 0.65 (0.45–0.94) 0.021 0.30 (0.22–0.40) < 0.001 0.17 (0.11–0.24) < 0.001 Adjus edc1 0.41 (0.26–0.64) < 0.001 0.87 (0.54–1.41) 0.580 0.44 (0.28–0.69) < 0.001 0.71 (0.42–1.20) 0.200 0.44 (0.28–0.69) <0.001 0.63 (0.34–1.17) 0.144 Pa e nal moni‑ o ing C ude10.60 (0.48–0.75) < 0.001 0.63 (0.49–0.81) < 0.001 0.33 (0.26–0.41) < 0.001 0.86 (0.65–1.14) 0.289 0.46 (0.37–0.57) < 0.001 0.24 (0.18–0.32) <0.001 Adjus eda1 0.60 (0.46–0.76) <0.001 0.65 (0.50–0.85) 0.001 0.34 (0.26–0.43) < 0.001 0.80 (0.59–1.09) 0.154 0.45 (0.35–0.58) <0.001 0.24 (0.17–0.33) < 0.001 Adjus edc1 1.38 (0.94–2.04) 0.103 0.81 (0.55–1.19) 0.285 1.00 (0.67–1.48) 0.997 1.06 (0.68–1.65) 0.785 0.91 (0.63–1.33) 0.639 0.75 (0.45–1.23) 0.255 Family suppo C ude 0.81 (0.76–0.86) < 0.001 0.92 (0.86–0.99) 0.029 0.68 (0.64–0.72) < 0.001 0.85 (0.78–0.92) <0.001 0.70 (0.66–0.75) < 0.001 0.52 (0.48–0.56) <0.001 Adjus eda0.82 (0.77–0.88) <0.001 0.95 (0.88–1.03) 0.240 0.71 (0.67–0.75) <0.001 0.84 (0.77–0.91) < 0.001 0.72 (0.67–0.77) <0.001 0.53 (0.49–0.58) < 0.001 Adjus edb0.97 (0.89–1.07) 0.549 0.94 (0.84–1.05) 0.250 0.89 (0.80–0.98) 0.013 0.92 (0.81–1.04) 0.183 0.85 (0.76–0.94) 0.003 0.76 (0.66–0.87) < 0.001 Pee suppo C ude 0.86 (0.81–0.91) < 0.001 1.07 (0.99–1.15) 0.070 0.84 (0.79–0.88) <0.001 0.94 (0.87–1.01) 0.080 0.89 (0.84–0.95) < 0.001 0.64 (0.60–0.69) < 0.001 Adjus eda0.82 (0.77–0.87) <0.001 1.02 (0.95–1.10) 0.587 0.78 (0.74–0.83) < 0.001 0.88 (0.82–0.96) 0.002 0.85 (0.80–0.91) <0.001 0.61 (0.56–0.66) < 0.001 Adjus edb0.90 (0.82–0.98) 0.019 1.14 (1.02–1.27) 0.017 0.96 (0.87–1.05) 0.333 0.94 (0.84–1.06) 0.321 1.01 (0.92–1.12) 0.783 0.83 (0.73–0.94) 0.004 Teache suppo C ude 0.66 (0.59–0.74) < 0.001 0.69 (0.61–0.78) < 0.001 0.41 (0.37–0.46) < 0.001 0.64 (0.56–0.74) <0.001 0.54 (0.48–0.60) < 0.001 0.31 (0.27–0.36) < 0.001 Adjus eda0.68 (0.60–0.77) <0.001 0.73 (0.64–0.83) <0.001 0.45 (0.40–0.50) < 0.001 0.62 (0.54–0.71) <0.001 0.56 (0.49–0.63) <0.001 0.33 (0.28–0.39) < 0.001 Adjus edb0.94 (0.81–1.09) 0.420 0.89 (0.76–1.05) 0.169 0.73 (0.63–0.85) <0.001 0.65 (0.53–0.79) < 0.001 0.80 (0.67–0.95) 0.011 0.65 (0.51–0.82) < 0.001 Classma e sup‑ po C ude 0.56 (0.49–0.63) < 0.001 0.64 (0.55–0.74) < 0.001 0.43 (0.38–0.49) <0.001 0.77 (0.67–0.90) <0.001 0.52 (0.46–0.59) < 0.001 0.28 (0.24–0.33) <0.001 Adjus eda0.59 (0.51–0.68) < 0.001 0.69 (0.59–0.80) <0.001 0.50 (0.44–0.58) <0.001 0.79 (0.68–0.93) 0.004 0.55 (0.49–0.63) <0.001 0.33 (0.28–0.40) <0.001 Adjus edb0.86 (0.71–1.03) 0.091 0.81 (0.66–0.99) 0.041 0.97 (0.80–1.18) 0.783 1.10 (0.88–1.38) 0.382 0.87 (0.72–1.05) 0.155 0.80 (0.62–1.04) 0.096 Pe cei ed school clima e C ude 0.50 (0.44–0.57) < 0.001 0.62 (0.54–0.72) <0.001 0.33 (0.29–0.37) < 0.001 0.70 (0.61–0.81) < 0.001 0.49 (0.43–0.54) < 0.001 0.26 (0.22–0.30) < 0.001 Adjus eda0.53 (0.46–0.61) <0 .001 0.67 (0.57–0.78) <0.001 0.37 (0.32–0.42) <0.001 0.72 (0.62–0.83) <0.001 0.53 (0.47–0.60) <0.001 0.29 (0.24–0.34) < 0.001 Adjus edb0.72 (0.60–0.85) < 0.001 0.82 (0.67–1.00) 0.052 0.57 (0.47–0.68) < 0.001 0.90 (0.72–1.12) 0.339 0.78 (0.65–0.95) 0.012 0.49 (0.38–0.63) <0.001 Page 31 o 33 Gus a ssone al. 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