In its latest report, the World Health Organization (WHO) expressed concerns that the COVID-19 pandemic has a serious global impact on mental health, as the 2020 survey revealed a minimum increase of 25% in the incidence of anxiety and depressive disorders (35.6% and 27.6%, respectively). Emphasizing the importance of mental health, which has become prominent during the COVID-19 pandemic, the WHO has stated that it is an important and urgent problem for everyone, and not just those with specific mental illnesses, citing the need for specific and active change as well as commitment [1].

Childhood and adolescence are critical phases for the onset of mental disorders. It is known that 50% of lifetime mental disorders develop before the age of 14, and 75% before the age of 24 [2], while a study in South Korea also showed that approximately 50% of adult mental illnesses develops before the age of 14 [3]. Additionally, the COVID-19 pandemic and infection mitigation measures not only directly affect children and adolescents but also have a huge impact on their families, schools, and communities. Children and adolescents who are ultimately subjected to these socio-ecological influences are considered to be the most vulnerable in terms of mental health [4]. According to the COVID-19 Adolescent Mental Health Survey conducted by the Korea Trauma Stress Society, the anxiety or depression risk group with at least moderate severity was found to be 17.5%, while 10.17% reported “self-harm or suicidal ideation” within the last two weeks [5]. Moreover, according to Statistics Korea, the suicide rate in 2021 increased by 1.2% compared to the previous year, and the increase rate of suicide among teenagers was 10.1%, the highest among all age groups [6]. As shown, along with the COVID-19 pandemic, the vulnerability in terms of mental health in children and adolescents has increased, and in the long term, negative experiences during this phase of growth and development can lead to various physical and mental diseases, as well as affect their quality of life.

As most children and adolescents attend schools, it is an obvious setting for addressing the health and mental health needs of children and adolescents. It has become a tradition to implement physical health promotion and public health interventions, such as vaccination at schools, and school mental health has received international attention in recent years. This is because mental health promotion is a determinant of educational outcomes. There are two approaches to helping children and adolescents with mental health problems. The first is a system that identifies risk groups by screening tests or individual reports, and then connects necessary measures and mental health professionals with them. The second is a preventive and universal intervention method that regularly provides mental health literacy (MHL) or gatekeeper education for children and adolescents. Promoting the capacity for MHL with a preventive and universal approach is essential, given the importance of mental health problems in children and adolescents, who have become more vulnerable during the COVID-19 pandemic, and in adolescence, which is the critical period of onset of lifelong mental illness. In addition, this can be an important basis for active early detection of mental health risk groups or for effective connection and management.

The purpose of this review is to examine the necessity of an educational program that promotes MHL in schools as a preventive and universal intervention for children and adolescents in South Korea and to consider the implementation process.

To this end, the following will be examined in detail to serve as the basis for preparing effective and sustainable measures to promote MHL in South Korean schools:

1) Concept of MHL

2) The need to promote MHL among children and adolescents in South Korea

3) Effectiveness and characteristics of MHL programs for children and adolescents worldwide

4) Development of MHL programs for middle and high schools in South Korea and future projects

In 1988,the WHO defined health literacy as “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health” [7]. Health literacy is the key factor that determines a person’s health throughout his life, and its influence is stronger than that of other factors such as an individual’s economic level, employment status, education, and racial or ethnic group [8]. Health literacy is an important personal asset for maintaining and improving individual health, and at the same time, it is an important foundation for reducing health inequality, developing national health policies, and facilitating the operation of the health system [9]. Thus, health literacy is recognized as an important global health concept. Specifically, the recent COVID-19 global pandemic has served as an important basis for individuals to acquire knowledge and coping mechanisms to fight infectious diseases while facilitating national cooperation in the ever-changing national quarantine measures and support system.

Mental health isrecognized as an important part of health along with physical health in modern society, and its importance is gradually being emphasized. However, according to the 2013 WHO Mental Health Survey report, a worldwide lack of awareness of the need for mental health treatment and negative attitudes toward it (e.g., stigma, negative views on treatment) have been pointed out as the biggest obstacles for mental health treatment [10].

The term MHL was first used by Jorm et al. [11], and the concept has since been continuously developed and expanded. Inaccurate knowledge of mental health can lead to negative attitudes, prejudice, and discrimination toward mental health problems and treatment. Kutcher et al. [12] defined MHL as a part of the overall health literacy, and emphasized that all four key elements that are organically connected to each other should be included. The concept of MHL, which is currently widely used, is defined including the following four abilities: 1) understanding how to obtain and maintain positive mental health, 2) understanding mental disorders and their treatments, 3) decreasing stigma related to mental disorders, and 4) enhancing help-seeking efficacy (knowing when and where to seek help and developing competencies designed to improve one’s mental health care and self-management capabilities).

MHL should be provided to everyone in basic processes such as part of the regular school curriculum, college orientation programs, and employment education, which may be customized according to the developmental stage (elementary, middle, high school, university student, adult, etc.) or social situation (school, workplace, mental rehabilitation center, etc.) [12]. The MHL acquired in this process becomes the most basic competency for individuals to find, rationally judge, and utilize various mental health-related knowledge, information, education, activities, programs, and so on, so that they can become the subject of comprehensive mental health management.

In the 2021 mental health survey conducted by the Ministry of Health and Welfare of South Korea, the lifetime prevalence of mental illness was 32.7% for males and 22.9% for females, indicating that more than a quarter of the adult population experience mental illness at least once in their lifetime. However, only 12.1% of people diagnosed with mental disorders received professional help, suggesting a lack of awareness of mental illness and problems asking for help [13]. In addition, in a study on the prevalence of mental disorders in children and adolescents targeting elementary, middle, and high school students in South Korea, only 17% of students with various mental disorders reported seeking help from mental health professionals [14].

The COVID-19 Youth Mental Health Survey conducted by the Korea Trauma Stress Association in 2021 revealed that there was a great need for mental health services, with about 50% who responded that psychological assessment, mental health information, and mental health programs were necessary, and 36% responded that they needed psychiatric treatment, but only 17.4% were aware of mental health services, or hot line numbers [5].

In the case of the “Student Emotional and Behavioral Characteristics Test,” a screening test conducted annually in elementary, middle, and high schools in South Korea, it is important to have an appropriate management system for the selected target group. However, according to recent data, 67% of the reasons for parents’ refusal to connect with the reference system (such as mental health institutions or hospitals in the community) were due to low awareness of students’ emotional and behavioral problems, while 26.6% was due to the refusal to receive psychiatric treatment. In contrast, 67% of the students said that their reason for refusal was low awareness of their emotional and behavioral problems, and 18.2% said that they refused to receive psychiatric treatment [15]. Due to the lack of knowledge of mental health, prejudice, and stigma, resistance to connecting with mental health institutions, hospitals, or medical institutions in the community is also a practical difficulty concerning schools.

Meanwhile, from 2011 to the present, intentional self-harm (suicide) has been the number one cause of death in adolescents aged 9 to 24 years in South Korea annually [6]. The seriousness of adolescent suicide is further heightened by various coexisting psychiatric diseases, including depressive disorder. However, in a study on the types of suicide based on the 2018–2019 student suicide report, the so-called silent type with no apparent problems and no clear environmental risk factors was remarkably high at 48.6% [16]. This is a significantly higher rate than the results of studies in other countries, such as the British study with 19% latent types [17] and the Israeli study [18], which showed 20% latent types. This indicates that these individuals tend to be unaware of their own emotional and behavioral difficulties, or that they did not seek help due to prejudice and social stigma, suggesting that MHL should be provided not only to the risk groups but also to general students. Adolescents are the least likely age group to seek help for their mental health problems and face several known key barriers [19]. They lack accurate knowledge about mental health problems, do not recognize their own problems properly, have stigma or prejudice related to mental health problems, and tend to try to solve these themselves rather than seek professional help. These barriers prevent adolescents from adequately managing their mental health problems and seeking help.

In South Korea,schools have been conducting mental health screening tests called the “Student Emotional and Behavioral Characteristics Test” for risk group identification every year since 2012. Various school mental health programs have been implemented, including life-respecting education programs; suicide prevention programs, including gatekeeper training, mental health education, and consultation programs for teachers; and psychological first aid for school programs. However, in many cases, content related to mental health promotion or suicide prevention and coping is not covered in the regular curriculum of elementary, middle, and high schools. Most of them are implemented sporadically in the form of external support as an extracurricular activity and thus have limitations in terms of cost, efficiency, and longterm effects.

Considering the high prevalence of mental disorders in children and adolescents and the period of onset of lifetime mental disorders, including adulthood, it is very important to educate adolescents on the right knowledge and coping mechanisms in terms of their mental health. Having appropriate knowledge and skills about one’s own mental health during adolescence is essential for growing into a healthy adult, as the failure to recognize mental illness in adolescence and the inability to deal with it appropriately may lead to chronic mental illnesses.

Positive mental health status in adolescence is proportional to the level of MHL [20]. Recent worldwide MHL programs and effectiveness studies have reported an increase in youth MHL. As a result of conducting 10–12 hours of MHL programs as part of the basic school curriculum for 14–15 year old students in Canada, it was reported that the effects of the program included increasing mental health-related knowledge, reducing the stigma of mental illness, and having a more appropriate attitude compared to before education, and this persisted even after two months [21,22]. It was reported that an increase in knowledge and help requests, and a decrease in stigma continued even after three months through a 4-hour education program for 12- to 18-year-olds in the United States [23]. In the UK, an hour and 40-minute education targeting 13- to 15-year-olds showed an increase in knowledge and attitudes to reduce stigma compared to before education [24]. In Japan, a 45-minute educational program for 10- to 12-year-olds increased their knowledge of mental health and help-seeking compared to before receiving this education, and this persisted even after three months [25]. In Norway, a 3-day mental health program for students aged 13 to 16 years reported an increase in knowledge about mental illness and help requests and a decrease in prejudice and stigma compared to before the program, which also persisted after two months [26]. After a 7-hour MHL program conducted in Spain for 13- to 15-year-olds, it was reported that knowledge and help-seeking behavior increased significantly after implementation, and after 6 and 12 months compared to the control group [27]. A recent meta-analysis of effectiveness found that programs implemented in schools were effective both in the short term and in the long term in significantly improving students’ mental health-related knowledge [28]. However, it did not show significant results in reducing stigma or increasing help-seeking behaviors. Each program showed diversity, including one or more MHL elements, and it showed limitations in comparative analysis because it did not have a consistent validity evaluation scale.

Accordingto an analysis of the specific content of MHL programs [29], most include one or more of the four components of MHL. Knowledge of mental illness and stigma reduction is dealt with, and information on how to obtain and maintain positive mental health is lacking. Most of them targeted adolescents before the age of 14, which is important from a preventive point of view, considering the early onset of mental illness. Also, in about 50% of cases, it was implemented by general school teachers in charge of the youth. Most were implemented in schools and conducted face-toface, using supplementary materials, examples, and participatory strategies. The program duration varied depending on the situation. Among the elements of MHL, obtaining mental health-related knowledge and knowing how to ask for help showed effective improvement in a relatively short period. Reducing stigma and having an appropriate attitude showed results that did not change easily in a short time, suggesting the need for continuous additional education in the future. The biggest barriers to the implementation of the program were difficulties in cooperating with various school officials and the violation of the school schedule. Conversely, the use of interactive methods with those implemented as part of the regular school curriculum have been the most helpful. In addition, it was proposed to actively include methods for promoting and maintaining positive mental health among the four elements of literacy. In a qualitative study that investigated the need for a MHL program targeting 13- to 19-year-old students and their teachers, who are the final beneficiaries of the recent MHL program, both students and teachers reported a lack of MHL competencies and limited mental health promotion in the school environment. Both students and teachers reported the need for basic MHL, an interactive and easily accessible educational method, and a structure that can be continuously implemented in the school system [30].

In South Korea, efforts have been made to implement preventive and universal methods for the promotion of mental health in children and adolescents. The Korean Academy of Child and Adolescent Psychiatry has been conducting mental health campaigns and many psychiatrists have participated in free donation lectures nationwide every year since 2004 for children, adolescents, and their parents in the local community, and launched the “Understanding attention-deficit/ hyperactivity disorder” website (www.adhd.or.kr) to provide accurate and useful information to the general public. In addition, psychiatrists have provided mental health assistance in various forms such as consultations, crisis interventions, lectures, educational materials, and newsletters for students, teachers, and parents at the Ministry of Education, local offices of education, and schools.

However, as mental health problems in children and adolescents have recently increased and become a common problem, the need for education on MHL, which is the most important basis for all mental health programs or interventions, has increased; however, so far, there has been no MHL program implemented in South Korean schools. Accordingly, the “School Mental Health Resources and Research Center” of the Ministry of Education has developed a MHL program that teachers can use in the middle school and high school curricula through a 2020–2021 research service.

The purpose of this program is to cultivate the ability to ask for appropriate help when needed by increasing understanding and awareness of mental health, developing the ability to manage one’s own mental health, and lowering prejudice or stigma about mental illness through “MHL” programs for middle and high school students. It was developed by a team composed of nine child and adolescent psychiatrists with experience in the school mental health field. Mental health specialists use the feedback from teachers in the school field through consultation. The program for middle school students was developed first, followed by that for high school students. Each program for middle or high school consists of four 1-hour sessions in the form of direct education by teachers during regular class time at school. It consists of four hours of lecture materials, a teacher’s guide, and learning materials for the students. To properly apply and use MHL skills in real life, it is important to have all four elements of MHL described above and all four elements are included in the composition of the subject and content: first, how to obtain and maintain positive mental health; second, how to reduce stigma or prejudice against mental illness and have an appropriate attitude; third, correct knowledge about common mental disorders in children and adolescents and knowledge to recognize symptoms and signs of mental health problems or diseases suspected to oneself or around them; and fourth, how to ask for help quickly when needed, specific information, and how to help others. Considering the level of students and teachers, the contents of the classes included easy and simple expressions, news clips, videos, and quizzes to help students’ interest and understanding. It consists of the process of directly applying the four elements of MHL using case examples of common disorders. The program materials are provided free of charge on the website of the “School Mental Health Resources and Research Center” (www.smhrc.kr) of the Ministry of Education, and teachers can directly download and use it in schools. Teachers will be able to provide education after reading the detailed teachers’ guide, and professional aid is available through the School Mental Health Resources and Research Center. When each regional office of education requests training for teachers, the center connects them to psychiatrists for the training.

Currently, the most realistic way to implement MHL programs in schools is to secure time for it during school schedules. Currently, counselors (teachers) or health teachers can conduct 6 hours each year for “life-respecting and suicide prevention education,” which are prescribed as compulsory education by the Korean government (Ministry of Education). However, due to a lack of understanding among schools and teachers regarding the relationship between MHL and suicide prevention, active promotion is needed. In the future, research on the effectiveness of educational programs, feedback from students and teachers in the field, various educational methods, and the development of programs targeting elementary school students should continue. In addition, training for teachers who will implement this is essential, and MHL for parents is also necessary. Above all, for effective implementation, a nationwide dissemination of MHL through the Ministry of Education or the Regional Office of Education, active consultation and systemic support by psychiatrists, and an overall system that can continue to connect with mental health institutions or hospitals in the community are needed. Ultimately, it is expected that MHL will be included as part of the school’s regular curriculum so that students’ teachers can continue to teach it in class within a stable structure.

It is most important for children and adolescents to have proper awareness and knowledge of mental health issues and to be active in managing their mental health positively and seeking help for any mental health problems, by having MHL skills through the Korean regular school curriculum. The promotion of MHL will be the basis for building an efficient system that promotes mental health, early detection, early intervention, appropriate referral, and the continuous provision of environmental help through increased communication and cooperation in the entire path of care that connects student-schools-homes-communities-specialized medical institutions. In addition, in the long term, it is expected that by maintaining one’s mental health throughout life and having the ability to properly cope with mental illness, it will contribute to raise the level of mental health of the entire nation, and lower the rate of various mental illnesses and suicides.

In this review, the necessity and implementation considerations of a MHL program as a universal and preventive intervention in South Korean schools was determined. Therefore, the literature review was limited to MHL programs mainly implemented in schools for adolescents. The current situation in South Korea and the contents of the developed MHL program was reviewed. Therefore, data on MHL in various target groups, such as the general public, parents, out-ofschool youths, and vulnerable groups, were not included. Awareness of mental health is highly related not only to individual problems, but also to society as a whole. Thus, in the future, it will be necessary to pay attention to, and make efforts to improve, MHL in various target groups.

Considering the importance of mental health problems in children and adolescents, who are more vulnerable due to the COVID-19 pandemic, and with childhood and adolescence being the main phase of onset of lifelong mental illnesses, it is essential to enhance the capacity of MHL with a preventive and universal approach. Positive mental health in adolescence is proportional to a higher level of MHL, and various MHL programs in schools targeting adolescent students have been reported to be effective worldwide. In South Korea, there is a great need for education that can promote MHL in schools, and an active dissemination and further development of the current program and textbooks, and a plan for continuing education in the regular curriculum in the future.

Data sharing not applicable to this article as no datasets were generated or analyzed during the study.

The author has no potential conflicts of interest to disclose.

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