How young people understand mental health survey questions: a qualitative think-aloud study from the Swedish National Public Health Survey

Abstract Background In light of the diverging trends in young people’s mental health, where reports of declining health coexist with indicators of improved well-being, this study aimed to explore young people’s reasoning about survey questions concerning psychological distress in the Swedish public health survey. Methods A ‘think-aloud’ design was employed, where 33 young people aged 16–25 were interviewed about public health survey questions concerning mental health. The interviews were analysed using qualitative content analysis. Results The participants struggled with both the wording and the framing of the questions: the concepts of anxiety, worry, and unease were perceived as overlapping yet difficult to separate; stress was experienced as both positive and negative; time frames were interpreted in inconsistent ways; and response options were sometimes regarded as too narrow. These ambiguities indicate that responses were influenced by participants’ interpretations rather than solely by the phenomena the questions were intended to capture. Conclusion Trends in self-reported mental health must be interpreted in light of how survey items are understood. While continuous review of public health surveys is necessary to maintain validity, this complicates long-term trend analyses. There is a risk that current survey data either over- or underestimate changes in mental health if younger generations understand and respond to survey items differently than earlier generations. These interpretations could persist as cohorts age, underscoring the need for future research on how different generations understand and respond to mental health survey questions across the life course. Survey data alone seem insufficient to capture key nuances of young people’s mental health, making qualitative approaches a necessary complement to public health policy and practice. Advancing this field also requires the development and validation of more contextually relevant survey questions that better reflect how contemporary youth understand and talk about mental health.