Author ORCID Identifier

https://orcid.org/0000-0002-5701-189X

Semester

Spring

Date of Graduation

2026

Document Type

Dissertation

Degree Type

PhD

College

School of Public Health

Department

Social and Behavioral Sciences

Committee Chair

Keith Zullig

Committee Co-Chair

NA

Committee Member

Alfgeir Kristjansson

Committee Member

Steve Davis

Committee Member

Scott Huebner

Abstract

Background. Adolescent mental health is a critical public health concern, particularly in rural Appalachian communities where rates of depression, anxiety, and substance use exceed national averages and access to mental health resources remain severely limited. Traditional mental health frameworks rely predominantly on the identification and reduction of psychopathological symptoms, neglecting the independent contributions of positive well-being to adolescent risk and resilience. The Dual-Factor Model (DFM) of mental health offers a more comprehensive alternative by simultaneously assessing subjective well-being (SWB) and psychopathology, classifying individuals into four distinct groups: Complete mental health, Vulnerable, Symptomatic but content, and Troubled. Despite the DFM’s growing utility in academic and behavioral research, its application to substance use outcomes, environmental protective factors, and educator perceptions in the rural Appalachian population are largely unexplored. Aims. This dissertation aimed to: (Aim 1) test whether DFM of mental health classifications significantly differentiate adolescent substance use behavior among Appalachian middle school students; (Aim 2) examine whether five contextual and environmental protective factors (school connectedness, community safety, neighborhood ties, collective efficacy, and organized leisure time activities) differ significantly across DFM mental health classification in this population; and (Aim 3) explore middle school teachers’ subjective perspectives on the interplay between student mental health, life satisfaction, and substance use risk in rural West Virginia (WV) using Q-methodology. Methods. (Aim 1 and 2) Spring 2022 cross-sectional data from the Young Mountaineer Health Study (YMHS; N = 1698), a NIH-funded prospective cohort study of Appalachian adolescents across five West Virginia counties, were used. Psychopathology was measured using the Oregon Adolescent Depression Project Conduct Disorder Screen (OADP-CDS) and 13 anxiety and depression items from the Symptom Checklist – 90 (SCL-90). SWB was measured using the Brief Multidimensional Students’ Life Satisfaction Scale (BMSLSS). Participants were classified into the four DFM groups using established T-score cutoffs. In Aim1, linear regression models examined associations between DFM group relationship and substance use while controlling for gender, race, and family socioeconomic status. Chi-square tests and a series of one-way ANOVAs with Tukey post hoc comparisons were also applied to various substance use outcomes to assess group differences. In Aim 2, a series of one-way ANOVAs with Tukey post hoc comparisons examined differences across the five contextual variables by DFM group. For Aim 3, a purposive sample of 12 middle school teachers were recruited from the five YMHS counties and completed a 41-statement Q-sort instrument. Statements were drawn from a structured concourse informed by the DFM and life satisfaction domains. Data was analyzed using principal component analysis (PCA) with Varimax rotation in Kade software. Results. (Aim 1) DFM group membership significantly differentiated by substance use across all outcomes. The Troubled group consistently reported the highest substance use risk, followed by the Vulnerable and Symptomatic groups, with the Complete group reporting the lowest prevalence of use. Notably, the Vulnerable and Symptomatic groups did not differ statistically from each other on any substance use measure, suggesting that low SWB, regardless of psychopathology level, elevates behavioral risk. (Aim 2) Significant DFM group differences emerged across all five contextual variables. SWB emerged as the primary organizing variable: adolescents with high SWB consistently reported stronger school connectedness, greater perceived community safety, more robust neighborhood ties, and higher participation in leisure activities. Critically, the Vulnerable group clustered with the Troubled group on nearly all measures, despite the absence of clinical psychopathology, underscoring independent risks associated with diminished well-being. (AIM 3) Four distinct teacher viewpoint factors emerged: Factor 1 (Strong Support System) emphasized parental guidance as the primary protective factor; Factor 2 (Multiple risk Factors and Uncertainty) reflected perceived powerlessness and unpredictability of substance use risk; Factor 3 (Importance of Environment; the largest group) endorsed a comprehensive ecological view centering on positive school climate, peer relationships, and family support; and Factor 4 (Importance of Mental Health) highlighted teachers’ roles in detecting use and attending to individual student dynamics. Consensus statements across all factors reflect shared recognition that mental health and life satisfaction jointly influence substance use vulnerability. Conclusion. This dissertation applied the DFM of mental health to a set of interconnected public health questions in a rural Appalachian youth population, employing a multi-method approach that moved from individual classification (Aim 1) to environmental context (Aim 2), to educator perspectives (Aim 3).  Across all three aims, SWB consistently emerged as a critical and independently actionable construct, one that was associated with both behavioral risk and engagement with protective environmental resources, and that educators intuitively recognized even without formal DFM training. The Vulnerable group’s alignment with the Troubled group across both behavioral and contextual outcomes highlights a persistent gap in symptom-focused screening frameworks. Together, these findings support a prevention model that promotes positive indicators of mental health alongside the reduction of psychopathological symptoms, and that engages teachers as informed frontline partners in culturally responsive, school-based prevention efforts for Appalachian youth.

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