Designing Mental Health Technologies that Support the Social Ecosystem of College Students

Abstract

The last decade has seen increased reports of mental health problems among college students, with college counseling centers struggling to keep up with the demand for services. Digital mental health tools offer a potential solution to expand the reach of mental health services for college students. In this paper, we present findings from a series of design activities conducted with college students and counseling center staff aimed at identifying needs and preferences for digital mental health tools. Results emphasize the social ecosystems and social support networks in a college student’s life. Our findings highlight the predominant role of known peers, and the ancillary roles of unknown peers and non-peers (e.g., faculty, family) in influencing the types of digital mental health tools students desire, and the ways in which they want to learn about mental health tools. We identify considerations for designing digital mental health tools for college students that take into account the identified social factors and roles.

INTRODUCTION

Mental health problems are on the rise among college students. According to the 2017 National Survey on Drug Use and Health [1], the prevalence of mental illness has risen from 19% to 26% among American adults aged 18-25 over the last decade, while rates remained stable for adults aged 26 and older. At the same time, suicidal ideation and attempts increased more among young adults than among other age groups. In addition, college counseling centers report a growing number of students with significant mental health issues on their campus [48]. Digital mental health tools, such as smartphone applications, promise to reach and support young adults more promptly, efficiently, and cost-effectively [42, 43]. Yet designing technologies for this population requires better understanding the unique needs of young adults and social contexts within which they are situated.

College students are at a particularly vulnerable time in their development, as most lifetime mental disorders have their first onset between the ages of 18 and 24 [40]. It is also a time of increased independence, known in the developmental psychology literature as “emerging adulthood” [5] with most young adults moving away from their parents and dealing with the stress of adult responsibilities for the first time. They are under increased pressure to succeed academically, financially, and socially [11, 37]. Despite their susceptibility to mental illness, college students report numerous barriers to mental health treatment. Many students do not recognize a need for treatment, assuming that symptoms of depression and anxiety are typical of college life [21]. For those who recognize a treatment need, they often report limited access to care, concerns about stigma, and skepticism of the efficacy of care [22, 54]. While college campuses often feature free access to mental health services, less than 50% of students with depression use them [20].

Within HCI, there is increasing interest in student mental health [39, 45, 59, 81]. The focus of these studies has been on understanding the context of poor mental health in individual college students and identifying strategies and tools for improving their mental health. Furthermore, mental health technologies, including web-based and app-based tools for depression and anxiety, have been developed and tested in a variety of populations, including college students [29, 42]. However, there exists a research-to-practice gap in digital mental health, such that most tools developed and tested in clinical trials fail to be taken up in real world care settings [45]. For college students, inappropriate or inadequate design of tools to match the day to day experiences of students has been suggested as a key contributor to this gap [37]. Notably, the rich social roles that other individuals play in college student life have typically been ignored in the development and design of these technologies within both the HCI literature as well as the psychological/medical literature. Understanding the roles of other individuals is particularly important because of the important role that socialization plays during the college years [6].

While past research in the field of digital mental health has focused on using digital tools to seek peer support [25, 81], what has not been examined is the nuances of who individuals turn to when seeking mental health support and how they turn to them. In this study, we had two major goals. First, we wanted to start to identify college students’ mental health needs and what type of digital mental health tools could potentially help them address common mental health problems such as depression and anxiety. Second, we wanted to better understand how students wanted to learn about and use these tools. This is part of a larger study focused on designing and implementing digital mental health tools for students. Through a partnership with two universities in the United States, we conducted co-design workshops with 20 college students and 10 college counseling center staff members, and individual interviews with 15 college students and 4 counseling center staff members. This is the first study, to our knowledge, that examines these particular questions by examining the role played by known peers, as well as unknown peers, and non-peers in college student mental health management. It builds upon and extends the study by Park [59], who identified a “Mosaic of Social Support” in which college students seek social support from different social groups based on their support needs by focusing on nuances of the types of support that they are looking for and the social context of that support.

Through this study, we identify a rich social ecosystem of college student life dominated by peer influence, and illustrate how the role of peers and other individuals – including faculty, family and people from one’s culture of origin – influence both the types of digital mental health tools students desire, and how they want to learn about these tools. In particular, we identify that students do not want to just connect with peers for mental health support, but they also rely on their peers as referral sources and, more generally, as sources of credible knowledge. This context shapes students’ interest in and willingness to engage with different types of mental health support. We discuss how these social factors can translate into opportunities to design digital mental health tools that are more desirable and engaging for college students.

RELATED WORK

This work adds to a body of work in HCI around the role of technology in mental health. In this section, we will first draw on this body of work and explore the work specifically on college students’ mental health to articulate how our research expands on this literature.

Technology Use in Mental Health Research

There has been increasing interest in HCI on the role of technology in mental health. As online and mobile technologies have become ubiquitous, individuals have access to a variety of new tools to support them in treating and managing their mental health concerns [25, 65]. Many of these tools are accessible at any time and from virtually any location via mobile devices such as smartphones. The penetration of internet access, particularly through smartphones, now extends across demographic groups and socio-economic strata, and includes many otherwise hard-to-reach populations [4]. Furthermore, since digital mental health tools are often low-cost and anonymous to use, they potentially overcome some of the important barriers that exist in relation to traditional mental health services (i.e., cost and stigma) [72]. Findings from the medical literature suggest that, among individuals with mental health conditions like depression, digital mental health tools are largely perceived as an acceptable alternative to in-person services, including among young adults [8, 35, 61, 74]. Also, individuals have increasingly incorporated technology-supported mental health management strategies into their daily lives. For example, individuals with depression and other mental health conditions have appropriated a number of digital tools that were not designed with mental health in mind, such as using digital calendars, alarms, and to-do lists to organize and motivate depression management [67].

To date, digital mental health tools have taken various forms. They include psychoeducation and skill-building tools [36, 66, 79], applications that facilitate tracking and reflecting on one’s own mood and behavior [15, 47, 56], games that facilitate learning and rehearsing skills for managing mental health issues [34, 76], and online therapies through which individuals communicate synchronously or asynchronously with providers [68, 69, 78]. The majority of these tools focus on the individual end user, although some digital mental health tools have explicitly focused on the provision of support from others. Peer support may occur “organically” (i.e. self-organized online support groups) [19, 24], or through dedicated tools that connect individuals with mental health concerns and may offer training to peers or employ moderators or facilitators to establish group norms and guide discussions [16, 30, 53, 57, 58]. Digital mental health tools may also operate alongside in-person therapy, and with or without coach support [9, 32, 47, 69]. Recent work has also shown that the importance of sociality in these digital mental health tools should not be underestimated [15]. Users with mental health concerns engage in a wide variety of different social interactions, across multiple communication channels in order to meet their own needs.

While some studies have examined how digital mental health tools can address mental health issues in college student populations [42], these tools have primarily been focused on psychoeducation and skill-building, and have typically failed to consider the prominent roles that others, particularly peers, play in the lives of college students. This is especially salient in those dealing with mental health concerns, as entire communities around specific challenges, such as depression, are occurring online [3, 27, 28]. College students are unique in that they are in highly social environments, and there is a need to understand the desired role of others in digital mental health tools. The following sections outlines the HCI literature on mental health among college students.

Mental Health of College Students

The mental health of college students is increasingly being recognized as an area of research for HCI scholars around the world [39, 45, 59, 81]. To date, research has focused primarily on symptoms of stress, anxiety and depression. Stress management is a key construct for mental health researchers because stress is a known contributor to the development and maintenance of mental health conditions, including anxiety and depression [51]. The reasons for this increased focus are due to (1) the high levels of mental health concerns observed in college students, (2) the inadequacy of existing face-to-face services in meeting college student mental health needs, and (3) because most students are adept enough to benefit from digital tools. Many college communities are unable to keep up with the increasing demand of students seeking mental health services [46, 80]. The insufficiency in mental health resources is compounded by the ineffectiveness of mental health campaigns on campus, which largely rely on brochures and lectures. However, people with mental health problems often suffer from a lack of energy and motivation, preventing them from attending these events [60].

Existing research in HCI has primarily focused on how college students use technologies for self-management of mental health. For instance, Lee and Hong [45] worked with 23 Korean university students in a workshop format over a two week period to establish goals for behavior change related to life stress and practice personalized interventions. While the workshops were face-to-face and participants kept track of their behaviors using a hard copy worksheet, Lee and Hong presented opportunities for digitizing a personal informatics system for stress management based on their workshop learnings. Similarly, Kelley et al. [39] examined students’ experiences and challenges adopting self-tracking technologies to support mental wellness goals. An online survey of 297 college students revealed that respondents tracked a wide array of health items (e.g., steps, workout, weight, sleep), primarily using smartphone apps and wearable devices, and that many of them shared personal health data with others including doctors, family, and friends. However, the authors also found that “unhealthy means of self-care” were prevalent, highlighting the need for educating students about helpful self-management strategies and the importance of tailoring self-monitoring interventions to the unique needs of college students.

Yet some recent work shows that college students use technologies to fulfill their social needs. For example, in a survey of 560 college students in Hong Kong, Zhang [81] found that over 80% of the respondents reported stressors such as schoolwork overload, concerns about appearance and weight, financial difficulties, and interpersonal conflicts. These stressors prompted college students to self-disclose on Facebook as a means of catharsis and seeking social support. The results showed that self-disclosure on Facebook dampened the negative relationship between stressful life events and life satisfaction, and was positively related to perceived social support. Similarly, Park and colleagues [59] outlined the various sources of support that American college students draw on when managing their mental health. They coined the students’ social support networks as the “Mosaic of Social Support” and provide a foundation for understanding social support practices in university students and the role of social support from various others (e.g., close friends, parents, and anonymous online communication partners) in managing mental wellness. Park also outlined opportunities for technology-mediated social support, with a focus on flexibility and sustainability of online support.

Furthermore, as Park and others have pointed out, emerging adults on college campuses are embedded in rich social ecosystems [23, 59, 73]. College campuses are environments in which emerging adults are surrounded by peers and educators, and in which distinct traditions and norms are often established within the campus community [23, 55]. The relationships established, along with the resources available and cultural norms present, set the tone for the social environment.

In this paper, we build on Park’s work [59] by highlighting the roles of other individuals in forming personal concepts around mental health and help-seeking, in addition to the roles others do and can play as individuals seek and receive social support.

METHODS

This data was collected as part of an ongoing partnership with two universities focused on the development and implementation of app-based mental health tools for college students. Data collection for this study occurred in two phases: 1) co-design workshops and 2) individual interviews. All study procedures were approved by the authors’ Institutional Review Board prior to enrolling participants.

Phase I – Co-Design Workshops Participants

A total of 30 individuals (20 students, 10 counseling center clinicians) participated in the co-design workshops. Students were recruited through print advertisements at the counseling center and from emails sent through student organizations. Counseling center staff members were recruited via email and by presentation at a staff meeting. Participants had to be at least 18 years old and either enrolled as a student at a participating university or employed as a counseling center staff member at a participating university. Participants were predominantly female (83%) and were ethnically and racially diverse (including 4 participants who identified as Hispanic or Latino, 8 participants being African American, and 5 participants being Asian).

Phase I – Co-Design Workshops Procedure

Co-design workshops, which lasted approximately 90 minutes, were conducted in the counseling center conference room at each institution. Students and counseling center staff from the cooperating institutions met together in small groups (10 or less) and participated in workshop activities coordinated by the lead author. Participants were provided with lunch and compensated $30 (USD). As an ice-breaking activity, participants were each asked to share an idea for improving the design of a band-aid. Participants were then asked to consider the following hypothetical stress management tool:

A tool that students can freely access, complete brief mental health assessments, receive feedback, and build upon their own stress management/coping skills by receiving access to a handful of interactive, clinical tools. Students whose assessment scores indicate that they may benefit from in-person evaluation and counseling will also receive information about counseling center services (and potentially other resources on campus).

They were given a stack of Post-It notes and asked to respond to the question: “What features would you want to see in the tool?“

After five minutes, the participants were prompted to share their ideas, and to arrange their Post-It notes into clusters of similar ideas. This process was repeated, but with the question: “What are the best ways to advertise a tool like this to students on campus?”

After the Post-It brainstorming activities, the research team explained to participants how to create a storyboard. Participants were then broken into groups of 2-4, and each group put together storyboards demonstrating a hypothetical student’s journey within the stress management program, while keeping these points in mind:

• How the student learned about the mobile app.

• Why the student decided to download it.

• What types of mental health questions are asked.

• What the feedback would look like.

• What stress management or coping skills would be included.

• When the student would they use it.

• What information the student got about on-campus services.

• Whether or not they followed up with counseling center services and why.

After 15 minutes, each group shared their storyboard. The workshops concluded with a brief discussion of final ideas and reflections on each other’s ideas, and allowed time for questions to be answered.

Phase II – Individual Design Interview Participants

In the second phase, the lead author conducted individual semi-structured interviews with 15 students and 4 counseling center staff members. Counseling center staff members were recruited via email and by presentation at a staff meeting. All counseling center staff members were eligible to participate. For students, in addition to being at least 18 years old and enrolled at one of the participating universities, inclusion criteria specified that participants should have at least moderate symptoms of depression or anxiety, to ensure that the resulting app design would be accessible to students experiencing mental health symptoms. Depression and anxiety were measured by a score of greater than 10 on the Patient Health Questionnaire (PHQ)-9 or Generalized Anxiety Disorder (GAD)-7 scales, respectively [41, 71]. Students were recruited through print advertisements at multiple locations on campus, emails sent through student organizations, and emails sent directly to co-design study participants who agreed to be contacted for future research. Interested students were sent an online screening questionnaire to establish eligibility. As seen in Table 1, participants were predominantly female and were ethnically and racially diverse.

Table 1:

Individual Interview Participants

Part.	Age	Race	Hispanic or Latino	Gender
1	23	African American/White	No	Female
2	21	African American/White	No	Female
3	24	Asian	No	Female
4	28	African American	No	Female
5	28	Asian	No	Female
6	18	White/More than one race	Yes	Female
7	27	White	No	Female
8	22	White	No	Female
9	22	More than one race	No	Female
10	25	More than one race	Yes	Female
11	21	African American	No	Male
12	31	White	No	Female
13	25	Declined to respond	Yes	Female
14	19	White	Yes	Male
15	23	African American	No	Female
S #1	39	White	No	Female
S #2	35	White	No	Female
S #3	62	White	No	Female
S #4	39	African American	No	Female

Phase II – Individual Design Interview Procedures

The interviews lasted approximately 45 minutes. The first 15-20 minutes of the interviews were focused on college student mental health care. Participants then were presented with a wireframe prototype of the stress management app for students that had been developed based on ideas generated during the co-design workshops. Participants were asked questions regarding design preferences. At the end of the interview, mock-ups of advertisements for the tool were presented to student participants to gain insights on how and in what settings they would like to learn about this new tool.

DATA ANALYSIS

Co-design workshops and individual interview sessions were audio-recorded and transcribed. Due to the nature of the recordings and transcriptions, individuals could not be uniquely identified in the co-design workshops, and thus data from these workshops are labeled with “co-design participant.” Data from the individual interviews are labeled with participant identification numbers. The workshop and interview transcripts served as the primary data source and were analyzed by the authors using an inductive thematic analysis approach primarily focused on identifying semantic themes based on Braun and Clark’s methodology [12]. This method allowed the coders to become familiar with the data as they systematically organized individual codes into broader themes. To provide an example, “Challenges of in-person services for mental health support” (code) → “Peer’s Influence on Seeking Help” (subtheme) → “The Role of Known Peers” (theme). Transcripts were read by two members of the study team, and preliminary codes were discussed between these two coders. A codebook was developed and coding was completed on all transcripts using the qualitative data analysis program NVivo. The authors met regularly throughout the analytic process to discuss the codes and ensure validity.

FINDINGS

Consistent with past research on college life and the developmental stage of emerging adulthood [6], college students who participated in this study lived in a tightly-knit social environment where other individuals, in particular peers, played a significant role in their lives. The influence of others was present as students discussed their barriers to traditional mental health care, their existing coping strategies, the types of digital mental health tools they desired, and the ways in which they would want to learn about digital mental health tools. Below, we highlight these areas through describing the roles of known peers (i.e., similar aged individuals with whom an individual has relationships), unknown peers (e.g., strangers found online who share mental health concerns) and non-peers (e.g., faculty, family).

The Role of Known Peers

Connecting with known peers (e.g., close friends) in the college student social environment was often discussed by students and counseling center staff as a coping strategy employed by students. Known peers could be both supportive and unsupportive for mental health and wellness. For instance, some peer activities were brought up as unhelpful for mental health – namely, using alcohol and drags with friends to escape the stress of college life. The social use of substances was brought up by many students and by the majority of counseling center staff interviewed.

However, more often, peer relationships were discussed as a resource for support. One participant noted that friends are easiest to get support from, since “they are very reachable. In the sense that I, we live together. ” (Participant #8) Because social relationships were prominent and friends can be highly embedded in one another’s lives, there were nuances observed in how known peers (including friends) served as barriers and facilitators to help seeking.

Peer’s Influence on Seeking Help

For both student and non-student populations, there are a number of barriers to accessing traditional mental health care services (e.g. face-to-face appointments for counseling, psychotherapy or medication management) [20, 22, 49]. Our participants discussed many well-established barriers to care, such as cost, time, and inconvenience. More commonly, though, they reported barriers reflective of their social environment. There was a distinct fear of being negatively perceived by peers who learn about their accessing mental health services. Some of these fears were based on perceived response while others were a result of actual interactions. As one participant, with a history of seeking services at her college counseling center noted,

I was just afraid like, ‘Oh what if I ran into someone I know’ like coming in here even like outside on the stairs. (Participant #1)

These sentiments were echoed by another student who had disclosed to friends that she was receiving mental health care, and whose friends initially misinterpreted and magnified the gravity of her mental health situation in a manner with which she was not comfortable.

Saying what I was doing, like saying that I was going to therapy … I was like, ‘Oh, I don’t want them to think like I’m like ‘crazy’ or something’ you know what I mean? (Participant #2)

While these participants had felt comfortable enough to seek out traditional services, their concerns about how others evaluated them appeared fairly pronounced. For some, this fear of negative evaluation from others became internalized. One participant stated,

I guess with the peers also just like feeling guilty thinking that you couldn’t deal with whatever’s going on at the moment on your own. (Participant #5)

This suggests she evaluated her own help-seeking in relation to the behavior of others.

However, peers could also be supportive. One participant reflected on how a close friend changed her perception of therapy.

For most of my life, I thought like therapy like and going to the therapist, I was like, … ‘There’s like something seriously wrong with you if you do that.’ But then, actually, right before I came to college, I was hanging out with this girl who I’ve known my whole life, and she was telling me all these things about how like she was going to therapy, and I was like ‘wait. ‘ … she just really changed my whole perspective of like what therapy can do for you. And just like, that it’s okay to like want help … so I was excited. I was like, ‘You know, maybe I would benefit from that.’ (Participant #2)

As the above quote highlights, close friends (a type of known peer) can play a valuable role in supporting and promoting mental health care, and help to set norms regarding the acceptability of services.

Designing Digital Mental Health Tools for Known Peers

Peers not only could normalize help-seeking, but in some cases would share information with one another and even encourage the use of existing digital tools for mental health and wellness. Discussing her ongoing use of a popular meditation app, one participant stated,

One of my friends told me about it. She’s like a big yogi, so she told me to do it… she got word of this like meditation challenge. So, we were like doing it together and like holding each other accountable. (Participant #10)

Here we see that leveraging existing social relationships facilitated deeper engagement with and accountability toward digital health tools.

As the development of digital mental health tools was discussed, the importance of social context was apparent. In particular, these tools would need to address the ways that individuals found themselves frequently co-present with peers, but did not always feel socially connected.

Co-presence of others raised concerns about privacy, since students often lived in relatively small, shared spaces (e.g. room sharing is common). They noted a lack of reliably private space for phone calls or conversations. Consequently, multiple students discussed the need for text-based resources about mental health, which could be accessed discreetly while in the presence of others.

Individuals also noted that, despite the frequent presence of others, this did not always translate to feeling socially connected. Some reported “feeling alone” in the presence of others. The widespread nature of personal technology, including social media and music streaming from smartphones, was occasionally viewed as contributing to isolating people:

Nowadays everybody has earphones in and I mean it’s just so easy now to not to just fly under the radar. And I think technology just helps people ignore not only their problems, but everybody else’s too. (Participant #2)

Early in the course of data collection, it became clear that digital mental health tools for college students should not focus exclusively on the online world, but also build positive connections with peers face-to-face, so that they might move from co-presence toward a sense of community. One participant suggested,

Use it to build a community, so resources could include connecting in person, rather than just online with other individuals or resources. (Co-design participant)

There were abundant requests for a digital mental health tool to list events on campus and information about different organizations, and this appeared in line with the recognized need for mental health promoting strategies to be embedded within social contexts. Students wanted to be reminded of not just organizations and events, but also of known supportive people to whom they could turn when feeling stressed, as when one student proposed:

You can enter in names, pictures, or whatever. So, if you’re ever feeling alone, you can look at it and be like, ‘Look at all these people that I can talk to right now.’ (Co-design participant)

Participants also described wanting digital tools that could not just help them, but also allow them to provide support to peers who may be struggling with mental health concerns. Some spoke of features that would allow them to offer anonymous affirmations to others. However, features for helping others need to be designed with the limitations of students in mind. As one participant commented, information on providing help to friends should,

Make it clear that if you do help a friend you are not like a therapist or anything. So, kind of like putting boundaries and all of that … Like, if you wanna help someone, you can listen to them and provide suggestions and like that’s all you have to do, like, you don’t have to go like above and beyond. (Participant #10)

Finally, the prominent role of peers was apparent in the ideas discussed for effectively spreading the word about a resulting digital mental health tool for students. Since perceptions and decisions regarding mental health tools were largely guided by individuals’ relationships with peers, the primary ways in which people wanted to learn about tools were word of mouth type strategies. The importance of informal word of mouth recommendations became apparent through the storyboarding activity conducted during co-design workshops. Having participants generate stories about a hypothetical student’s journey with the mobile stress management program resulted in deeper insights into the role of peers and the value of word-of-mouth dissemination strategies that had not been identified during the brainstorming exercises. Multiple storylines included students recommending the hypothetical app to other students, and the phrasing around these recommendations appeared vital to the acceptability of the message. As one student stated,

And for our story, we had a friend who is suggesting the app to another friend, and he said, ‘Hey, I use this app daily to help me stay positive while at school,’ and we didn’t say, ‘Hey, I have a problem; you should use this, too.’ So, we said, ‘Just to stay positive at school,’ and his friend responded, ‘I’m sad, but I’ll try it.’ (Co-design participant)

Consistent with the centrality of peer influence, strategically engaging students in leadership positions was frequently mentioned. Participants discussed having student-led campus clubs and organizations take the lead on promoting tool availability to their members. As one student noted,

Having student organizations – this be a requirement that they talk about this at the beginning of the year with members to destigmatize use. If it’s coming from other students, they might be more likely to use it versus think that they’re the weird person because they’re using this. (Co-design participant)

Setting a social norm around tool use appeared to be a particularly important role for peer leaders to play, and there was also discussion of having peer student housing staff, community advisors (CAs) or resident advisors (RAs), spread the word on tool availability. Student housing staff play a unique role on campuses both as fellow students and as leaders within residence halls with responsibility to support the students on their floor.

As far as the CAs, just bring it up at the floor meeting, because after syllabus week, you’re like, ‘Hey,’ and just bring it up, I guess, at the end of the meeting and say, ‘If you need any help navigating it, I’m here to help you,’ and just have the CAs be a resource for the app, as well. (Co-design participant)

In general, students were looking to a variety of peers for positive messages about mental health and wellness and to learn about accessible methods of receiving mental health support.

The Role of Unknown Peers

In an increasingly digital world, college students have access to unknown peers, and there appeared to be a strong desire for connection broadly, rather than exclusively focusing on maintaining or strengthening connections with known others. Unknown peers can play supportive roles and serve as resources that are perceived as relevant and meaningful to college students. These were not peers in the sense of necessarily sharing a stage of life or a college student identity, but instead were united around shared mental health challenges and desires for connection.

This interest in connecting with unknown peers may stem from multiple causes. While college students are often surrounded by known peers, many reported that they didn’t feel comfortable talking about their mental health with people they know, and instead made use of online searches to normalize symptoms and issues.

Yeah, if you search online… for anything you’re feeling about…, and you look around, you feel like a lot of people are going through the same things that you’re going through. And so you realize you’re not the only one… Just knowing that a lot of other people in the United States or in the world are going through whatever you are going through, this is a supportive thing. (Participant #8)

While known peers may provide direction and accountability, unknown peers may play a significant role in helping students feel supported and understood. Students reported that they have sought support from both known and unknown peers who could validate and normalize their symptoms. As students can increasingly use technology to connect with unknown peers with shared interests and experiences, interactions with unknown peers can provide students with a more diverse social support network.

Access to social support networks through social media has also shifted the landscape in which college students seek and provide support to one another. Some students described using social media as a generally positive coping strategy such as:

I know for a fact… social media definitely… for Facebook and others, I always see posts about… “Whoever is having a bad day just like remember you know, you know you’re a good person.” Just… helpful positive things so… I know for a fact because I always see it in Facebook… someone’s always sharing something about… ‘I don’t know who needs to hear this but you know you’re a good person’ so I know that it can definitely help. (Participant #14)

Receiving this relatively passive form of support, in which the participant was reading a message that was not specifically meant for him, was deemed as useful and motivating.

As participants brainstormed features they would like to see in digital mental health tools, they expressed desires for technologies to enable them to socialize with and seek support from unknown peers, although the specific communication channels varied. One participant recommended Facetime, noting,

That would be good if you’re maybe feeling lonely, like you see everybody else Facetiming, so that would be a chill way to just talk to somebody and have somebody to talk to. (Co-design participant)

Others specified a preference for text-based communication, emphasizing the anonymity it can provide.

I think that is a really important point because when you’re struggling with that it’s hard for you to admit to other people that you are. And it’s kind of nice to have an anonymous community if you’re not really open to sharing with a lot of people. And so, it does kind of create a community without saying it out loud that you are struggling with something. (Co-design participant)

These desires appeared to stem from how challenging it can be to disclose mental health struggles to others, and appeared to be reciprocal in that people wanted to both provide and receive support to one another. One student mentioned that she would like “ways to get involved or help other students with their struggles with mental health or that wanna talk about it.” (Co-design participant)

In addition to synchronous digitally mediated communication with unknown peers, participants also valued asynchronously accessing the experiences and recommendations of unknown peers. The idea of having peer-generated content came up frequently in the co-design workshops and the individual interviews. These ideas ranged from providing lists of tips to more multimedia rich content including,

I would wanna watch videos of someone who’s going through the same situation as I am. Maybe hearing what they have to say, how they feel, like, ‘Oh, yeah. I feel the same way. ‘ What they did, so that I can solve the problems or something. Their experience, all that. (Co-design participant)

Students seeking both a sense of understanding and problem-solving strategies commonly desired the lived experience of peers, whether known or unknown.

The ability to leave and view feedback on mental health strategies was consistent with broader social norms, with students likening this to being able to read online reviews prior to making purchases or decisions:

You could click that one and then you could find out… other people’s responses like what helped them and stuff like that… Because… whenever I wanna buy like something or whenever I wanna… go do something but… I’m not sure about it, like if I’m gonna buy a new Macbook or something, I’m gonna go to the reviews, because. hypothetically some problems might occur with this Macbook. (Participant #14)

Because students are used to being able to access the opinions and experiences of unknown peers through online platforms, it follows that they are interested in relying on those opinions and experiences when making decisions about their mental health management.

The Roles of Non-Peers

Relationships with peers, both known and unknown, were commonly discussed throughout this elicitation work, but they were not the only relevant and important relationships discussed. Additional roles emerged as relevant, including faculty, parents, and members from one’s own culture. While peer-led word-of-mouth campaigns were most commonly identified as a way to spread information about digital mental health tools, non-peers could also play a role in spreading awareness and normalizing use of these tools. For instance, participants discussed that faculty members could introduce and support the use of mental health tools by introducing the tool in class, or potentially listing information about it on their syllabus and/or online class portals.

Similarly, there was recognition of the support role played by parents, which often included the provision of emotional and informational support. Because parents play an important role in the lives of many students, participants encouraged the idea of having parents receive information about the tool during orientation because “parents might be pushing their kids to use it more.” (Co-design participant) Thus, there are several other non-peer adults that are relevant to the dissemination of digital mental health tools.

Participants were also attuned to how the roles played by non-peers can be culturally dependent. There was a general consensus that stigma around mental health has decreased in mainstream American culture in recent years, but that perceived stigma was clearly still present and more pronounced within certain cultural groups. Individuals from those groups were not likely to discuss mental health issues with their parents, particularly if they perceive their parents as having stigmatizing views on mental health. As one Korean American participant commented,

In present media there’s like a lot of shows like addressing mental illness but I know for even like a lot of cultures that’s like a huge thing and at [university] there’s diversity. Even in, like I’m Korean, and my parents don’t really believe in that. So, it might be like what you’re brought up with. A lot of people don’t really talk about it. And you know, people shrug it off when it should be like a really big issue if you do have a mental illness. (Participant #3)

Cultural and other identity-based concerns also included the potential “fit” with an assigned counselor or therapist. As clinicians at both university counseling centers were predominantly white, students noted concerns such as,

Finding maybe like a counselor that is maybe like a person of color or like culturally competent, that is also a barrier. (Participant #10)

Having a poor “fit” with a clinician can be associated with premature termination of treatment [38, 44, 75]. This was echoed by a participant:

For a lot of students who eventually get through the process of actually getting to a counselor of some sort, if they don’t like the person, like don’t match with them then they might be like disenchanted, or like you know persuaded not to continue pursuing. (Participant #12)

Mismatches with counselors can be problematic, as individuals often interpret a failed therapeutic relationship as indicating that therapy is ineffective for them.

DISCUSSION

This study examines American university students’ mental health needs and desires for digital tools, as well as the contexts in which students want to learn about and use digital mental health tools. In our findings, we identified the pivotal roles that others play within the social ecosystem of college student life. Social connection was at the forefront of discussion throughout our elicitation work. Our findings highlight the predominant role of known peers, and the ancillary roles of unknown peers and non-peers. Known peers were most heavily discussed and appeared to play the strongest roles in student interest in and decision making on mental health tools, while unknown peers and non-peers played smaller and less discussed, yet important roles.

These findings are consistent with the psychology literature which emphasized socialization and identity formation as key parts of the developmental trajectory for typical age college students [6]. The late teens and early twenties are rife with change for many young people, and as individuals explore and form their own identities, they typically identify heavily with their social networks [5]. While existing models of social ecosystems [13] and social support networks [73] provide an overview of social factors relevant to college students, our findings highlight that the college student social ecosystem is unique in the intensely prominent roles played by peers.

Through this study, we build on Park’s [59] “Mosaic of Social Support” by highlighting the roles of other individuals in forming personal concepts of mental health and help-seeking and offering social support. Park emphasized the role of social support in navigating existing mental health resources, and focused on student needs when building social support groups, the types of tailored support provided by each type of group, and the limitations participants experience with each group. Our study extends this work by examining how mental health resources could be designed and disseminated to better reflect the importance of social relationships, highlighting the role of known peers, as well as the ancillary roles of unknown peers and non-peers (e.g., faculty, parents). We found that individuals draw on all these relationships in making mental health related decisions. Thus, we clearly need to consider the varied social roles of college student life when thinking about the design of digital mental health tools and the implementation plans for those tools.

In the following section, we identify considerations for designing digital mental health and wellness tools for college students by discussing social factors identified in this study.

Designing for College Student Mental Health

There is a clear need to consider the social circumstances, and roles played by other individuals, when designing digital mental health tools for college students. While individuals report interest in a number of tools and services that can be delivered digitally (e.g., relaxation exercises, information about campus resources), the social circumstances of college life often dictate ability and interest of individuals to engage with tools. In this section, we detail a number of items which designers of digital mental health tools should consider.

Little alone time

The prototypical social experience with very little alone time needs to be considered. As students are often living with peers in relatively small spaces (e.g., room sharing is common), they often do not have reliably private space for phone calls or conversations. Thus, there was a need expressed for text-based informational resources, which could be accessed discreetly while in the presence of others. This reflects other work in HCI on mental health which has found that individuals want to use different communication modalities (e.g., text, voice, face to face) based on their current need for privacy [14].

Gaining support from their peers

Reflecting the dominant role of peers, students often want to learn about mental health and wellness from one another rather than only from an authority figure. This was evidenced in our data by the requests to have student-generated content, testimonials from users, and reviews of coping strategies. Resulting digital mental health technologies should consider methods for generating these social connections around mental health information and support, whether that be through direct communication (e.g., message boards, chat features) [58], testimonials about representative problems [64], or other means. However, user generated content comes with a variety of challenges and there is a risk of inappropriate or incorrect information being provided [2, 52]. Particularly in the context of tools focused on health and wellness, it is important that messages conveyed are safe, inclusive, useful and evidence-based. To balance the desire for student-generated content with the requirement that messages are safe, inclusive, useful and evidence-based, specific strategies, such as pre-screening user-generated content or routine monitoring of content with removal of items deemed inappropriate, may be required.

Desire to connect with “real world” resources

While the current generation of adolescents and young adults are often criticized for the amount of time they spend online [77], we found that students often wanted to use digital mental health tools to connect with resources in the physical, rather than online, space. There was a clear desire to be more involved in “real world” situations (e.g., social events held by campus organizations, meeting with existing student support resources). For digital mental health tools to be engaging for college students, they may need to consider the campus environment and community resources available to students and provide support for students to more healthfully engage with their community so that they may build relationships with peers and non-peers.

Framing the tools for “well-being”

The utility of digital technologies for mental health will therefore be influenced by the rich social context of college life. The extent to which these factors are applicable to other digital health tools (e.g., those focused on different areas of physical health, such as sleep, diet, and exercise) is not definitively known from this study, yet results suggest the social ecosystem should be considered when designing digital health tools for college students. Positive behavior change often involves leveraging social support and ensuring behaviors generalize across contexts, such that digital tools need to help individuals engage in the behavioral targets in varying contexts of their day-to-day lives. Unique to the mental health context of this study, a key design preference arose around the de-emphasis on “mental health” or clinical language [63]. Consistent with past research, several participants spoke of existing stigma around mental health issues and mental illness, and noted that this stigma can serve as a barrier to accessing treatment and support [31]. There were suggestions to promote use of a digital mental health tool as a means “to help stay positive” as well as requests to make the interface and content of the tool “as least morbid as possible.” Thus, it might be more appropriate to design digital mental health tools to not immediately be recognizable as focused on mental health. This also echoes work in assistive technology that calls for technology to help manage stigma and work beyond the mental health condition [26, 62, 70]. Rather, there was considerable interest in using tools that focus on self-care and are “less mental health infused.” For instance, explicitly using behavioral strategies known to be effective for mental health, such as encouraging physical exercise, relaxation practices, and prompts for social connections, may be more acceptable to college students than an explicit focus on depression or anxiety and may facilitate enhanced peer-to-peer communication about the strategies.

Accessing the peer network to disseminate digital mental health resources

These considerations should be paid not just in the design of the digital technology platform but also in the implementation plan for the digital tool. An implementation plan is a schedule of the activities, costs, anticipated difficulties and proposed solutions that are needed to effectively deploy a tool into practice. As noted in the introduction, there is a large research to practice gap in the space of digital mental health tools and most tools developed and tested in clinical trials fail to be taken up in real world care settings, including college campuses [42, 50]. Consistent with the emerging field of implementation science and with marketing research, health care innovations are unlikely to succeed in the absence of strategic efforts to embed the innovation into the day to day experience of the intended users [7, 10, 18]. In a crowded healthcare marketplace, the days of “if we build it, they will come” are over. HCI researchers designing technologies to support health and wellness should consider simultaneously working on the design of the implementation plan for the technology they are designing, which in this context, would account for students’ social ecosystem.

Implementation plans can take many different forms [17, 33] and, in this study, word of mouth campaigns were prominently identified ways in which participants would want to learn about digital mental health tools available to them. Thus, an implementation plan for a digital college student mental health tool would likely extend beyond typical plans for establishing the hardware, software and approvals needed to make the tool available, and include the development of relationships needed to enact word of mouth campaigns within multiple levels of the student social ecosystem. The implementation plan may also leverage technology to support the implementation, for example, information about the digital mental health tool could be included in existing student web portals and on the college’s course management system.

LIMITATIONS AND FUTURE WORK

While we attempted to recruit a diverse sample of students and clinicians, we recognize that our sample could be biased towards individuals particularly interested in digital mental health tools and towards individuals who are more involved on campus. Thus, it is unclear if the results are fully representative of the needs and preferences of all college students, particularly those who may be unlikely to engage in discussions surrounding mental health. Additionally, this sample is potentially less representative of non-traditional students, such as those that work full-time in addition to attending classes or live off-campus with partners and children. Future work should consider online design activities that may appeal to students uninterested in in-person activities, particularly because these may be the students who could benefit most from digital tools.

Furthermore, our discussion was primarily focused on common mental health conditions, such as depression and anxiety in the United States. Thus, the design implications may not be immediately generalizable when considering mental health technologies to support more serious mental health conditions, such as schizophrenia and when considering mental health technologies to support students in non-Western cultures. Further work should examine how mental health technologies can support more serious mental health conditions as well as the type of appropriate support for students in different cultures.

CONCLUSIONS

This study examines university students’ mental health needs and desire for digital tools, as well as the contexts in which students want to learn about and use digital mental health tools. The important roles played by known and unknown others was evident in how students discussed their barriers to traditional mental health care, their existing coping strategies, the types of digital mental health tools they desired, and the ways in which they would want to learn about digital mental health tools. We contribute to the HCI literature with the identification of this rich social roles that appear to drive college student interest and decision making around use of mental health resources. We further contribute by identifying opportunities for designing and implementing mental health technologies in ways that match the identified social considerations.