There is growing concern about the mental health and wellbeing of higher education (HE) students [1–4], not least because of associations with academic performance. Higher education institutions (HEIs) have an obligation to provide support for the mental health and wellbeing of their enrolled students. Demand for student support services (SSS) is increasing [5], which is likely to result in increased waiting times before students receive support. This may increase the risk of their problems escalating, and may lead to negative consequences for both the individual and HEIs. The proportion of HE students who fail to complete their studies has recently risen to more than 22 % in the UK [3]. Recent UK HEI fee increases [6, 7] add further pressure on HEIs to be cost-effective, show quality and value for money, and enhance ‘student experience’—an important influence on the ratings, intake, and income of HEIs.
A number of reports have documented the mental health problems experienced by HE students [2–4, 8–10]. This literature indicates a high prevalence of mental health problems, although there is an absence of well-conducted studies in this area. Responses to a recent electronic survey conducted by the UK National Union of Students showed that 8 % of the students identified as ‘having a mental health problem but not seeking diagnosis’, 2 % identified as ‘currently seeking for a diagnosis’, and 10 % of students identified themselves as having been diagnosed with a mental health problem and believed this diagnosis still applied to them [10]. Alongside this, the Royal College of Psychiatrists [4] noted that 4 % of HE students in the UK seek help from a counsellor for emotional and psychological difficulties each year. Official statistics from HESA suggest that the proportion of students in the UK declaring a mental health difficulty on entry to university has gone up from 0.5 % between 1994 and 1995 to 3.6 % between 2006 and 2007, while numbers have doubled between 2012 and 2013 [6]. A much larger proportion experience psychological or study skill-related difficulties that keep them from achieving their true academic potential and enjoying the university experience to its fullest [4, 9]. This finding is supported by another UK study that found 90.5 % of students surveyed would rank exams or assessments as reasonably stressful or very stressful, while other stressors identified included time management and deadlines (83.3 %), and considering career prospects (75.2 %) [11].
Alongside these challenges, HEIs are facing major cuts to their budgets. In the last UK Governmental Spending Review, cuts of up to 40 % over 4 years were announced [12]. This further challenges the ability of UK HEIs to offer effective student support services. On-site SSS exist to deal with students’ psychological and study skill difficulties, yet limited resources mean that they struggle to cope with the high demand [4, 9]. In some cases, the average waiting time between referral and assessment for counselling is 9 weeks, i.e. more than one academic term [13]. Seeking help via private routes is an alternative option, but usually at a cost unlikely to be affordable for most students. A further concern is that the high demand reported is unlikely to mirror true needs. As many as 30 % of students would not feel comfortable to report their concerns [11], and consequently their needs remain unidentified and thus unmet.
Therefore, alternative means of supporting students should be sought, especially for students who experience mild to moderate difficulties that impact on their studies and student experience and whose needs are not prioritised within HEIs SSS. The Royal College of Psychiatrists [4] has proposed ‘to increase the availability of, and access to, self-help programs such as proprietary or web-based interactive cognitive-behavioural therapy (CBT)’ (p. 20). Online interventions are effective, easy-to-use, low-cost, and can be used anonymously without the potential stigma related to face-to-face treatment [14]. The internet is rapidly expanding as a support tool for psychological problems [15] and as a platform for the delivery of psychological therapies [16, 17]. Treatment of depression using internet-based CBT or problem-solving therapy (PST) has been found to be successful [18, 19], and potentially as effective as face-to-face therapy [19]. A recent systematic review indicated that for many mental health problems, there is little difference between different self-help approaches and whether or not there was guidance and administration by a practitioner [20]. Moreover, internet-based support systems can offer access to psychological and study skill support for a complete cohort of students across each HEI, overcoming the time and resource limitations to which traditional support services are subject.
However, there is limited literature regarding existing internet-based support systems specifically designed for HE students. The few online systems that are on offer to address psychological needs of adults, such as ‘MoodGym’ [21], ‘e-couch’ [22], and ‘Living Life to the Full’ [23], are designed for the general population. A system currently on offer by some HEI for the support of their students is Computer Aided Lifestyle Management (CALM), but there is very limited material describing its development or investigating its feasibility, effectiveness, or student satisfaction [24]. Another online psychological treatment is the ‘SilverCloud Health’ platform [25], which provides help and support packages. Current programmes available target symptoms of depression, stress, anxiety, and eating disorders. However, neither ‘SilverCloud’ nor ‘CALM’ address study skill problems. MePlusMe will fill this gap.
MePlusMe
Recently, iConcipio has developed an online multimedia intervention called MePlusMe, which meets the need for a system addressing mild to moderate psychological and/or study skill difficulties of HE students. It is an easy-to-use system offering two different routes, a symptoms-route (‘Questionnaire’) or a techniques-route (‘Library’), to access support techniques that match differing styles and needs, ensuring maximum flexibility and utility of the system. Students can practice these techniques in their own time and space, as and when needed, whilst using a rating system to monitor their progress. This ongoing self-management aims to promote students’ personal effectiveness in addressing internal challenges and environmental demands. The self-monitoring process is further supported by a messaging service, in the form of motivational reminders to the user’s inbox within the system, to their personal email accounts, and, if they choose to, to their personal mobile phone. These messages encourage them to return to the system to practise the techniques and complete the post-intervention measures. Furthermore, a social network where students can post their thoughts on the ‘Thought Wall’ and other students have the option to ‘like’ or ‘share’ these thoughts in other social media (Facebook and Twitter) is present, allowing students to interact with each other anonymously for mutual support.Footnote 1 This built-in community of students acts as an additional support resource, normalising the students’ experience and giving them a feeling of belonging and fitting into a group. The social network is monitored and regulated by expert facilitators. Moreover, a number of filters are embedded within the system to ensure that only students with mild to moderate difficulties are using it. Where applicable, those with more significant difficulties are referred to more appropriate services, such as their HEI student support mechanisms or mainstream helplines and help centres.
Students who want guided help can start using the system by completing the Questionnaire (symptoms-route). This interactive questionnaire follows a specific taxonomy to identify students’ psychological difficulties, focusing on anxiety and depression symptom. Additionally, symptoms of anxiety and depression have a high comorbidity. This was taken into account in the development of the initial Questionnaire, which differentiates between students who experience only anxiety symptoms, only depression symptoms, or a combination of both. The Questionnaire was designed to differentiate between the different types of presenting problem that were identified during development of the system as most prevalent in the target group (students) and for which there was clear evidence for the effect of this mode of supported self-help intervention.
The version of the Questionnaire in the described trial differentiates between three broad types of presenting problem, involving either predominant features of anxiety, or of depression, or mixed anxiety and depression features. The questionnaire statements have been adapted from established tools, including clinical questionnaires (Hospital Anxiety and Depression Scale [HADS] [26]; 7-item Generalised Anxiety Disorder Scale [GAD-7] [27]; Patient Health Questionnaire [PHQ-9] [28]) and a formal interview (Mini International Neuropsychiatric Interview [MINI] [29]). The HADS, GAD-7, and MINI informed the choice of anxiety questions. The HADS, PHQ-9, and MINI informed the choice of depression questions. iConcipio undertook extensive pilot testing (n = 491) that showed these questionnaire items to be acceptable and to effectively provide initial filtering of presenting problems (Tzotzoli, personal communication). However, the Questionnaire is designed in such a way that it is expandable. Future launches of the system may include more questions and thus may cover a wider array of psychological difficulties. Upon completion of the Questionnaire, a package with techniques is suggested based on the best-fit intervention tailored to students’ identified needs.
An alternative route that can be followed by students is via the Library (techniques-route). Here, students can freely browse all the available psychological and educational techniques and create a personalised package to help them improve in the areas of personal effectiveness on which they choose to focus. Both routes lead to a personal space called ‘My Place’, where students will find their package of techniques, either the package assembled for them as determined by their ‘Questionnaire’ answers or the package that they have assembled themselves in the ‘Library’.
The psychological techniques are derived from CBT. There is strong evidence supporting the effectiveness of CBT in addressing a range of emotional difficulties and associated behaviours [30–33]. Techniques considered by the expert clinical team to most likely be acceptable, feasible, and effective in the target HE population were selected for inclusion in this intervention. The educational techniques consist of the most up-to-date practical skills, extensively tested and shown to improve students’ performance [34]. They aim to help students focus their efforts better and develop successful study skills and strategies.
The techniques are presented in the form of animated videos which demonstrate evidence-based psychological and/or study skill techniques. Videos are a pioneering media for communicating evidence-based techniques to non-expert audiences, as research shows that multimedia aids learning by engaging both verbal and visual information-processing channels [35, 36].
The system has a ‘bottom-up’ design, following a symptoms- and a techniques-driven approach, to avoid the potential stigma that may be associated with applying labels to difficulties. It aims to achieve more effective and immediate results by focusing on how to ‘cope’ better with the student’s current challenges. The language, visual appearance, and feel of the system are also chosen carefully to address its target group. Overall, this online intervention is based on current scientific knowledge and best practice, and provides a mosaic comprising implicit (e.g. nudge theory, [37]) and explicit (e.g. relaxation) state-of-the-art psychological and educational strategies (e.g. how to prepare for exams).
Development
The development of MePlusMe has followed the Medical Research Council (MRC) guidelines for developing complex interventions [38]. The system has been developed in three stages, in collaboration with both students and HE providers. Initially, we conducted two market research projects. The first targeted counsellors and psychologists working in HEI SSS, using a semi-structured interview to collect information regarding the operation of existing services, and their common practices, needs, and challenges. The second project was conducted with HE students via an online survey, which will be detailed in a future publication (Goozée, Papadatou-Pastou, Barley, Haddad, & Tzotzoli: Survey to inform the development of an online support system for higher education students: a brief report, sumitted). This research sheds light on the most common difficulties that students face at universities, their opinions of online support systems, and what features they believe make such systems useful.
Recently, a proof of concept study was completed with the participation of five UK HEIs (King’s College London, University of Edinburgh, University of Roehampton, Bournemouth University, and University of Warwick; n = 873 students) to ensure that the development of MePlusMe is acceptable and reflects end-users’ needs [Touloumakou, Goozée, Papadatou-Pastou, Barley, Haddad, & Tzotzoli: Elearning support system for HE students with psychological and study skill difficulties: proof of concept study,” submitted]. During this study, uncertainties that were identified in the development of the system were examined, and feedback regarding the system’s acceptability and feasibility was obtained. Encouragingly, preliminary data showed that students like and need such a system.
In addition, an in-depth discussion with executives from HEIs took place following testing to gather their thoughts and opinions. This feedback alongside findings from the proof of concept study allowed refinement of the initial design. As an example, wording and graphics were altered to better appeal to an older student group, as well as younger students.
Moreover, the system is being continually developed in collaboration with two advisory boards. Firstly, the universities’ advisory board (UAB) ensures that MePlusMe addresses the requirements of HEIs services, as well as student needs. Secondly, iConcipio’s research and clinical team, consisting of senior academic and clinical psychologists from various HEIs and NHS hospitals, ensures that MePlusMe adheres to the best psychological practice, and that all research projects follow relevant guidelines.
Aims of study
Following the activities outlined above, a full-scale feasibility study is now warranted. The study will commence in spring 2016 and recruitment of HEIs started in spring 2014. The study will evaluate the feasibility, acceptability, and potential effects of MePlusMe. It will specifically evaluate potential effects on students’ mood (symptoms of anxiety and depression), mental wellbeing, study skills, and everyday functioning, and their engagement and satisfaction with the system. This paper describes the protocol for the feasibility study. This is a crucial step, as its intended outcomes will inform a randomised controlled trial (RCT), leading to a wide-scale incorporation of the system within HEI SSS.