Developing and Evaluating a Stepped Change Whole-University approach for Student Wellbeing and Mental Health

Promoting good mental health within university students is a priority. Anxiety, depression and self-harm are rapidly increasing. University mental health services report demand beyond their capacity. Effective ways to prevent student mental difficulties are urgently needed. Further, university should be a positive life experience and promote students' emotional fitness and ability to thrive.

Research and student feedback recommend changing university culture, environment and teaching to promote wellbeing. Stepped care in which students move through different steps based on need is also suggested to improve student wellbeing and service capacity. This starts with wellbeing promotion and prevention for all students, steps up to self-help for those with mild symptoms and to professional support for those with elevated symptoms. However, these approaches have not been rigorously tested in universities. We don't know which elements best promote good student mental health. We don't know what approaches work best for the diverse student body across gender, ethnicity, sexuality, sociodemographic background. We will test initiatives within the university environment and at each of the steps, see which initiatives students use, how well they work, and identify which work best for which students across diverse groups. Students will be active partners in shaping, delivering and evaluating all research.

We will use repeated twice-yearly online surveys across 6 universities (110k undergraduates) to assess student wellbeing and mental health and understand what helps or hinders students seeking and getting help. A digital self-monitoring tool allows students to track their wellbeing, stress, and what support they use over time so we can map how they move through stepped care and how different steps interact with each other.

To test whether changing university environment promotes wellbeing, first we will evaluate embedding compassion into education: teaching about diversity and mental health, practising kindness and understanding for self and others, and making assessment more flexible and responsive to students. Focus groups will explore how students experience this approach. Second, we will introduce a voluntary online mental health literacy course for first year undergraduates that teaches what influences mental health, how to promote wellbeing and how to seek help. Surveys before and after the course will test if it increases students' knowledge, healthy behaviours, helps-seeking and wellbeing.

To better understand how to make self-help work for students, randomised trials will test book-based guided self-help to build personal strengths, unguided digital self-help to prevent depression in high-worrying students and digital self-help for depression and anxiety. We will compare supported versus unsupported digital cognitive-behavioural therapy, meditation and peer support apps to find out which app(s) students find most acceptable and explore which students most benefit from. We will test self-help with and without support because unsupported self-help can reach vastly more people and there is uncertainty about whether and for whom supported self-help is more effective.

To improve the efficiency of student mental health services, we will test if adding a digital self-monitoring tool shared between student and clinician improves student experience and time to recovery by enabling care to be more proactive and responsive (e.g., more frequent meetings if symptoms rise).

From this research, we will develop an evidence-based integrated model of inclusive and acceptable student wellbeing and mental health support. In partnership with students and university leaders, this model will inform policy recommendations. We will develop guidance, courses and tools to promote student wellbeing that are easily added to existing systems or that use tried-and-tested low-cost technology to ease their adoption and ongoing use.

Our research involves a rigorous evaluation of whole-university and stepped care frameworks to promote good mental health in students using a multi-disciplinary approach drawing on the humanities, psychology, psychiatry, information technology and statistics, working collaboratively across 6 universities. To address objective 1, we will introduce different whole-university (embedding compassion in education; online mental health literacy course) and stepped care interventions (digital self-monitoring) in a phased way across collaborating universities.
To address objectives 2,3,5, a repeated biannual online student wellbeing survey at the start and end of the academic year, with cross-sectional and longitudinal components, will collect self-report quantitative data (demographics, mental health outcomes, process measures, attitudes, knowledge of and behaviours related to stepped care) from students across multiple institutions. Students can use a digital self-monitoring tool and electronic personal health record prospectively, with brief measures of wellbeing, stress, symptoms and use of support to address objective 2. We will test whether this tool helps students to better use stepped care. Observational experiments will collect pre- and post-intervention quantitative and qualitative data using a core set of outcome measures and examine data from biannual surveys to assess the impact of introducing each intervention. To address objectives 6, 7, focus groups will explore students' experiences of these initiatives including positives, negatives, areas to improve and relevance to diverse groups. To address objectives 1,4,5, randomised trials will compare different variants of digital self-help including guided vs unguided self-help. To address objective 4, pre-randomisation measures will assess potential predictors of heterogeneity of treatment effect. Repeated weekly web surveys within the trials will assess change in putative mediators to support objective 5.