MePlusMe is an online, multimedia intervention designed to meet the needs of students with mild to moderate psychological and study skills difficulties. The system offers assistance in supporting mood and wellbeing and in developing effective study skills. A rigorous approach to the development MePlusMe has been adopted. An initial consultation to help begin conceptualising the development of the system and to tap on the knowledge and experience of mental health providers within four HEIs; London School of Economics, University College London, King’s College London, and Kingston University. The questions focused on students’ most common difficulties at university, current practices and challenges within institutions, and inquired about the need for and design of a potential online solution. At the same time, HE students (
n = 61) were surveyed, using an online survey tool (to better understand their needs at university, their potential engagement with an online system, and their preferences with regards to features, functions, and style of such a system [
21].
Furthermore, in a proof-of-concept study [
22] 873 students from five UK HEI (King’s College London, University of Warwick, University of Edinburgh, Bournemouth University, and University of Roehampton) took the online surveys and their responses confirmed suitability of the system and that it addresses students’ needs in HE. These responses informed further development on the visual aesthetics, language, and functionalities of the system.
Fitness for purpose
There are two different routes into the available content, either through a ‘symptoms route’, which comprises of a questionnaire that assesses the individual needs of the user and provides a custom-built package of multimedia content that aims to address these issues, or through the ‘Library’, which relies on user selection of content, depending on their needs at the time. The content is then available for users to access at their leisure.
The ability to choose between the two available routes when using the system gives students control of how to access help depending on their situation at any given instance. Students who can identify their symptoms but don’t know what help they need can go through the Questionnaire route, while students who know what help they are after can go directly to the Library. The flexibility of this approach, which is integral to the system, aims to help students feel empowered by choosing how to get the help they need.
Furthermore, the Questionnaire has been meticulously developed through the adaptation of established clinical instruments to ensure effective differentiation between different categories of symptoms. Those instruments were the Hospital Anxiety and Depression Scale (HADS) [
25], the 7-item Generalised Anxiety Disorder Scale (GAD-7) [
26], the Patient Health Questionnaire (PHQ-9) [
27] and a formal interview (Mini International Neuropsychiatric Interview [
28]. The adapted Questionnaire was piloted on (
n = 491) students for its ability to provide an initial filtering process and identification of presenting difficulties [
35]. The main aim is to provide effective differentiation between three categories of presenting problems, namely predominantly anxiety, predominantly depression or a mix of both. However instead of a diagnosis, MePlusMe makes use of symptoms and links clusters of symptoms with specific evidence-based psychological techniques. Therefore, once the Questionnaire is completed the user is presented with a tailor-made package based on the identified needs. In other words, this bottom-up design allows students to visit the system as many times as they need during their studies and get immediately bespoke advice to address the specific difficulties they face each time. This is effectively the most innovative element of MePlusMe.
The system offers optional motivational reminders, provided as the default option of MyPlan, in the form of emails aim to encourage users to return to the system regularly. A self-rating system is used to monitor progress for 8 weeks and provides feedback to students at specific intervals in the form of a graph. At week 8 the students also receive a stamp (i.e., badge) with the message “I did it!” on their completed graph to reward their effort, perseverance, and achievement.
A within-the-system social network is provided for users in the form of a Thoughtwall—a space where students can post their thoughts and feelings whilst using the system; students can also share their graph once they completed working on a particular topic at the end of the 8 week period. This space is monitored by expert online moderators and thoughts are going live within 24 h. Engagement of users is encouraged, with the option of (a) ‘sharing’ their own posts, including a feature that allows users to post them onto other social media, like Facebook and Twitter and (b) ‘liking’ other users’ thoughts. Issues of anonymity have been addressed, by the ‘thoughts’ appearing under the username that was originally specified by users during registration. It is the users’ choice if they decide to share their thoughts under their username from their social media account [
35].
MePlusMe, uses a host of evidence-based techniques to address psychological difficulties. Evidence on the efficacy of online interventions [
36] and findings on the effectiveness of guided self-help as a mean of delivery compared to face-to-face [
37], informed both the design and the content of the system. In particular, cognitive behavioural therapy (CBT) and Problem Solving Therapy (PST) are the core behind the design of this online intervention system. As a result, techniques that have been shown to be successful in treating symptoms of anxiety, such as a Worry Decision Tree [
38], and of depression, such as Behavioural Activation [
31] have been incorporated into the design. Cognitive Defusion, a technique that can be used to deal with negative self-talk or thoughts [
31‐
33], is also part of MePlusMe’s toolkit. Techniques that can help with study skills difficulties (e.g., time management, staying motivated, and memory techniques) were also chosen.
All the above content is delivered through several channels. Animated videos, as well as short text have been utilised to present different materials within MePlusMe. This has been built according to the Cognitive Theory of Multimedia Learning [
39] and relies on the assumptions that the active process of learning, which involves filtering, selecting and organising information, can be facilitated through the use of different channels. This makes the assimilation of information easier for the user, and the learning process more effective.
The content, language, visuals, sounds and overall the feel, layout, and functionality of MePlusMe have been heavily influenced by students’ feedback following Goozée et al.’s survey [
21] and a proof-of-concept study [
23]. Examples of this outcome are: the specific difficulties (symptoms of anxiety and depression) targeted to be addressed via the chosen techniques, the way questions were phrased in the questionnaire and the language used in the videos’ scripts, the colours and graphics throughout the system including the voiceover and the male and female character featured in the videos as well as features such as the blackout button that allows students to “escape” quickly to another website. Furthermore, the system was carefully developed in order to consistently avoid using pathologising language and diagnostic terms and focuses instead on describing the symptoms and experiences targeted.
The ability for users to personalise the platform has also been added to the system. For example, students can choose their own pictures hanging on the “wall” or their own scenery from the “window”. Personalised products have been found to elicit greater emotional investment [
23,
40], thus this feature could increase the users’ ‘emotional bonding’ to the system. In that way it aims to promote repeated use and better engagement.
Target group and filtering processes
MePlusMe has been designed specifically to address the needs of HE students. The system targets needs that call for psychological and/or study skill support and which are relevant to the biggest subset of the student population that has largely been ignored thus far: individuals with subclinical symptoms of depression and anxiety that would perhaps ‘fall through the cracks’ of traditional support systems, or face long waiting times when seeking treatment. MePlusMe pitches itself to this big bulk of students who at some point during their studies will experience mild to moderate difficulties and has been designed with this specific target group in mind. However, students with no symptoms, but a desire to improve their personal effectiveness, may also feel attracted to use the system given its unassuming design that emphasises solutions and avoids stigmatisation. The system is welcoming and open to students who wish to use it for such purposes.
Several filtering processes are in place, to ensure that students who need added levels of support can be directed to the right services. A highly visible “In case of emergency” button (i.e., panic button) has been placed in a prominent spot in the first screen a user encounters when enters MePlusMe’s Home page. This is to be used in case of immediate and pressing difficulties felt by the user, and provides immediate access to alternative routes, such as mainstream mental health helplines or contact with the HEI’s own SSS. The use of such panic buttons is widespread in online and mobile technologies that address mental health issues [
41].
The second filtering system in place at initial login and it is a host of screening statements, which the user is asked to agree or disagree with, such as “You have taken risks to the point where it regularly affects your health and/or disrupts your daily life”. Every statement has an underlined word that is further explained with examples. If a user relates to these statements then they are provided with further guidance, which consists of alternative routes of support. These can include going to their primary healthcare provider or seeking support within the University SSS. Users who at the time might not relate to these statements can proceed using the system, but are again presented with these statements every 3 months. The aim of this is to have a robust and consistent monitoring system in place, in case users’ difficulties escalate. In those cases a user is again presented with information on how to access appropriate help.
Another filter put in place is the completion of the Visual Analogue Scale (VAS) by the student every few weeks from commencement of use of the system (week 2, 4, and 8). The system is designed so that if two consecutive scores are recorded as low on the system, the user receives a message in their personal space within MePlusMe (MyMessages) and is advised to seek further support via the SSS or through primary care. Frequent monitoring is a vital feature of the system. It ensures that students with severe difficulties are being directed to more appropriate sources of support.
Finally, if a user, whilst answering the Questionnaire, does not relate to any of the presented symptoms, they are advised to look through Library content in case they find a technique that could be useful to them. They are further advised to seek alternative support services that could be more suited to their needs at the time. This path acts as another filter to identify students with difficulties that can be best addressed by other, more appropriate, services.