Papadatou‑Pastou et al.

Int J Ment Health Syst

[Link]
(2019) 13:51
International Journal of
Mental Health Systems

RESEARCH Open Access

Exploring the feasibility and acceptability

of the contents, design, and functionalities
of an online intervention promoting mental
health, wellbeing, and study skills in Higher
Education students
Marietta Papadatou‑Pastou1* , Lauren Campbell‑Thompson2, Elizabeth Barley3, Mark Haddad4,
Caroline Lafarge5, Eamonn McKeown4, Louise Simeonov6 and Patapia Tzotzoli7

Abstract
Background: Substantial numbers of students in Higher Education (HE) are reporting mental health difficulties, such
as mild to moderate symptoms of depression and anxiety. Coupled with academic skills challenges, these difficul‑
ties can lead to decreased academic performance, low levels of study satisfaction, and eventually drop out. Student
support services are facing budget cuts and can only attend to limited numbers of students, usually the ones who
present with more severe mental health problems. Moreover, face-to-face contact may not appeal to those students
who feel embarrassed by their problems or are afraid of being stigmatised. To address this important problem, an
online psychological wellbeing and study skills support system called MePlusMe, has been developed to provide
personalised support to its users. In the present study we investigated the feasibility and acceptability of the contents,
design, and functionalities of the system.
Methods: An offline version of the system was introduced to 13 postgraduate and undergraduate students (mean
age = 31.3 years, SD = 10.25 years; 4 males) in a UK HE Institution, who presented with mild or moderate mental
health difficulties. The participants evaluated the design of the system, its functionalities, and contents at Baseline and
at Weeks 2, 4, and 8.
Results: Participants found the system easy to use, professional, and efficient and its contents non-judgemental and
informative. Participants stated that engaging with and practicing the techniques targeted at mental health difficul‑
ties led to improvements in positive thinking and self-confidence, while the study skills techniques were practical.
Suggestions for further improvement included the development of an app and an option for direct engagement with
professionals.
Conclusions: The findings confirmed the acceptability of the contents, design and functionalities of the system,
while providing useful information to inform its further development. Next steps include a feasibility study, which will
test and quantify the effects on everyday functioning, mood, mental wellbeing, and academic self-efficacy after using
the system, and subsequently a randomized controlled trial, which will evaluate its effectiveness.
Keywords: Students, Mental health, Higher education, Online intervention, MePlusMe, Wellbeing

*Correspondence: [Link]‑pastou@[Link]
1
School of Education, Faculty of Primary Education, National
and Kapodistrian University of Athens, 13A Navarinou Str, 106 80 Athens,
Greece
Full list of author information is available at the end of the article

© The Author(s) 2019. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
([Link] which permits unrestricted use, distribution, and reproduction in any medium,
provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ([Link]
publi​cdoma​in/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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Papadatou‑Pastou et al. Int J Ment Health Syst (2019) 13:51 Page 2 of 15

The life of a Higher Education (HE) student can come Anxiety and depression symptoms are the most com-
with a wealth of exciting experiences, invaluable memo- monly reported by HE students [8]; with over 77% of
ries, and new challenges. However, during such a critical students reporting depression-related symptoms, 74%
period of personal, social, and academic development, reporting anxiety-related symptoms, and a 74% co-inci-
some of these new challenges may result in initiating or dence rate [2]. The Royal College of Psychiatrists (RCP)
exacerbating existing mental health issues or in making found that students are more likely to experience mental
study skills challenges more prominent [1]. A worrying health difficulties or symptoms compared to age-matched
number of students have indeed been found to experi- peers outside of HE [9]. Worryingly, these findings may
ence mild to moderate symptoms of depression or anxi- underestimate the true scope of the issue due to the
ety, with the number of students who experience mental social stigma surrounding mental health difficulties or
health difficulties whilst at university increasing [2]. An due to such difficulties being undetected or unreported
online system for psychological, as well as academic, sup- [10]. Indeed, studies have shown that although student
port has been designed to specifically address the grow- support services are frequently advertised by HEI’s,
ing needs of HE students, MePlusMe. Here we present many students are reluctant to seek support [9, 11] or
evidence for the feasibility and acceptability of the sys- avoid doing so [12]. A national survey conducted in
tem’s contents, design, and functionalities. 2013 on behalf of the National Union of Students (NUS)
reported that 8% of students identified themselves as
Background “having a mental health problem but not seeking diagno-
An increasing number of students in Higher Education sis” [13] with 10% reporting having been diagnosed but
Institutions (HEIs) are experiencing mental distress and not actively seeking treatment. Within the United States,
mental health conditions in the UK. In 2015 the Higher a recent study found using the 12-item general health
Education Statistics Agency (HESA) reported that a questionnaire [14] that 32% of doctoral students are at
total of over eighty thousand students requested coun- risk of having or developing a common psychiatric disor-
selling from their HEI’S, compared to sixty thousand in der, with the most common being depression [15].
2013, a rise of over 27% [3]. YouGov’s 2016 national sur- The effects of mental distress and untreated men-
vey found that one in four students suffer with mental tal health conditions can be debilitating, and has been
health issues, with 77% experiencing depression-related highlighted in HE students in the form of decreased lev-
symptoms and 74% experiencing anxiety-related symp- els of academic performance [16]. Study skill problems
toms [2]. More recently, the World Health Organisation and poor psychological wellbeing, independently and in
(WHO) World Mental Health International College Stu- conjunction have been found to negatively impact aca-
dent Initiative reported that one in three first year uni- demic potential, decrease levels of engagement, lower
versity students experience symptoms of a mental health graduation rates, and increase academic dropout rates
condition [4]. Furthermore, the WHO contributed to a [2, 17]. HESA has reported substantial numbers of stu-
study at Ulster University in Northern Ireland to moni- dents experiencing study skill difficulties i.e. over 90%
tor student wellbeing using the WHO World Mental of students reported issues with exam stress and dead-
Health Composite International Diagnostic Interview line stress [3]. Another recent study found that 92% of
(WMH-CIDI). Results showed high baseline prevalence students attending university counselling sessions were
rates of both short-term and long-term mental health having problems completing their academic work [18].
and substance disorders, Attention-Deficit/Hyperactivity For international students, other study skill difficulties
Disorder (ADHD) and suicidality, with more than 50% of may present themselves. For example, a big challenge for
new undergraduate students reporting a lifetime disor- international students concerns studying in a non-native
der. Alarmingly, co-morbidity was common with 19.1% of tongue. Although there is a minimum language require-
students experiencing three or more disorders at a given ment for HE course entry, even when students do meet
time [5]. the entry criteria they may not be familiar with technical
In 2014 HESA surveyed 2843 students and found that terminology for a specialist subject area. This has been
the prevalence of depression and anxiety was 15.6% found to be problematic for some international students
among undergraduate students (13% for graduate stu- at the initial stages of a course and during an already
dents) [6]; whilst internationally a meta-analysis involv- pressured time [19].
ing 24 studies conducted in the USA, UK, EU, and
other nations identified a weighted mean depression Student support services
prevalence of 30.6% [7], although these studies all used HEIs often provide on-site student support services
validated self-report measures rather than diagnostic which may include academic services, such as essay writ-
interview methods. ing courses, employment services, such as Curriculum

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Papadatou‑Pastou et al. Int J Ment Health Syst (2019) 13:51 Page 3 of 15

Vitae (CV) workshops, and on site counselling. Data away from home and internationally, leaving them with-
requested under the Freedom of Information Act shows out support outside of term time. It is therefore impera-
that between 2011 and 2016 there was an 84% increase tive that a flexible solution is found.
in the number of students contacting the counselling
support service at their HEI [20]. A 94% increase was Online support
found by the Institute for Public Policy Research (IPRR) The RCP [9] suggests self-help programmes and guides
[21]. Moreover, 67% of HEIs were found not to be able such as web-based interactive cognitive behavioural ther-
to provide students access to NHS mental health special- apy (CBT) for non-emergency situations, leaving face-
ists who can deliver interventions onsite and 23% not to to-face counselling prioritized for those with a severity
work closely with NHS secondary mental health services of distress, disabilities and academic difficulties. The use
[21]. Financial pressures placed on HE students due to of these tools will likely increase the number of those
government funding decreases in particular courses, seeking diagnosis and treatment [30] as well as improve
such as nursing, as well as high student to lecturer ratios standards of treatment [31, 32] and continuity of care and
have led to an increased demand for study support needs. reduce dropout rates in HEI’s and possibly improve aca-
For example, the National Student Loans Company pro- demic grades [33].
visional data for the academic year of 2016/17 showed There is substantial evidence that supports the effec-
a decrease of almost £0.6 billion or 36% was awarded tiveness of computer-based programmes when com-
based on the previous year [22]. Early data shows that for pared to face-to-face CBT [31, 34, 35]. In addition to
2017/18 a further fall of £0.55 billion is to be expected this, groups that may be hard to contact on a face-to-face
[23]. Other possible explanations for the increased num- basis, such as those with anxiety disorders and depres-
bers in HE students experiencing mental health difficul- sion, may particularly benefit from online CBT [36].
ties are the removal of protective factors, for example, Computerised programmes and application-based CBT
larger class sizes compared to those in high school can also enable the user to maintain anonymity and privacy,
make it more difficult to socialise for some, and increased avoid being subjected to long waiting lists and removing
demands on academic staff can result in less individual the stigma that surrounds appointments with a counsel-
support for students. Another explanation for increased lor [37]. Recent studies have shown great progress with
demand could be the 2016 British government Widening the use of online support systems as interactive interven-
Access Scheme, which aimed to encourage students from tions, demonstrating their positive impact on accessibil-
wider backgrounds to apply for HE and indeed resulted ity and their flexibility [38, 39]. Furthermore, effects have
in a steady 2% increase in university applications between been shown to be longitudinal, with self-reported symp-
2015/16 and 2016/17 [24]. toms significantly reduced 12 months post participation
In 2011 the RCP reported that access to mental health [40, 41].
services on the NHS has progressively narrowed down to In recent years, several web-based systems have started
focus on high-intensity treatments and severe illnesses, to offer psychological support, advice, and information to
resulting in the clear majority of students presenting the public, for example NHS Silvercloud and PLUS [42].
with mild to moderate symptoms not fitting the criteria However, most of these systems focus on the general
for NHS Primary Mental Health Care [9]. This narrow- population and only a few address the study skill issues
ing of focus is the result of an influx of self-referrals for that HE students face. The few systems that target HE
primary mental health care services from the general students, for example, “CALM” (Computer Aided Life-
population to the NHS [25] due to increased accessibility style Management) and “Students Against Depression”,
and awareness. The effect of this increasing demand on have yet to be tested for their feasibility or effectiveness
HEIs’ student counselling services has been substantial. and unfortunately do not address study skills [42]. More-
Students are often left without adequate support as stu- over, these systems offer pre-made, non-tailored pack-
dent to counsellor ratios are typically less than favourable ages for specific conditions.
[26]. Students frequently report response times to their The present paper will investigate the feasibility and
initial enquiries at up to 2-weeks [9] and up to 9 weeks acceptability of the contents, design, and functionalities
from referral to assessment [27]. Research suggests that of MePlusMe, an online support system designed spe-
long waiting times can result in poorer mental health cifically for HE students who are facing mild to moder-
outcomes, such as more days in inpatient care and longer ate psychological and/or study skill difficulties, or for
recovery times [28]. students who just simply want to take care of their psy-
Another limitation of student support services is the chological wellbeing and improve their academic com-
lack of continuity of care that students may face when petence. MePlusMe is the only system that currently
using them [29]. For example, many students now study offers personalised interventions in video format for HE

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Papadatou‑Pastou et al. Int J Ment Health Syst (2019) 13:51 Page 4 of 15

students by addressing depression and anxiety symptoms techniques include strategies such as how to stay moti-
and study skill difficulties. Unlike these, the packages vated and manage time effectively. The use of multime-
offered by MePlusMe can vary each time depending on dia has been suggested to facilitate the active process of
the user’s present difficulties, thus facilitating multiple learning [51], which is why the techniques are presented
uses from the same user, resulting in an increased likeli- in a relatable animated audio-visual format accompanied
hood of recurrent and long-term engagement. by downloadable printouts. The package of techniques
that are to be practiced by the user is stored on the user’s
MePlusMe “MyPlace”. Students can login and watch the videos any-
iConcipio has designed a web-based solution under the time and from anywhere they wish. A reminder option
name MePlusMe [43]. It is designed to help students with that users are encouraged to make use of and which
mild to moderate mental health and/or study skills diffi- sends emails prompting them to return and practise their
culties, as well as students who do not present with any techniques within a period of 8 weeks, is also available.
specific difficulties but who desire to learn how to take Users are also asked to report how well they are
care of their psychological wellbeing and improve their doing over time, starting on the day they undertake the
study skills. MePlusMe can be used as a stand-alone tool Questionnaire or Library route and then after 2, 4, and
or alongside traditional face-to-face services. 8 weeks. This self-monitoring progress is shown in the
Several filters throughout the system, including a form of a motivational graph. When a package is not rele-
“panic button”, refer students with severe difficulties to vant anymore, students can archive it for later use. More-
other services for more intensive support. The rest of over, they can quickly access and restore past packages
the students can easily use the system by following one any time they wish in order to use them again. MePlusMe
of the two available routes. The first is a symptoms-based further offers an integrated, monitored online peer sup-
assessment (Questionnaire route) that invites users to port network. Student engagement is encouraged in this
identify the symptoms they experience, and the second social section of the site, called “Thoughtwall”, a space
is a technique-driven approach (Library route) whereby where students can post their thoughts under their cho-
users select directly their preferred techniques. Both sen nickname, “like” the shared thoughts of other users,
routes lead to a customised package of psychological and share their progress graph after completion of a
wellbeing and/or study skill techniques presented in 2D package. They can also share their thoughts and graphs to
animated video format. other sites outside MePlusMe. Finally, students can per-
The screening questionnaire has been adapted from the sonalise their profile by uploading pictures of their pref-
following established tools and clinical questionnaires: erence on their “Wall”.
the Hospital Anxiety and Depression Scale [HADS] [44];
the Generalized Anxiety Disorder Scale [GAD-7] [45]; System development
the Patient Health Questionnaire [PHQ-9] [46]; and the Preliminary market research conducted via the use of
Mini International Neuropsychiatric Interview [M.I.N.I.] semi-structured interviews with counsellors and psy-
[47]. The HADS, GAD-7, and M.I.N.I. formed the choice chologists working in student support services within
of anxiety symptom-based questions. The HADS, PHQ- four UK HEIs (London School of Economics, King’s
9, and M.I.N.I. formed the choice of depression symp- College London, University College London, and King-
tom-based questions. ston University) revealed current challenges and posi-
The design of the questionnaire addresses symptoms, tive responses to the enquiry about an online solution
instead of conditions/diagnoses and the system automati- (Tzotzoli, personal communication, 2011). This step
cally links clusters of symptoms with specific video tech- enabled researchers to gather an understanding of cur-
niques. As a result, each package represents the best-fit rent support services, the challenges they are facing, and
solution for students tailored to address the specific dif- whether an online system could fit into the market. An
ficulties they face each time. The library route leads to online survey was subsequently conducted which helped
the package of techniques that students themselves see to identify difficulties faced by students at university,
as best-fit to address their challenges. This route allows opinions on online support systems and what features
students the flexibility to edit their packages at any point students may want the system to include, or what may
by adding the techniques that they prefer or by deleting look appealing on the site [52]. Findings demonstrated
unsuitable techniques. a demand and space in the market for an online system,
All the techniques that are provided are evidence- and they further highlighted student needs and system
based. The psychological techniques derive from current requirements. iConcipio was awarded a Proof of Concept
treatment models such as Cognitive Behavioural Ther- Grant (Smart Award) which allowed a beta version of
apy (CBT) and Mindfulness [48–50] and the study skills MePlusMe to be constructed to demonstrate the system

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Papadatou‑Pastou et al. Int J Ment Health Syst (2019) 13:51 Page 5 of 15

during a proof-of-concept study [53]. With the help of a PHQ-9 [46], and the Warwick-Edinburgh Mental Well-
cohort of 873 students from five UK HEI (King’s College being questionnaire (WEMWB) [54].
London, University of Warwick, University of Edinburgh, Participants were recruited using various channels,
Bournemouth University, and University of Roehampton) including advertisements posted on the University’s
the proof-of-concept study confirmed the conceptual online portal (blackboard), communications from the
and practical value (suitability) of MePlusMe. Feedback Student Union and social media. Leaflets about the study
was collected from students about the main aspects of were also distributed around the campuses and at the end
the proposed design, system contents, aesthetics, and the of some lectures. The University student support services
process of delivery. The results from this study were then and the student engagement team also provided infor-
used for system refinement. Members of an Academic mation about the study to students where appropriate.
Advisory Board and a Research Advisory Board, consist- Recruitment communications included basic informa-
ing of clinical psychologists and academics have further tion about the study, what it entailed, and the eligibility
ensured that MePlusMe’s design and contents adhere to criteria. The study received ethical approval by the host
best psychological practice and supervised this work. institution (anonymised for the peer review process).

Registration to the study

Scope of the present study
Whether they were recruited online or face-to-face,
To date, iConcipio has developed the contents of
potential participants were given a link to a webpage
MePlusMe, namely the design and all the initial video
where they could read detailed information about the
techniques and certain functionalities of the platform,
study. They were also presented with the screening state-
with the exception of some automatized ones. The pre-
ments to decide whether alternative services would be
sent study aims to collect qualitative data on the fea-
more suitable to them and allow them to exit at this time
sibility and acceptability of the MePlusMe’s contents
point. Remaining participants were then presented with
in order to further develop the system. Furthermore,
the consent form. They had to agree to all statements on
data gained from participants will contain user feed-
the form and register themselves to participate in the
back on how engaging they found the media elements of
study by leaving their contact details. They were then
MePlusMe (the video techniques). It will introduce this
contacted by the research team within a few days of reg-
material offline to UK HEI students who will be admin-
istering to invite them to the face-to-face group session.
istered one of the routes (Questionnaire or Library) and
Each student had to attend a group session only once;
who will then receive their own customised package of
twenty face-to-face sessions were offered in total.
techniques. Students will answer questions regarding
the system’s design, functionalities, and video contents.
Materials
They will then be advised to use their suggested tech-
The system
niques on an as and when needed basis. The students will
MePlusMe, the online support system developed by
be approached again to answer questions regarding their
iConcipio, the contents of which was under study here,
interaction and satisfaction with the video techniques on
offers access to techniques tailored to users’ needs and
weeks 4 and 8 of the study. It is expected that students
designed to address mild to moderate symptoms of
will enjoy MePlusMe’s personalized, friendly, and easy-
anxiety and depression, as well as study-related difficul-
to-use design, as well as the multimedia instructional
ties. Following registration, users can either follow the
videos alongside their supporting documents. We expect
symptoms-route (‘Questionnaire’) or the techniques-
to see sufficient engagement with MePlusMe’s techniques
route (‘Library’), before they receive a tailor-made pack-
as well as positive feedback about MePlusMe’s design and
age with techniques that best address their needs at the
contents.
time (see Figs. 1 and 2). Techniques are demonstrated
using 2D animated videos. Users can then practise these
Methods techniques in their own time. A detailed description of
Recruitment and eligibility the system can be found in the introduction. For the pur-
Undergraduate and postgraduate students undertaking poses of the present study, an offline demo version of the
full- or part-time study at the host University were eli- system was used.
gible for inclusion. Potential participants also had to be
over 18 years old and comprehend English well enough to Generalized Anxiety Disorder Scale [GAD‑7] [45]
understand the intervention materials. They also had to The GAD-7 is used as a screening tool and a severity
present only minor to moderate, and not severe, psycho- measure for generalised anxiety disorder. It comprises
logical difficulties, as assessed using the GAD-7 [45], the

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Papadatou‑Pastou et al. Int J Ment Health Syst (2019) 13:51 Page 6 of 15

Fig. 1 Screenshot of the Library route

Fig. 2 Screenshot of the Questionnaire route

seven items and is scored using a four-point Likert Patient Health Questionnaire [PHQ‑9] [46]
scale ranging from ‘not at all’ (scored “0”) to ‘nearly The PHQ-9 assesses the severity of depressive symp-
every day’ (scored “3”). The items are negatively framed, toms. The scale includes nine statements scored using a
therefore higher scores indicate increasing symptoms. four-point Likert scale ranging from ‘not at all’ (scored
Possible scores range from 0 to 21, and scores of 5, 10, “0”) to ‘nearly every day’ (scored “3”). The items are nega-
and 15 are taken as the cut-off points for mild, moder- tively framed, therefore higher scores indicate increas-
ate, and severe anxiety. ing symptoms. Possible scores range from 0 to 27; scores
ranging 0–4 indicate no depressive symptoms, 5–9 mild,

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Papadatou‑Pastou et al. Int J Ment Health Syst (2019) 13:51 Page 7 of 15

10–14 moderate, 15–19 moderately severe, 20–27 severe Everyday Functioning

depressive symptoms. The users’ everyday level of functioning was assessed
using the question “How well are you getting on now in
your daily life”, which was measured using a five-points
Warwick‑Edinburgh Mental Wellbeing scale [WEMWB] [54] Likert scale ‘not at all well’ to ‘extremely well’.
The WEMWB scale was used to assess participants’
mental wellbeing. The WEMWB comprises 14 positively System evaluation questions
worded wellbeing statements and uses a five-point Likert At Baseline, participants were asked the reason they
scale ranging from ‘none of the time’ (scored “1”) to ‘all decided to participate in the study (possible responses
of the time’ (scored “5”). Higher scores indicate enhanced to select all that apply: “I am currently having a diffi-
mental wellbeing. Possible scores range from 14 to 70. cult time studying at university”, “I am currently having
England’s population mean score is 51.6 (SD = 8.70) a difficult time emotionally at university”, “I think the
(Health Survey for England. 2010; n = 7020). support system (MePlusMe) is a great idea and I want
PHQ-9, GAD-7, and WEMWB ratings were obtained to find out more”, “I have nothing better to do”, “Other,
at baseline and repeated at Weeks 2, 4, and 8. The please specify”). They were moreover asked how sat-
absence of severe difficulties was also ascertained during isfied they were with the features and the contents of
the screening phase, where participants were presented MePlusMe (i.e., Questionnaire, Library, MyPlace, the
with statements with regards to risky and/or aggressive video techniques) with response options including
behaviour, unusual sensory experiences or beliefs, and “Very poor”. “Poor”, “Fair”, “Good”, “Very Good”, what
intentions of self-harm, and were prompted to think they liked and did not like about the overall design of
whether they relate to any of these experiences. Partici- the system (open-ended questions), whether they liked
pants who related to any of these statements would auto- the name (“Like a lot” to “Dislike a lot”), whether they
matically be given information on where to seek more liked the “MePlusMe Philosophy” video (“Like a lot” to
appropriate help, including the accessible mental health “Dislike a lot”), whether they used other online support
helpline services SANE ([Link] and systems (e.g., self-help websites, MoodGym, Living
Nightline (https​://[Link]​[Link]/), and they would Life to the Full) and how they compare to MePlusMe,
be excluded from the study. However, none of the partici- as well as their overall satisfaction of the system (“Very
pants screened out for this reason. satisfied” to “Very dissatisfied”). They were also asked to
comment on areas for improvement.
At Weeks 4 and 8, participants were asked how often
Academic Self‑Efficacy scale [ASE] [55] they watched (“Everyday”, “1–3 times/week”, “1–3 times/
The SEF was used to measure self-efficacy regarding month”, “Only once”, “Never”) and practised the tech-
study-related skills. The original scale was developed niques (“Μore than 3 times/week”, “1–3 times/week”,
with U.S. college students and comprises 27 statements “1–3 times/month”, “Only once”, “Never”), how they
that describe positive study-related behaviours (e.g., tak- felt MePlusMe has helped them so far (open-ended),
ing good lecture notes) and uses a ten-point scale where whether they contacted student support services after
0 means ‘not at all confident’ and 10 means ‘extremely accessing the materials (“Yes”/”No”), where they will
confident’. The scale was adapted with permission of its seek support in the future if need be (“Approach Stu-
authors in two ways: (a) some items of wording were dent Union only”, “Approach Student Union in addition
adapted to enhance comprehensibility for the UK setting, to using MePlusMe”, “Only use MePlusMe”, “Not sure”,
for example “term papers” were replaced by “coursework” “Other—Please specify”, their overall satisfaction with
and (b) two of the 27 items were removed (“Having more the system (“Very satisfied” to “Very dissatisfied”), how
tests in the same week” and “Getting along with family likely they are to recommend MePlusMe to a friend
members”) because they were of limited relevance to the (“Very likely” to “Very unlikely”), and whether they
study participants. We used a total self-efficacy score plan to continue using the system after the completion
(rather than examining separate subscales), and so pos- of the study (“Definitely will continue” to “Definitely
sible scores range from 0 to 250, with higher score denot- won’t continue”). They were also invited to share their
ing greater self-efficacy. Although this item removal will recommendations to improve MePlusMe. Participants
affect the psychometric properties of the measure, we had the opportunity to provide qualitative feedback to
consider this effect to be of limited importance because questions, where appropriate.
we are using a total (rather than sub-scale) score, and
(because this is an exploratory feasibility study) using
scale score only for descriptive analyses.

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Papadatou‑Pastou et al. Int J Ment Health Syst (2019) 13:51 Page 8 of 15

Procedure the documents necessary for applying the techiques. Par-

The study was conducted over an 8-week period ticipants were invited to watch at least one video and
between October and January 2018, and included (a) familiarise themselves with the other video techniques
an online session where students had the opportunity before being asked to answer questions about their expe-
to read in depth information about the study, decide rience with the system until that point (see “System eval-
whether they meet the study’s inclusion criteria and uation questions” for Baseline). At the end of the group
sign the consent form, (b) a face-to-face group session session, participants were encouraged to watch the vid-
(Βaseline), and (c) three online follow-up sessions at eos and apply the techniques in their own time. Partici-
Weeks 2, 4, and 8. All data were collected online using pants were reminded to expect e-mails at Weeks 2, 4, and
the Qualtrics software. 8 to complete the follow-up measures. In addition, those
who had opted to receive reminder emails, were told to
Group session (baseline) expect these on Days 4, 8, 12, 22, and 45. All participants
The aim of the group session was to introduce partici- were reminded to expect e-mails at Weeks 2, 4, and 8 to
pants to the system and its contents, take them through complete the follow-up measures.
the system’s assessment routes (Questionnaire or Library)
and create the individual packages of techniques tailored Follow‑up online sessions
to their needs. Most of the verbal information communi- Participants were asked to complete questions assessing
cated on the day were coming from a script to keep the their degree of current functioning, measures pertain-
same conditions across participants and to replicate as ing to their mental wellbeing (i.e., GAD-7, PHQ-9, and
closely as possible the experience of the fully developed WEMWB) and a self-efficacy questionnaire regarding
online system (i.e., verbal instructions were given as they study-related skill (i.e., ASE) at Weeks 2, 4, and 8. In addi-
would see them on the system). tion, at Week 4 and Week 8 they were asked to answer
In the first part of the session, participants were intro- questions regarding their engagement with the video
duced to the system by watching a video on the rationale techniques, potential after effects from their usage and
of the system (MePlusMe’s “philosophy”, which is avail- their overall satisfaction with the system (see “System
able online [56]) and were asked to browse the system evaluation questions” Weeks 4 and 8). Participants who
offline to get a feel of how it looked and worked. They had not submitted their answers were sent a reminder
were then logged into the system and asked to navigate 3 days after the date they were due to complete the online
their way through it, use its available functionalities and survey at weeks 2, 4, and 8.
access its contents. Baseline measures on their mental
wellbeing (i.e., GAD-7, PHQ-9, and WEMWB), level of Analysis
self-efficacy regarding study-related skills (i.e., ASE) ands All demographic and scale data and comment responses
demographic information were collected at this stage. to open-ended questions were transposed from the
In the second part of the session, participants were MePlusMe system to Microsoft Excel and, following
individually administered by a member of the research checking and appropriate coding, were entered into an
team the assessment route they preferred (Questionnaire SPSS (version 23) spreadsheet for descriptive analyses.
or Library) to identify their current difficulties. They The qualitative data collected via the open-ended ques-
were then asked how well they were functioning in their tions in the questionnaires was analysed using Thematic
lives whilst experiencing these difficulties (Visual Ana- Analysis [57], a common approach in qualitative research
logue Scale question). Participants were then required to for identifying patterns of meaning (or “themes”) within
name their package of techniques and indicate whether data. The researchers scrutinised the written comments
they wished to receive reminders to watch the videos for made by participants for patterns and categories and
the duration of the study. A 20-min break followed, dur- these are presented in tabular form below along with
ing which researchers used the students’ answers to put examples of the comments from which the themes were
together their individual personalised package of tech- derived.
niques, upload it in an individual folder on an online
storage provider and email students a link to access their Results
folder. Participant characteristics
After the break, participants were asked to log into Participants were ten undergraduate and three post-
their emails and click on the link sent to them to access graduate students at the multicultural, ‘post 1992’ Uni-
the folder. The folder contained their individual package versity in London (University of West London), a UK
of techniques in video format, a document explaining HEI. As may be seen in Table 1, nine of the thirteen
when to use each technique as well as, where applicable, participants were female, the mean age was 31.3 years

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Papadatou‑Pastou et al. Int J Ment Health Syst (2019) 13:51 Page 9 of 15

Table 1 Participants characteristics (GAD-7: Generalized Anxiety Disorder Scale, PHQ-9: Patient Health Questionnaire,
WEMWBS: Warwick-Edinburgh Mental Wellbeing scale)
Gender n Age (years) Status Year of study Baseline measures
mean (SD)
Mean SD Home EU Int/l 1st 2nd 3rd GAD-7 PHQ-9 WEMWB

Female 9 28.8 9.6 4 2 3 6 2 1 8.1 (2.7) 9.7 (6.2) 45.0 (9.7)

Male 4 36.5 10.6 3 1 0 1 1 2 6.0 (3.8) 5.3 (2.9) 48.3 (9.3)
Total 13 31.3 10.2 7 3 3 7 3 3 7.5 (3.1) 8.3 (5.7) 46.0 (9.3)

Table 2 Mean mental wellbeing score changes Progress and completion

over 8 weeks (standard deviation of scores in parenthesis) As shown in Table 2, out of the 13 initial participants,
(GAD-7: Generalized Anxiety Disorder Scale, PHQ-9: seven completed the follow-up measures in Week 2,
Patient Health Questionnaire, WEMWBS: Warwick- five in Week 4 and six in Week 8 (Week 8 attrition rate:
Edinburgh Mental Wellbeing scale) 53.85%). The study was not powered to determine the
Baseline Week 2 Week 4 Week 8 effectiveness of the intervention, but all participants
reported decreased symptoms of anxiety and depression
GAD7 7.5 (3.1) 3.1 (1.6) 2.2 (3.3) 3.3 (3.8)
and increased (Weeks 2 & 4) or stable (Week 8) wellbe-
PHQ9 8.3 (5.7) 4.1 (3.7) 4.4 (5.6) 4.7 (4.0)
ing scores, compared to the Baseline. With regards to
WEMWBS 46.0 (9.3) 54.4 (8.5) 48.4 (13.7) 47.5 (12.2)
the ASE scores (see Table 2), a general improvement in
n 13 7 5 6
scores was evident over the successive ratings, with all
Academic self- 151.1 (43.1) 169.4 (42.6) 181.2 (54.0) 178.5 (61.2)
efficacy
four of the participants who completed self-efficacy rat-
n 13 7 5 4
ings at Week 8 having improved scores compared to their
Everyday function‑ 2.38 (0.87) 2.71 (0.49) 3.60 (1.14) 3.33 (0.52)
baseline ratings. Similarly, the VAS (see Table 2) scores
ing showed an improvement at successive time-points to
n 13 7 5 5 Week 4, with a modest reduction in Week 8.

System evaluation
(SD = 10.25), with female participants younger by Impressions of the MePlusMe video that explains
nearly 8 years than their male counterparts. Seven were the rationale behind the system
White, one was African, one Caribbean, one Asian, and Participants reported both positive and negative impres-
one mixed (White/Black African). sions of the first MePlusMe video that they watched at
The responses to scaled questions indicated that Baseline, which explains the rationale behind the sys-
these data were sufficiently normally distributed for tem (MePlusMe’s philosophy [56]). Positive comments
mean and standard deviation values to be meaningful included comments on its style and good design, as well
descriptors: skewness statistics for all baseline find- as the ease of understanding and the non-judgemental
ings were found to be between − 0.5 and + 0.5, and content of the message. Negative comments centered
the Shapiro–Wilk test was non-significant for all scale around the fact that the video was not informative
measurements. enough, the fact that the basic style was unengaging, and
changes needed in the voice-over. Some of the comments
are listed below and can be seen in Tables 3 and 4.
Reasons for participating in the study
Out of the 13 initial participants eight reported that
they are “currently having a difficult time studying at Engagement with MePlusMe video techniques after first
university”, four reported that they are “currently hav- viewings
ing a difficult time emotionally at university”, seven that After first viewing the MePlusMe videos there was lim-
“the support system (MePlusMe) is a great idea and I ited subsequent engagement, with the two major fac-
want to find out more”, and two also selected “other”, tors identified were the fact that no re-watching was
explaining that they “want to improve coping tech- needed and time constraints. Some of the comments
niques” and that “I am interested in how things happen are listed below and can be seen in Table 5.
and why”.

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Papadatou‑Pastou et al. Int J Ment Health Syst (2019) 13:51 Page 10 of 15

Table 3 Positive impressions of first MePlusMe video Table 6 Positive outcomes from engaging with MePlusMe
Theme Participant comment examples Theme Participant comment examples

Style/well-designed It is design simple and efficient. Communicate Improved positive thinking and I tried to replace my negative
in a good way enhanced memory thoughts with positive ones
The video and animations were well done It has enhanced my memory
The way it was styled and presented was good Improved self-confidence I feel confident about myself and
The use of visual and audio the place I am right now
Ease of understanding It simple to understand/it is a great and easy Provided reassurance that self- It made me feel better knowing
way to start improving yourself improvement is possible there were more things I could be
doing to help myself
I like story boards, it is a very clever way of trans‑
ferring information. The audio is at a good Provided reassurance that others Assured me that everyone is going
pace and tone had similar experiences through the same issues and also
with the right thinking about
The video did a good job at explaining the them and solving them correctly
program
Provided practical outcomes I managed to have a pretty clear
Content of message I liked the mention that tendencies are your through study tips schedule
tendencies and are neither good nor bad
Good tips for planning exam study‑
ing in January
Good study tips
I like how it has a pragmatic
Table 4 Negative impressions of first MePlusMe video approach to actually giving you
some techniques and work sheets
Theme Participant comment examples which are tangible

Problems understanding message I thought the video could have

been more informative. It could
have explained a bit more about How has MePlusMe helped participants so far—positive
techniques etc outcomes
Basic style unengaging Simple animation—not so eye Participants generally expressed that their engagement
catching and a bit difficult to
relate to with the MePlusMe techniques was a positive experience.
Lack of ethnic diversity in video No specifically negative outcomes were identified. The
Choice of voice-over Interesting concept, but could have major positive outcomes identified were improved posi-
chosen another voice actor tive thinking and enhanced memory, improved self-con-
The way it was styled and presented fidence, reassurance that self-improvement is possible,
was good, only felt that the voice reassurance that others had similar experiences, practical
over should be sped up a little
outcomes through study tips. Some of the comments are
listed below and can be seen in Table 6.
Table 5 Reasons for reduced engagement with MePlusMe
videos after first viewings Evaluation of the features and contents
A high level of satisfaction with the Questionnaire
Theme Participant comment examples was indicated. As can be seen in Table 7, the extent of
Already incorporated techniques I tried to use them in my own style, endorsement of the particular features was consistently
so I watched them a few times and high, ranging between 69% for a single aspect (the clar-
then I used them according to my ity of wording within the Library), to 100% for several
lifestyle
elements (the video techniques as a whole; the layout
After watching once, I didn’t need to
re-watch the videos I just put the and the phrasing within MyPlace).
techniques into action and when I In addition to the above, participants reported that
did view them it was to refresh and the reasons behind their likely engagement in the
make sure I understood
future include the professional design, their confidence
Many of the techniques did not
really provide benefit from being that using the system will continue to be helpful and
repeated. I got lots of helpful advice the fact that the techniques were useful. It was also
for how to prepare for exams, and reported that the participants may use the techniques,
don’t feel that I would benefit from
watching the videos again without having to re-watch again the videos. When
Time constraints Due to time asked if they would recommend MePlusMe to others,
I’ve been busy they reported positively and their reasons for doing
so include a sense that others would also potentially

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Papadatou‑Pastou et al. Int J Ment Health Syst (2019) 13:51 Page 11 of 15

Table 7 Likert scaled responses concerning the MePlusMe Table 8 Aspects of MePlusMe which participant said they
system most liked and disliked
Participants rating % rating ‘good’ Most liked Most disliked
‘good’ or ‘very or ‘very good’
good’ Friendly tone Not new—other similar apps
Good functionality/ease of navigation Not engaging visually
Questionnaire
Ease of use Poor navigation
Layout/navigation—ease 10/13 (77%) 77
of use Visually appealing Limited in content/focus
Clarity of the wording/phras‑ 12/13 (92%) 92 Informative
ing, Personalised aspect
Usefulness 11/13 (85%) 85 Interactive features
Specific features (e.g., MyPlan) 12/13 (92%) 92 Library component
Overall 12/13 (92%) 92
Library
Layout/navigation—ease 11/13 (85%) 85 continue to use MePlusMe after the completion of the
of use
study, and most of participants claimed that if they will
Clarity of the wording/phras‑ 9/13 (69%) 69
ing seek support in the future, if need be, they will do so
Usefulness 10/13 (77%) 77 by approaching the student union in addition to using
Specific features (e.g. MyPlan) 11/13 (85%) 85 MePlusMe. Negative impressions were also identi-
Overall 11/13 (85%) 85 fied and were invariably related to the design and user
MyPlace experience. Specifically, participants reported ambigu-
Layout/navigation—ease 13/13 (100%) 100 ity in the wording of the questionnaire used to assign
of use the techniques, videos being too long but also too short
Clarity of the wording/phras‑ 13/13 (100%) 100 and the fact that the material covered is accessible else-
ing where. Table 8 presents the aspects of MePlusMe that
Specific features (e.g. MyMes‑ 12/13 (92%) 92 participants reported to like and dislike most.
sages
Overall 12/13 (92%) 92
Video techniques Discussion
Illustrations 10/13 (77%) 77 The present study investigated the feasibility, and accept-
Narrator’s voice 11/13 (85%) 85 ability of the contents, design, and functionalities of
Clarity of the study board 12/13 (92%) 92 MePlusMe. This investigation took place before the sys-
Ability to sustain interest 11/13 (85%) 85 tem’s online functionalities are fully developed in order to
Overall 13/13 (100%) 100 inform further development. Responses included positive
remarks as well as useful suggestions for the improve-
benefit, particularly if the scope of the information is ment of the system. MePlusMe was found to be practi-
expanded and the fact that the advice provided is prag- cal, easy to use, engaging, and tailored to users needs,
matic and useful. Suggestions for improving MePlusMe but also in need of enrichment of content and of using
include its development into an app form and the inclu- more diverse characters. Moreover, the questionnaire
sion of an interactive forum that would allow users to and library routes that were provided to the users and the
engage directly with professionals. The overall impres- subsequent steps (e.g., responding to the VAS scale) were
sion of MePlusMe’s system was positive and most users successfully navigated by users, showcasing the feasibility
were satisfied, as the system was found to be useful and of our approach.
practical, calming, relaxing, and easy to use and navi- When participants watched their first video describ-
gate through, having a clear and attractive design, being ing one of the techniques, they commented on its simple,
engaging as well as bespoke and tailored to the users professional, and efficient design, as well as on its good
needs. Most used the techniques 1–3 times a week or style and presentation. Moreover, they found the con-
more. Participants were uncertain whether they liked tents easy to understand and non-judgemental. While
the name “MePlusMe” “a lot” or “a little” with equal some participants found that the audio had a good pace
numbers of responders selecting these alternatives) and and tone, others considered it to be unengaging and sug-
that they had not used other online support systems gested changes in the voice-over, such as speeding it up
in the past (10/13 responders, 77%). None of the par- and using a different voice actor. A lack of diversity and
ticipants approached the student support services in an ambiguity in the wording of the questionnaire were
the duration of the study, most reported that they will also noted as was the simplicity of the animation and the

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Papadatou‑Pastou et al. Int J Ment Health Syst (2019) 13:51 Page 12 of 15

fact that is was not engaging visually. Participants were an initial survey of end-users [52] and a proof-of-concept
divided when it came to whether they liked the name study [53]. This way MePlusMe responds to the call for
“MePlusMe” or not. Further engagement with MePlusMe more research on such systems [42].
videos was limited, as participants found that not many Once the system is live, students will be able to use
repetitions were needed due to the contents being easily it anonymously, at their own space and time, as soon
understandable, but also due to time constraints. Overall, as symptoms arise and as often as they wish, removing
the techniques offered by MePlusMe attracted positive common barriers in help seeking [59–61]. This will allow
comments that included improvements in positive think- students to feel empowered by taking control over their
ing, memory, and self-confidence as well as reassurance mental health and personal effectiveness. It will further
that self-improvement is possible and that others have reinforce their motivation to change as well as their con-
similar experiences. The study skills techniques were con- fidence and help them develop long-lasting coping skills.
sidered to provide a pragmatic approach and useful tips. The online system will further host a space where the
Suggestions for further improvement were also collected. community of users will be able to provide additional
These included the system’s further development into an support to each other. This build-in community could
app and the option of having direct online engagement further help normalize the experiences of the users and
with professionals via a forum built into the system. give them a sense of belonging. The online nature of the
The comments and suggestions made by the partici- system is by default holistic and inclusive. Therefore, the
pants provide a valuable source of information for the system will be available to students who would not nor-
improvement of the system. We will keep developing mally seek face-to-face support. Furthermore, support
and adding animated video techniques onto the system. will be tailor-made to the needs of each user every time
This will give us the opportunity to introduce more they choose to use the system.
diverse characters so that all students will feel that they In addition to the benefits that the users will enjoy,
can relate to a character. Also since videos will vary in HEIs could optimize their resources should they include
length this will even out issues with regards to com- online support in their range of services. Systems such as
ments that videos are too long or too short. We will MePlusMe can indeed assist student support services to
also introduce new narrators so that different voices focus on cases presenting with severe difficulties, which
can appeal to our target group. Moreover, the devel- are more pressing and require face-to-face contact. At
opment of an app, through which users will be able to the same time, MePlusMe can be offered to all students
use the system via their smartphones, is also pending. who present with mild or moderate difficulties, as a com-
In addition, the possibility of having direct contact plementary service alongside the offline services. This
with professionals through the system is already being way, student support services will emphasize on preven-
considered and will take place through emails, video- tion, in a cost-effective manner [62]. Moreover, the sys-
conferencing and offline face-to-face treatment. Limi- tem can be used as a first line of support for students
tations of the present study include the small number on the waiting line to see a professional or as a fall-back
of participants (n = 13), which though adequate for plan, after therapy has been completed. MePlusMe could
qualitative [58] and feasibility evaluation, does limit further provide analytics on students’ wellbeing and aca-
the interpretation of the measure scores to a descrip- demic competence, which could allow HEIs to respond
tive analysis. Additionally, this study took place offline, to students needs in a targeted manner. This way, HEIs
rather than online which will be the standard mode of will be in an informed position to improve student expe-
delivery when the system is fully developed. rience, reduce drop-out rates, and achieve higher ratings,
When the online functionalities of the system are fully intake, and income (for a more detailed discussion on the
developed a feasibility study will follow, for which the benefits of online support systems designed for students
protocol has been already published [56]. This study will in HE see [42] and [43]).
allow for the assessment of the extent of change between
pre- and post-intervention time points, with regards Conclusions
to mood, wellbeing, academic self-efficacy, and every- MePlusMe, is a multimedia, online system aiming to pro-
day functioning. Upon the completion of the feasibility vide personalized support to HE students facing mild to
study, a Randomized Controlled Trial (RCT) will ensue, moderate mental health difficulties as well as study skills
in order to systematically measure the effectiveness of difficulties and students who just want to take care of
the intervention. Of note, of the six online support sys- their mental health and improve their academic compe-
tems recently identified as having been designed specifi- tence. It is the first system that is designed specifically
cally for HE students [42], only MePlusMe has conducted for HE students that tackles both potential sources of
development studies, such as the current one, as well as problems, psychological and academic, in a personalized

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Papadatou‑Pastou et al. Int J Ment Health Syst (2019) 13:51 Page 13 of 15

manner. Following a rigorous development process which Author details

1
School of Education, Faculty of Primary Education, National and Kapodistrian
includes a market research project with counsellors in University of Athens, 13A Navarinou Str, 106 80 Athens, Greece. 2 iConcipio Ltd,
HEIs, an initial survey of end-users [52] and a proof-of- South London and Maudsley, Camberwell, London SE 5 8 AZ, UK. 3 Univer‑
concept study [53], this paper explored the acceptability sity of West London, Paragon House, PR405, Boston Manor Road, Brentford,
Middlesex TW8 9GA, UK. 4 City, University of London, London, UK. 5 School
and feasibility of the system’s developed contents, design, of Human and Social Sciences, University of West London, Paragon, Boston
and functionalities, before its online functionalities are Manor Road, Brentford TW8 9GA, UK. 6 University College London, 1‑19
fully developed using qualitative data. Responses were Torrington place, London, UK. 7 My Psychology Clinic and iConcipio Ltd, 13
Orchard Rise, Richmond, Greater London TW10 5BX, UK.
overall positive, with useful comments and suggestions
for further improvement. A larger feasibility study of Received: 23 January 2019 Accepted: 17 July 2019
MePlusMe’s design and contents using both quantitative
and qualitative measures is currently underway in Riga
Stradins University in Latvia. A feasibility study with a
fully functioning system is the next step in the system’s References
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