Using Indirect Service-Learning to Promote Evidence-Based Digital Mental Health Tools on College Campuses

Abstract

Background

College students have increasing mental health needs; however, there has not been a related increase in services available. Mental health apps offer an avenue to support access to student mental healthcare.

Objective

This study incorporated an indirect service-learning project involving evaluating and recommending mental health apps to the college counseling center into an undergraduate clinical psychology course in order to (1) increase student self-efficacy and depth of learning, and (2) increase evidence-based mental health app usage on a college campus.

Method

The project was implemented during an online, synchronous 3-week course and 15 students participated in the study. Student self-report of self-efficacy was measured pre- and post-course and quantitative and qualitative reflections on the project were gathered post-course.

Results

Student self-efficacy increased from pre- to post-course. Additionally, students reported that the project met pedagogical objectives by engaging students, aligning with course content, and addressing APA learning goals.

Conclusion

The project holds promise as a means to improve student self-efficacy and enhance clinical psychology learning, while simultaneously disseminating evidence-based digital mental tools on college campuses.

Teaching Implications

App evaluation as indirect service-learning could be implemented in many applied psychology courses across multiple of course formats and lengths.

Keywords

indirect service learning clinical psychology student mental health apps

There is a growing need for mental health services on college campuses. Lipson et al. (2019) examined college student mental health diagnosis and treatment between 2007 and 2017 and found that suicidal ideation has nearly doubled from 6 to 11%, rates of diagnosed mental health conditions have increased from 22 to 35%, and rates of mental health service utilization have increased from 19 to 34%, with an increase from 7 to 12% for on-campus service utilization. There is clearly an increased demand for services; however, there has not been a related increase in resources to support these students. Instead, counseling centers are turning toward other methods, such as limiting the number of counseling sessions allotted per student per semester and/or instituting waitlists (Brunner et al., 2014).

A possible avenue for supporting access to college student mental health care is through digital interventions, specifically mental health apps, which could supplement existing services by providing stand-alone interventions or skill-building instructions. A recent review found that many mental health apps hold promises for improving anxiety and depressive symptoms in college students (Lattie et al., 2019). Many college counseling centers have already begun suggesting mental health apps to their students. In a recent analysis of college and university counseling center websites, 43% of the colleges promoted mental health apps on their websites (Melcher & Torous, 2020). However, of the apps recommended, 28% were no longer available on the app store, and of the ones that were available, only 16% had any efficacy research published in peer-reviewed journals (Melcher & Torous, 2020).

Mechler and Torous (2020) offered multiple recommendations for how counseling centers could improve their delivery of mental health apps, including using the American Psychiatric Association’s App Evaluation Model. This model recommends assessing (a) access and background, (b) privacy and safety, (c) clinical foundation, (d) usability, and (e) therapeutic goal of the app. Mechler and Torous (2020) also recommended involving students in the app evaluation and selection process, similar to efforts in healthcare settings that involved collaborations between providers and patients (e.g., Hoffman et al., 2019).

Furthermore, initiating and maintaining app use are additional barriers to engagement with this type of mental health support. Specifically, students report being more likely to use a mental health app if they know a specific app exists, perceive the app to be useful and easy to use, and if the app is recommended by therapists and/or peers (Levin et al., 2018; Mitchell et al., 2021; Holtz et al., 2020). Therefore, the goal of our study was to incorporate app evaluations into the framework of an undergraduate clinical psychology course at a small liberal arts college to create a sustainable mechanism for evidence-based app selections on a college campus. We partnered with the college’s counseling center to address the barriers to college student app initiation and engagement by creating app recommendations that were therapist and peer-approved, information about the apps that was peer-designed, and a broad advertising campaign that involved the counseling center website, college social media platforms, and posters across campus.

Service-learning is a high-impact teaching practice that addresses a community need and the pedagogical objectives of an academic course through the collaboration of faculty, students, and community partners (Meredith et al., 2020). Although service-learning has traditionally been conceptualized as an in-person practice, in the context of increasing online course offerings, both in light of growing national trends (Allen & Seaman, 2013) and more recently the COVID-19 pandemic, efforts have been made to bring service-learning online. Service-learning can be conducted completely online as indirect service-learning, research service learning, or advocacy learning. Whether students prepare materials and resources for a community agency, do research within the community, or apply theory and research to insight transformative change in communities, they do not have to directly engage with clients to take part in this high impact practice (Bringle et al., 2016). Online indirect service-learning dismantles the geographical barrier between students and communities that would benefit from their service. This strength is crucial for courses that are taught completely online, as it provides learners with opportunity to engage in civic inquiry, service, reflection, and action that otherwise could not be offered when learning remotely (Waldner et al., 2012).

As a high impact practice, indirect service-learning has the potential to enhance students’ critical thinking, problem solving, academic performance, resilience, and perseverance (Finley & Reason, 2016). These service-learning practices foster students’ sense of purpose, meaning, self-confidence, and self-esteem, which enhance their well-being and self-efficacy (Finley & Reason, 2016). Therefore, the implementation of indirect service-learning in virtually taught courses could be a viable option for engaging a larger population of students in work that cultivates various cognitive skills, well-being, and self-efficacy. We focused on self-efficacy as the primary outcome measure due to the relevance of this construct to both academic (e.g., performance and motivation for learning) and non-academic (e.g., self-esteem) student outcomes (Chen et al., 2001; Kim et al., 2012).

Service-learning can be particularly beneficial to undergraduate students studying psychology. When students are tasked with applying academic content to a service project, they practice acquiring socially responsive knowledge, professionalism, and communication skills—all of which align with the APA’s five learning goals (Bringle et al., 2016). By giving students the opportunity to engage with diverse communities in a professional setting, service-learning can particularly enrich the APA’s learning goals of Ethical and Social Responsibility in a Diverse World and Professional Development (Valdez & Lovell, 2021). Despite the benefits that service-learning can yield for psychology students, most current studies on service-learning outcomes do not report on psychology courses (Valdez & Lovell, 2021). For these reasons, additional research is needed on service-learning across a broad spectrum of psychology courses.

Current Study

The current study evaluated student outcomes following a clinical psychology course that incorporated an indirect service-learning project designed to improve access to digital mental health resources for college students. In the course, students partnered with the college’s counseling center to empirically evaluate and recommend evidence-based mental health apps for the counseling center to promote to the student body. The first aim of the study was to investigate changes in student self-efficacy (measured pre- and post-course). We hypothesized that student self-efficacy would improve from pre- to post-course given the documented benefits of service-learning on student outcomes (Finley & Reason, 2016). The second aim was to investigate student perceptions of the indirect service-learning component through quantitative and qualitative post-course feedback.

Method

Participants

This study took place during an upper-level clinical psychology course titled Digital Mental Health at a small liberal arts college. The course was offered as a remote, 3-week (4 credit) January module. There were 18 students initially enrolled in the course. Of the 17 students who completed the course, 15 completed the pre- and post-course surveys. Student demographics included 87.5% female, 75% White, mean age of 20.9, 75% 4th year students, and 44% first generation college students. Students received extra credit as compensation for participating (the equivalent of 1% of their final grade). Students were also offered an equivalent extra credit assignment of the same time length as an alternative to study participation.

Procedure

All study procedures were approved by the Institutional Review Board. Students received information about the study at the beginning of the course and then received a recruitment email with a link to the online survey on Google Forms at the beginning and end of the course. To ensure students completed the survey before too much course content had occurred (pre) and so that there was time to award extra credit at the end of the course (post), the surveys were only available for 48 hours following eligible students’ receipt of the recruitment email. The study was completed entirely online; students completed a series of questionnaires at the start of the course and the same questionnaires with one additional measure at the end of the course.

Indirect Service-Learning Project Description

This study focused on one component of the course, called the Mental Health App Project, which was an indirect service-learning project completed in collaboration with the college’s counseling center. Details of all phases of the project can be found in Table 1 (for assignment instructions and rubrics, see Stanger, 2021). The goal of the project was for students in the course to be involved in supporting the well-being of all students on campus by increasing access to evidence-based mental health support. In brief, the project consisted of consulting with the counseling center on desired outcomes, evaluating specific apps (both from an empirical perspective and an experiential perspective; aligned with the APA App Evaluation Model), presenting findings to the class, creating marketing materials for the recommended app, and completing a final presentation to the counseling center on the recommendations and materials created. Students were also required to incorporate aspects of their experience with this project into additional course assignments, such as their daily reading response and reflection papers, in which they were asked to integrate their experience with this project with their academic readings and other course content.

Table 1.

Phases of the Mental Health Apps Indirect Service-Learning Project.

Phase 1	The first author identified eight mental health apps, which met the following criteria: (a) free, (b) available in the Apple and Google app stores, (c) target anxiety, depression, sleep problems, or general well-being, and (d) have at least one peer-reviewed research study supporting efficacy. The apps were chosen using reviews of mental health apps for anxiety, depression, and general well-being among college students (e.g., Lattie et al., 2019), the One Mind PsyberGuide (https://onemindpsyberguide.org/), and an intention to have students evaluate a range of types of apps (e.g., general CBT, gamified, mood tracking, mindfulness, and AI chat bot). Apps were iCBT, IntelliCare, MindShift, MoodMission, MoodPrism, SmilingMind, SuperBetter, and WoeBot
Phase 2	The director of the counseling center came to our second class period to discuss the mental health needs and services on the campus and reasons for wanting to have mental health apps to advertise on campus and recommend to students
Phase 3	Students downloaded the app choices and ranked preferences. First author assigned groups of 3 students to each of the top 6 app choices. Two app choices (iCBT and IntelliCare) were immediately eliminated based on lack of student interest
Phase 4	Students used their assigned app daily to support their well-being. They also researched their app to prepare for a 10-minute class presentation documenting the following (aligned with the APA App Evaluation Model): (a) developers of the app (i.e., was it psychologists, researchers, a startup, tell us a bit about their work/mission), (b) how recently the app was updated, (c) how clear, transparent, and accessible is the privacy policy, is it clear if the app is collecting personal data and for what purpose, are there any other ethical concerns you read about or experienced, (d) what is the intended purpose of the app and what are the main features of the app, (e) what is the research evidence supporting the app at improving its intended targets and was the research completed by the company who made the app or by independent researchers (highlight research methodologies and findings, and any research done on college populations, since that was our target population), (f) how usable was the app (using an evidence-based usability metric), and (g) group’s final recommendation for whether the app would be suitable for the counseling center to recommend to student based on all of the above considerations. See Stanger, 2021 for assignment instructions and assignment grading rubric
Phase 5	Following the presentations, students were given the task of using the apps that other groups evaluated for a few days. Next, students completed an anonymous survey about their recommendations for which app(s) should be recommended to the counseling center, based on the class presentations and their experiences using the apps
Phase 6	Four apps were chosen by consensus to recommend to the counseling center—SmilingMind, WoeBot, MoodMission, and MindShift. Students worked in small groups either on a presentation for the counseling center documenting their process and progress or on creating promotional materials (info sheets and social media ads) for each app to provide to the counseling center for dissemination. See Stanger, 2021 for assignment instructions
Phase 7	Students gave a final presentation to the entire counseling center staff and were able to provide their recommendations, rationale for their recommendations, and the promotional materials for dissemination

Measures

Self-Efficacy

The New General Self-Efficacy Scale (Chen et al., 2001) is an 8-item scale measuring general self-efficacy. That is, how much people believe they can achieve their goals, despite difficulties (e.g., “Even when things are tough, I can perform quite well.”). There were five Likert-type response options (1 = strongly disagree to 5 = strongly agree) and the mean was derived to provide an overall score with higher scores indicating greater self-efficacy. Reliability was excellent at pre-course (α = 0.87) and post-course (α = 0.93).

Indirect Service-Learning Reflections

Quantitative Responses. At post-course, students completed six items from Gelmon et al.’s (2018) Community-Based Learning Student Survey to assess student perceptions of how the indirect service-learning component of this course impacted professional development, community engagement, and classroom environment. Students also completed three items developed by the University of British Columbia’s Centre for Community Engaged Learning (https://ccel.ubc.ca) to assess the impact of the indirect service-learning project on course content-specific outcomes. For both measures, there were five response options (1 = strongly disagree to 5 = strongly agree), and the mean of each item and the proportion of students who agreed or strongly agreed with each item were calculated.

Qualitative Responses. At post-course, students responded to two qualitative questions, which were adapted from Paulson (2018), in which they were used to assess service-learning in a clinical psychology course. Students were asked if the course objectives and the indirect service-learning component fit well together and to what extent the indirect service-learning component met their expectations.

Data Analysis Plan

Pre- to post-course comparison of student self-efficacy was evaluated using a paired sample t test. To evaluate post-course student indirect service-learning reflections, the questionnaire provided descriptive data (reported in Table 2) and the first and second author conducted a thematic analysis (Braun & Clarke, 2006) to identify themes within the two qualitative responses. The authors generated initial codes and searched for themes separately (Phases 1 through 3) and together reviewed and labeled themes (Phases 4 and 5).

Table 2.

Descriptive Results from the Quantitative Student Indirect Service-Learning Reflections.

Community-Based Learning Survey Items (Gelmon et al., 2018)	Mean (1–5)	Proportion Agree/Strongly Agree
Professional Development
The work I performed for the Mental Health Apps Project enhanced my ability to communicate my ideas in a real-world setting	4.33	13/15
The community aspect of this course helped me to develop my problem-solving skills	3.80	11/15
Community Engagement
I felt a personal responsibility to meet the needs of the community partner of this course	4.13	13/15
I feel that the work I did for the Mental Health Apps Project benefits the community	4.60	14/15
Class Environment
The other students in this class played an important role in my learning	4.67	15/15
I had the opportunity in this course to periodically discuss my community work and its relationships to the course content	4.20	13/15
Content-Specific Outcome Items (https://ccel.ubc.ca)	Mean	Proportion Agree/Strongly Agree
The community aspect of this course helped me articulate my values in relation to issues within the field of digital mental health	4.40	14/15
I understand how digital mental health connects to local community issues	4.53	14/15
I understand the role of psychologists who study digital mental health in society	4.20	14/15

Results

Self-Efficacy

Students’ self-efficacy was compared before and after the course. On average, students reported greater self-efficacy at post-course (M = 4.59, SD = 0.77) compared to pre-course (M = 3.91, SD = 0.67). This improvement was statistically significant, t(14) = 5.14, p < .001. The effect size for this analysis (d = 1.33) was found to exceed Cohen’s (1988) convention for a large effect (d = .80).

Indirect Service-Learning Reflections

Questionnaire Results

All items, item means, and the proportion of students who reported either agreeing or strongly agreeing with each item are noted in Table 2. At least 73% of students agreed with each item assessed from the Community-Based Learning Survey (Gelmon et al., 2018), and the mean score across all 6 items was 4.29 out of 5, indicating that overall students reported positive outcomes in the areas of professional development (communication and problem-solving skills), community engagement (responsibility to and positive impact on the community), and class environment (experience with peers and connection between project and remainder of the course). The least endorsed item (still gathering 73% agreement) described the impact of the project on their problem-solving skills and the most endorsed item (100% agreement) described the impact of peers in class on their learning. For the course content-specific outcome questions (https://ccel.ubc.ca), 95% (all but one student) agreed with all three statements, indicating that students generally believed that participation in the project shaped their understanding of both the field of digital mental health and the relevance of this field to their community.

Qualitative Results

Beyond students reporting that their expectations were met and that the course content and indirect service-learning experience aligned well, three themes emerged from the qualitative responses. Quotes from students that exemplified these themes are provided in Table 3.

Table 3.

Student Quotes from the Qualitative Student Indirect Service-Learning Reflections.

Theme	Example Student Quotes
Challenges of the professional world	“We looked at how [digital mental health apps] can be useful but looked at the challenges as well in order to find the best solution.”
	“By analyzing the apps’ flaws we were able to see/educate ourselves on what apps were most suitable for the [college] community in terms of aesthetics, privacy, and mental health support.”
	“One of our class objectives was to learn about how digital mental health resources can help expand our use of mental health services and what implications this has for the future of mental health care. The project showed us what these apps would actually look like and allowed us to think about if these apps could help bridge the gap between who needs/wants care and who gets care.”
Community impact and purpose	“Not only was I able to learn about new apps and help my community, but I was also able to learn more about my community and strengthen my bond with it. I feel personally excited to know that these apps are going to be helping people in need in my community.”
	“I loved that we got to talk directly with the Counseling Center about the issues they face.”
	“It was really helpful that the Counseling Center was as involved as they were. It felt like the material we were working on was not just a project but part of a bigger community event.”
Increased student motivation to comprehend and apply content	“I also loved creating info sheets and the other components that were not just papers. This helped me convey our group’s ideas in a digestible manner for all college students.”
	“The project allowed me to connect many of the course readings to the work we were doing for the college. The discussion with my group about the app allowed me to elaborate on my ideas and others’ ideas around the apps’ connection to class content.”
	“I feel like the Mental Health Apps Project helped me apply what we were reading to the real world, and even analyze some of the aspects of the apps we were reading about. It also always helped me feel like my work had purpose, so I was much more motivated.”

Challenges of the professional world. Students expressed that the indirect service-learning project was engaging and satisfying due to the challenges and problem solving involved. The primary challenges students discussed included the privacy and data use policies of the apps, the difficulties with the speed of app development compared to the speed of clinical trials investigating the apps, and the usability of the apps.

Community impact and purpose. Students reported that they valued the counseling center’s level of involvement in the project (i.e., attending class virtually with students at the beginning and end of the course). They also expressed that the project resulted in feeling a stronger connection to the college community and pride in the positive impact the project might have on their peers.

Increased student motivation to comprehend and apply content. Students indicated that both the project and the course content shaped their learning with the other, meaning the class readings helped them to better understand and evaluate their assigned apps and their experience evaluating the apps helped them appreciate the content of the class readings. Additionally, students noted that the project was motivating because the course content had an explicit purpose for their community and involved the creation of varied final products (i.e., infographics and presentations).

Discussion

These findings provide initial evidence for the utility of an indirect service-learning project in an online undergraduate classroom to improve student self-efficacy and enhance clinical psychology learning, while simultaneously disseminating evidence-based digital mental tools on college campuses. Consistent with the literature, this indirect service-learning experience increased students’ self-efficacy (Burton & Winter, 2021; Finley & Reason, 2016) which was especially encouraging given the short length of the course. Future research should investigate the maintenance of this effect post-course to understand the long-term impact of service-learning on student self-efficacy. In fact, the maintenance of self-efficacy gains is understudied across higher education research (van Dinther et al., 2011).

Overall, this indirect service-learning project met pedagogical objectives. Students overwhelmingly reported, across the quantitative and qualitative measures, that the project aligned with course content, mutually benefited themselves and the community, and addressed APA learning goals. Specifically, the course built on students’ knowledge base in a growing area of healthcare, enhanced students’ ability to critically evaluate consumer apps, developed interpersonal communication skills (both within peer working groups and in professional consultation and presentations with the counseling center), and ultimately increased their ethical and social responsibility by allowing them to participate in the dissemination of evidence-based mental health tools in their community. There was an interesting potential discrepancy between the development of problem-solving skills being the least endorsed item on the community-based learning measure (although still endorsed by most students) and the qualitative reflection that problem solving the challenges of the project was vital to their learning experience. It is possible that students were particularly responsive to the opportunity to put their problem-solving skills to use in a meaningful way, rather than the opportunity to improve upon these skills explicitly.

In addition, following the completion of the class, we saw tangible outcomes in which the counseling center did indeed use the student-produced materials (in addition to recommending the apps to specific students they were working with): multiple counseling center social media posts highlighted the apps, the infographic posters were posted across campus and throughout dormitories, and the apps have been added to the counseling center’s website, all of which were designed with the intention to decrease barriers to app initiation by the broader student body. We want to recognize that the counseling center’s motivation to engage in this project was critical to our success. The first author began this partnership by building a professional relationship with the director of the counseling center over the semester preceding this course. It was through this relationship that the first author engaged in conversations about the counseling center’s interest in gaining knowledge about mental health apps and in using apps to support students in more ways, which ultimately led to the design of this project. Consistent with research on fostering effective community partnerships for service-learning projects (Cronley et al., 2015), faculty are encouraged to prioritize relationship building to understand the unique interests, motivators, and needs of their college’s counseling center and to affirm buy-in at project conception.

Conclusion

Limitations

This was the first implementation of this project and there was no control or comparison condition. These findings are certainly preliminary, and we cannot determine a causal relationship between student participation in this project and the gains in student self-efficacy. We need additional implementations of this project with comparison conditions and larger samples to improve our understanding of the impact of this project on student personal and academic outcomes.

Additionally, this was a 3-week, 4-credit course that met for 3 hours, 5 days per week. We believe that this project would work well in other formats (hybrid, asynchronous, or in-person) and course lengths. In fact, the 3-week course likely made this project more difficult, given the expedited timeline to evaluate apps and compile final recommendations and outputs. With more time, students could evaluate which apps held their attention across multiple weeks—a consideration that came up often in both course content on attrition of app use (Baumel et al., 2019) and in student discussions of their app evaluation experiences.

This study did not assess student academic learning outcomes in a pre-post format. Although this is a valuable direction for future research, Gelmon et al. (2018) stress that given the rate at which student understanding of their role as learners and their professional skills develop, quantitative data should primarily be used for descriptive purposes in combination with qualitative methods. This is likely to be especially important in the context of a 3-week course. Despite these limitations, the experiences described by students in both the qualitative and quantitative data at the end of this course suggest that this project is a promising idea worthy of future iterations and further research.

Finally, although we were successful in our goal of producing the recommendations and making the recommended apps visible on campus in multiple ways, it was beyond the scope of this study to investigate the initiation or engagement with the recommended apps by the student body. Future research is needed to examine whether the steps taken in this course are sufficient to truly impact student mental health app adoption on college campuses.

Next Steps and Future Research

There are multiple changes that could be implemented to continue to improve the project and student learning. For example, students met with the counseling center staff at the beginning and end of the course, which they noted were some of the highlights of this project. In addition, we believe these meetings contributed to the counseling center’s use of our recommendations (Cronley et al., 2015). We hope to add a mid-course meeting for students to consult the counseling center after they have initiated their app evaluations to discuss new questions that arise after gaining academic content and experience with the apps themselves. This may enhance the partnership and further student learning outcomes by promoting active learning, professional communication, and agency over their eventual course outputs.

Although this project was completed during a 3-week online course, there is the potential for it to be implemented in any format of class (remote, hybrid, or in-person) and in other psychology courses that focus on psychopathology, such as clinical, abnormal, or health psychology. In a larger university setting, the project could be adapted such that students provide their app evaluations through surveys (in small groups or individually, instead of through presentations). As digital tools continue to propagate through the healthcare system (Arigo et al., 2019), there is increasing reason to incorporate these topics into our teaching across multiple psychology courses, both to help students become informed consumers and to strengthen their marketable job skills.

Finally, although we focused on the need for additional evidence-based mental health resources on college campuses, this project could be adapted to partner with high schools, where college students evaluate and provide recommendations and information on evidence-based mental health apps for younger teens. Additionally, given the pace at which new apps are developed, this project could be implemented each year within an institution. In fact, Mechler and Torous (2020) recommend this continued re-evaluation of apps due to the frequency of app changes (including apps being removed from the app store, adding paywalls, and changing privacy policies).

Footnotes

Acknowledgments

The authors would like to thank the Allegheny College Counseling and Personal Development Center staff for their collaboration on the execution of this project.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Data Availability Statement

The materials and data that support the findings of this study are available from the corresponding author upon reasonable request.

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