Drawing on social-cognitive theory as a guiding conceptual construct, this study will investigate the impact of crowd-sourced, socially constructed, and evidence-informed online and mobile technologies on self-efficacy to access and utilize mental health and wellness services. Social-cognitive theory recognizes individuals as being self-organizing, proactive and self-reflective [48-50] and conceptualizes self-development, adaptation, and change as being embedded within a broad network of socio-structural influences and psychological factors [28,51-53]. This study will draw from a theory of help-seeking that proposes a 4-stage process: awareness, expression, availability and willingness [22]. The process begins with an awareness of symptoms and the appraisal of having a problem that may require intervention. This awareness must then be articulated or expressed by the help-seeker in plain language that can be understood by others, and sources of help must be available and accessible [22]. Finally, the help-seeker must be willing and able to access support and disclose their concerns [22].

The Thought Spot platform was originally developed through the Mental Health Innovation Fund, a program established by the Ontario Ministry of Training, Colleges and Universities. While the original collaboration included the University of Toronto’s Faculty of Medicine (the lead organization), the Centre for Addiction and Mental Health (CAMH), Ryerson University, Ontario College of Art and Design (OCAD) University, and ConnexOntario, the project was always envisioned as a student-led innovation project focused on improving postsecondary students’ access to, and navigation within, mental health and addiction services. To achieve this goal, the idea of a digital map of all addiction and mental health services, starting with the Greater Toronto Area (GTA; Ontario, Canada), was proposed. This map would be developed in partnership with students, educators, and health service providers. It was envisioned that the map would respond effectively to the challenges presented by an often-fragmented system of mental health services available to students (eg, on-campus services and community-based services are funded separately, making navigation between services challenging). Creating an online mapping platform was seen as a way to increase access and ease of navigation, and to address other barriers such as stigma and a lack of mental health literacy. It was proposed that the scope of the map would be informed by a social determinants of health perspective, and its dissemination would be through Internet and mobile devices. The aim of the strategy was to support direct help-seeking intentions, attitudes, and behaviors by increasing knowledge of appropriate services for postsecondary students, and minimizing the need for intermediaries (ie, friends, family, family physician).

Project leaders at CAMH identified an open-source software (Ushahidi) that could both display mapped information and allow for crowd-sourcing, a strategy aimed at supporting the sustainability of the Thought Spot platform and allowing for the participation of youth in its development. Second, the project team initially seeded the map with data supplied by collaborating organization Kids Help Phone and project partner ConnexOntario. From that starting point, the team used a participatory model of engagement to work with 65 university and college students to develop the platform. The students were recruited from institutions across the GTA to work on all aspects of the project. Students were organized into 2 teams, focusing respectively on production and development, to lead the development of the digital intervention, as well as several working groups that focused on specific aspects of the project, including design, promotion, and knowledge translation. The participatory approach defined specific roles for student leadership and student decision-making. A project steering committee balanced student and organizational input, enabling students to make a wide variety of key decisions on issues such as the name of the project, the logo, project management, and product design. This work included the organization of the original seeded mental health resource data with a taxonomy, which became the basis for categories through which users would enter the map and/or filter the data. The categories include health and wellness, sex and relationships, legal and financial, work and school, spirituality and well-being, and friends and family. Through this work the students developed Thought Spot as a platform that aimed to:

1. Mobilize other students to share their knowledge about services.

2. Discover wellness options in their area.

3. Build peer networks.

4. Read reviews and comments from peers about services.

5. Add their own thought spots or services.

In order to create a mobile version of Thought Spot, the project hosted Hackathought, an open digital hackathon event in Toronto in November 2014. This work led to the development of a native mobile app (iOS and Android), as well as a responsive design of the Thought Spot website, which allows for optimal viewing across a range of devices (eg, desktop computer monitors, tablets, and mobile devices). These platforms were all completed in March 2015.

User-generated information has been entered in the Thought Spot platform for over 1000 mental health and wellness spots (eg, campus health centers, mental health and substance use services, peer support, crisis information, public parks, libraries, yoga studios). The platform has been further developed through a series of workshops in which teams of students verified the spots and customized them for peers seeking services, adding commentary and information that students would want to know in language that speaks directly to them.

The main functionality of the Thought Spot platform allows users to geo-locate themselves and search for spots through an interactive map (Figure 1). Spots can be searched according to cost, hours, catchment, and other parameters such as the availability of specific lesbian, gay, bisexual, transgender, transsexual, two-spirit, intersex, questioning, queer, and Aboriginal services (Figure 2). Once an appropriate spot has been located, users can access more specific information about the service (such as accessibility, languages offered, and wait list information), allowing them to decide whether the service is right for them (Figure 3).

Additional functionality includes crowd-sourcing, an increasingly important data-gathering technique that allows users of a content-rich resource to submit revised and/or new information that, after vetting, is fed back into the resource [54]. Thus, Thought Spot users can add additional spots, allowing them to grow the platform and shape it according to their needs and interests (Figure 4). This built-in crowd-sourcing functionality also includes the ability for users to give a simple thumbs up or thumbs down rating to individual services, and to make comments about particular services (Figure 5). Finally, building on an idea that came from the winning entry from the Hackathought event, users can find wellness walks built into the map (Figure 6). These routes are intended to reinforce the overall wellness focus of Thought Spot by encouraging students to take healthy breaks from their studies and other activities, and to explore the city in which they are studying, and become more connected with its communities. A functional Web version of Thought Spot [55] and a mobile app (for iOS and Android) are readily available online via free download. These platforms have gone through a series of usability testing sessions with student participants, using the state-of-the-art facilities and expertise at the University Health Network (UHN) Centre for Global eHealth Innovation. The current state of the platform has been assessed at Technology Readiness Level 6 [56].

The current study to optimize the Thought Spot platform will be conducted in two distinct phases, which will aim to (1) optimize the Thought Spot Web and mHealth platform through youth engagement, and (2) evaluate the impact of Thought Spot on self-efficacy for mental health help-seeking and health literacy among university and college students through a randomized controlled trial (RCT).

Participants will be recruited across 3 participating postsecondary institutions in the GTA: University of Toronto, Ryerson University, and George Brown College, which have respective enrolments of 84,556, 38,000, and 31,187 students [57-59]. Recruitment strategies will include invitation letters on public university bulletin boards, health and technology academic department listservs, student groups, Residence Life staff, and social media (Twitter, Facebook, and Instagram). All participants will be required to sign a consent form prior to being recruited into either phase of the study. Once participants have provided informed consent, they will fill out a nonidentifiable demographics form. This demographic information will be used for comparison purposes, reporting findings, and preparing formal evaluation reports.

To take part in Phase 1 of the project, participants must be transition-aged youth (16-29 years) [60] of any gender who are currently enrolled in part-time or full-time studies at any Canadian postsecondary institution. To take part in Phase 2, participants must be transition-aged youth (16-29 years) [60] of any gender who are currently enrolled in part-time or full-time studies of one of the 3 participating postsecondary institutions. All participants must have functional competency in English. Phase 2 participants must also currently be seeking mental health support or have a self-identified need for mental health support, and must have access to digital devices compatible with the Thought Spot digital platform. Participants who self-identify as having been hospitalized within the last 3 months for a mental health or addictions concern will be excluded from both phases of the study.

The Thought Spot platform and its implementation will be optimized using a model of engagement in which transition-aged youth attending colleges and universities colead all aspects of the project [60]. Students will have ownership of process, product, and deliverables. The engagement goal is to create a context in which students draw on their strengths and lived experiences, and in the process increase their health literacy, reduce mental health stigma, and become advocates for good mental health. The research question for Phase 1 is: How can the Thought Spot intervention be optimized to enhance its current functionality, and increase the potential for its sustainability and adoption among postsecondary students, through youth engagement?

The goals of Phase 1 are to (1) optimize the Thought Spot platform to more effectively meet the needs of end-users; (2) explore students’ motivations and identify personal, behavioral, and environmental influences that will affect their uptake of the Thought Spot platform; and (3) assess Thought Spot’s feasibility, usability, and acceptance by the target population.

An RCT, with 2 arms, will be conducted in Phase 2 to assess the impact of Thought Spot on self-efficacy for mental health help-seeking and health literacy among our target population. Students in the intervention arm will have access to the Thought Spot platform (online and mobile versions), while the control arm will receive usual care (access to campus health services, Web- and print-based information materials). The study will last 6 months. Participants in the intervention arm will receive an in-person tutorial on how to use Thought Spot, as well as access to an online tour the app video. Data will be collected from participants through online questionnaires at baseline, 3 months, and 6 months. The full procedure regarding the design of the RCT and administration of the intervention will be codeveloped with students in Phase 1.

The main outcome measure will be changes in help-seeking intentions, measured by the General Help-Seeking Questionnaire (GHSQ), which will be administered at baseline, 3, and 6 months. This scale is composed of 10 items measured in a 7-point Likert scale that ranges from Extremely Unlikely to Extremely Likely. The items are sources of help (eg, parent, friend, family doctor) and the participants are asked their likelihood of seeking help from each source. The 10 items are usually split into informal help sources, formal help sources, and I would not seek help from anyone.

We will also use the Actual Help-Seeking Questionnaire (AHSQ) and Attitudes Toward Seeking Professional Psychological Help Scale-Short Form (ATSPPH-SF) to measure secondary outcomes: help-seeking behaviors and help-seeking attitudes. These scales are most often used in help-seeking studies [72], and have been used in similar studies and with similar populations, often together [13,22,73,74].

Adequate internal consistency has been reported for the GHSQ in studies of high school students aged 12-19 years (Cronbach alpha range of .70–.90) [75,76] and university students (Cronbach alpha=.67) [77], as well as adequate validity and very good test-retest reliability (r=.86) [75]. The correlation between intentions to seek mental health care for personal-emotional problems and actually seeking care has been found to be positive and significant for the GHSQ (r s[218])=.17, P<.05). The ATSPPH-SF has demonstrated good internal consistency (Cronbach alpha range of 0.82–0.84), 1-month test-retest reliability of 0.80, and a correlation of 0.87 with the longer ATSPPH scale, among samples of college students [78-80].

In addition to these scales, we also plan to explore self-reported changes in self-stigma using the Self-Stigma of Seeking Help Scale [81] and self-efficacy using the Youth Efficacy/Empowerment Scale - Mental Health [82]. We will also gather data on demographics and general mental health status (Global Appraisal of Individual Needs - Short Screener, Canadian/CAMH version) [83] to examine trends, comparisons, and correlations between the study groups.

A sex- and gender-based analysis will be completed when analyzing data for Phases 1 and 2. An economic evaluation of the Thought Spot intervention compared to usual care will also be explored to determine the potential cost-effectiveness and financial implications of sustainable and widespread use of Thought Spot throughout Canadian postsecondary campuses. The evaluation will be conducted from the perspective of future potential Thought Spot funders (eg, other Canadian postsecondary institutions). The primary outcome to be assessed will be the change in helping-seeking intentions among the target population.

We are using computer-generated random allocation of subjects to the intervention and control arms, by means of the Research Randomizer website [85]. This will be a partially blind study, in that the process of inviting students and collecting data will not be done by the researchers. Missing values will be minimized by sending reminders to participants at least 3 times, and the offer of an honorarium at the end of the fourth data collection point. It is possible that students in the control group may use Thought Spot, so we will ask control subjects at the end of the final survey whether they accessed Though Spot during the study. This approach will allow us to carry out a sensitivity analysis to exclude control subjects who accessed Thought Spot. To mitigate this possibility, we will investigate password protecting the platform or tracking email addresses through a sign-in process during the trial period. We cannot guarantee that control subjects will not interact with intervention subjects, causing some contamination, but given the personal nature of mental health conditions, we believe this risk will not be highly prevalent.

Certain members of the research team were involved in the development of the original Thought Spot platform. To avoid bias or perception of bias, the scientific lead for the project, who was not involved in the development of the original Thought Spot platform, will oversee the RCT.

We hypothesize that transition-aged youth who receive the intervention will show a greater improvement in intentions for, and self-efficacy in, help-seeking for mental health concerns, compared to those who are allocated to the control group (usual care; resource pamphlet). We also hypothesize that participants in the intervention arm will show greater improvements in health literacy, increased self-efficacy in managing their mental health concerns, and a reduction in mental health stigma, compared with the control arm.

This protocol outlines the important next steps in understanding the role of the Thought Spot platform on the behavior of postsecondary, transition-aged students when seeking information and services related to mental health and addiction issues. Phase 1 of the study will allow for the continuation of cocreating and coproducing a solution that will be further optimized to meet the needs of its target population. The first phase will have the added benefits of potentially raising awareness of mental health issues, and providing an opportunity for students to become involved in ensuring that their peers have timely access to appropriate services. Phase 2 of the study will explore the efficacy of the crowd-sourced platform in improving students’ sense of self-efficacy and their ability to seek appropriate information and services in a timely manner. The results of the RCT study will further contribute to our understanding of how best to support postsecondary, transition-aged students who are seeking information and support related to mental health and addiction concerns.