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 [A Mobile App Design to Motivate Help-

Seeking Behavior in University Students with

Mental Illness]

A thesis submitted to the Graduate School

of the University of Cincinnati in partial fulfillment

of the requirements for the degree of

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in the Myron E. Ullman Jr. School of Design

College of Design, Architecture, Art and Planning by

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[Tianran Chen]
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Bachelor of Art, University of Washington

Committee Chair [Yong-Gyun Ghim]

3/16/21

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ABSTRACT

Background: University students have a high prevalence of mental illness, but

research demonstrates they are reluctant to seek help.

Objective: This study aimed to improve their help-seeking behavior by assessing

the challenges university students faced that prevent them from seeking help.

Methods: University students aged 18-25 with mental illness who reluctant to seek

professional mental health assistance were recruited through an online survey. The study

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used qualitative research methods to access participants’ attitudes towards mental illness
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and help-seeking behavior. Interviews were conducted to gather a deeper understanding

of their barriers and frustrations. Participatory design sessions and three rounds of
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prototype testing were conducted at the design phase from design concept to high-fidelity

prototype in order to measure the efficacy of the design.

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Results: A total of 73 responses were collected, and 46 of them are eligible

participants. Interviews were conducted with seven eligible participants. The result

indicated that negative attitudes are significantly associated with mental illness. In

addition to the negative attitudes, the participants also indicated that lack of awareness,

knowledge, trust, social and financial support were barriers for them to taking action. A

mobile app that includes a series of key elements that fights the barriers that prevent them

from help-seeking was proposed.

Conclusion: Participants expressed high interest in the mental health app and

appreciated some of the main features in contrast to the current in-person and web-based

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services portal. The mobile-based application should be able to provide an efficient

mental health service for university students who have a mental illness, especially in

terms of help-seeking behaviors.

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ACKNOWLEDGEMENTS

Working on this thesis project is one of the biggest challenges in my academic life.

I want to acknowledge and thank everyone who supported me and collaborated with me

to make this project successfully completed.

I would like to thank Professor Yong-Gyun Ghim especially, my thesis advisor, and

to the members of my thesis committee Dr. Vidourek and Shane Meeker. They helped a

lot in shaping my research and design ideas. I’m deeply appreciated the time,

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encouragement, and guidance that they have provided throughout this year. I would also

like to acknowledge Counseling and Psychological Services (CAPS) clinician for walking
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me through the typical mental health services and offered a lot of useful information.
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I will be grateful to my parents and family for their selfless support. And I would like

to thank my friends for their understanding, encouragement, and insightful discussions

through the process of completing this thesis project.

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TABLE OF CONTENTS

ABSTRACT v

ACKNOWLEDGEMENTS viii

TABLE OF CONTENTS ix

LIST OF TABLES xi

LIST OF FIGURES xii

GLOSSARY, LIST OF SYMBOLS AND ABBREVIATIONS xiii

CHAPTER 1. INTRODUCTION 1

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CHAPTER 2. LITERATURE REVIEW 3
2.1 Mental Health Among University Students 3
2.2 Mental Health Service in Universities
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2.3 Utilization of Mental Health Services 8
2.4 Awareness and Education of Mental Health 11
2.5 Use of Mobile Application 14
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CHAPTER 3. THEORETICAL FRAMEWORK 17
3.1 Overview 17
3.2 Positive Design Framework 17
3.3 The Fogg Behavior Model (FBM) 19
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CHAPTER 4. METHODOLOGY 21
4.1 Research Process 21
4.2 Secondary Research 23
4.2.1 Benchmarking 23
4.3 Primary Research 26
4.3.1 Survey 26
4.3.2 Expert Interview 27
4.3.3 User Interview 28

CHAPTER 5. RESULTS 30
5.1 Overview 30
5.2 Survey 31
5.3 Expert Interview 33
5.4 User Interview 36
5.4.1 Current Mental Health Condition 37
5.4.2 Attitudes towards Mental Illness 38
5.4.3 Previous Help-Seeking Experiences 39
5.4.4 Barriers of Getting Help 39

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5.4.5 Frustrations and Expectations of Mental Health Services 39
5.4.6 Opinions about Technology-Based Services 41
5.5 Persona 42

CHAPTER 6. DESIGN AND EVALUATION 43

6.1 Design Concept 43
6.2 Prototype: Features 44
6.2.1 Journal 44
6.2.2 Self-Care 46
6.2.3 Professional Mental Health Service and Crisis Support 46
6.2.4 News and Activities 47
6.2.5 Communication 47
6.2.6 Privacy Protection and Insurance Information 48
6.3 Prototype: Color 48
6.4 Prototype: Evaluation and Refinement 52

CHAPTER 7. DISCUSSION AND CONCLUSION 67

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7.1 Summarization 67
7.2 Limitations and Opportunities 69

REFERENCES 72

APPENDIX A: SURVEY QUESTION

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APPENDIX B: INTERVIEW QUESTION 84

APPENDIX C: IRB PROTOCOL 86

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LIST OF TABLES

Table 1 - Survey Outcome: Cause of Mental Illness 32

Table 2 - Survey Outcome: Personalities of People with Mental Illness 32

Table 3 - Survey Outcome: How to Treat People with Mental Illness 33

Table 4 - Iterations Based on Feedbacks 55

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LIST OF FIGURES

Figure 1 - Students Usage of On-Campus/Off-Campus Mental Health Services 9

Figure 2 - Positive Design Framework 18

Figure 3 - A Behavior Model for Persuasive Design 19

Figure 4 - Overall Research and Design Process 22

Figure 5 - Thought Development Loop 35

Figure 6 – Persona 42

Figure 7 - Emotional Effect of Color on Viewers 50

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Figure 8 - Paper Sketch 53

Figure 9 - Low-Fidelity Prototype

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Figure 10 – Iteration: Background Color 58

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Figure 11 – Iteration: Discover Page 58

Figure 12 – Iteration: Appointment-Making Page 59

Figure 13 – Iteration: Service Page 60

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Figure 14 - Interaction Flow 61

Figure 15 - Iteration: Journal Page 63

Figure 16 - Iteration: Journal Report Page 63

Figure 17 - Iteration: Contact Page 64

Figure 18 - High-Fidelity Prototype 66

Figure 19 - Action Model 68

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GLOSSARY, LIST OF SYMBOLS AND ABBREVIATIONS

MH the letter Mental Health

FBM the letter Fogg’s Behavior Model

CAPS the letter Counseling and Psychological Services

UC the letter University of Cincinnati

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CHAPTER 1. INTRODUCTION

Mental health is a major concern for university students at any level. Failure to seek

professional assistance in order to deal with mental health issues can lead to even the

worst outcomes, including mental disabilities or even suicide. There must be a solution to

alleviate underlying stressors that contribute to mental health issues in university

students. Therefore, the objective of this study is to motivate help-seeking behaviors

among university students, who have anticipated or may develop mental health issues.

According to the United States (US) Census Bureau Report (United States Census

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Bureau, 2018), there are almost 20 million higher education students across the US with
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more than 4000 colleges and universities. The need for solving university mental illness

problems is clear. This is because the researchers in the previous study indicated that an
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estimated 10% of all university students in the nation have been diagnosed with

depression, 25% had been treated for mental health issues, and 40% reported greater

than average stress and anxiety (Beiter et al., 2015, p.90). Therefore, the estimated 40%
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of higher education students experiencing some form of mental health issues would

translate into about 7.8 million higher education students needing or desiring some form

of mental health service.

By and large, the most prevalent platform to manage mental health among university

students is the student counseling center. These types of centers typically follow the same

general format from one university to another. That is, they are given offices and rooms

from which to operate, students are informed of the counseling centers’ existence, and

are encouraged to avail themselves of the counseling center when the need arises.

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University students are aware that most, if not all, universities offer mental health

services. However, utilization of these mental health services is relatively low. This is due

to an apparent disconnect between student’s awareness of them and their willingness to

access them. According to NIMH (National Institute of Mental Health) 2019 report, the

adults aged 18-25 who received treatment for their mental illness was 8.7% lower than

the adults aged 26-49 years old and 17.9% lower than those aged 50 or older (74.3%)

(NIMH, 2020). Furthermore, the actual location of (on-campus and off-campus) such

mental health services does not appear to be a significant deciding factor in whether

mental health services are accessed.

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While most students are aware of some element or aspect of mental health, it is
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clear that most students do not fully understand its effect on those experiencing it. For

instance, other research indicates that a low level of mental health literacy, in other words,
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lack of awareness of mental health, and lack of knowledge of the causes, treatment, and

consequences, will lead to negative attitudes towards people with mental illness (Gomez-
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Lopez et al., 2005; Lauber, 2008). Essentially, the negative attitudes will make people

want to hide their condition and keep people with mental illness from exhibiting help-

seeking behaviors.

In addition, this study discovered lack of trust and support, privacy considerations

and financial concerns appear to be influencing factors of help-seeking behavior for

university students. Thus, the objective of this study is to motivate help-seeking behavior

in university students by assessing the influencing factors of help-seeking behavior.

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CHAPTER 2. LITERATURE REVIEW

Mental Health among university students is a significant issue. The issue is well-

documented and, in fact, so prevalent that universities typically have mental health

counselors and staff within their own department. The sole responsibility of these mental

health professionals on campus is to provide guidance, counseling and referrals for

students that are experiencing some form of mental health problems. One study reports

a full 88% of all universities counseling center managers said that severe psychological

problems had increased over the last five years and that 75% of those who experience

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serious psychological issues do so prior to 25 years of age (Pedrelli et al., 2015, p.505-
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507). Thus, mental health can, if left unaddressed, undermine a university’s overall

success as a higher learning institution.

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2.1 Mental Health Among University Students

Since the existence of mental health issues in the higher education environment is
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quite well established, the underlying factors contributing to these issues should be

explored. Stress is a vital element during the process of acquiring a formal higher

education degree. Research has identified that stress and hormones released after

stressful events act as an important modulator of learning and memory processes which

are critical to educational contexts (Vogel, 2016). Stress is also a very common

phenomenon in higher education. This is because of the importance placed on the burden

of heavy academic workloads, maintaining academic performance, academic

achievement, and professional success. Furthermore, when these stressful events are

combined with other stressors such as paying bills, it can create a highly stressful

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environment for students and result in mental health issues. In addition to the stressful

environment under higher education settings, many university students are finding

themselves essentially on their own for the first time in their lives while also navigating

more complex financial aid requirements (Pedrelli et al., 2015, P.503-504). Moreover,

students usually encounter new challenges in their newly independent lives.

Such new challenges appear just as these students are facing adult issues and all

of these stressors, pressures, and combine with other regularly occurring problems.

These are those such as new relationships, relationship experiences and living situations

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relating to factors like the exploration of gender, racial and many other different identities

(Liu et al., 2019). Therefore, university students face major pressures and stressors at
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almost every turn. Such stressors span the gamut of social interactions from personal

friendships to academic interactions in the classroom. There are also existing studies that
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indicate university students suffer from a wide range of potential stressors that can

negatively affect their mental health.

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Higher education is a high-stakes environment. This is because most higher

education costs are high and carry long-term effects on career paths and outcomes of

university students. Research has indicated that the ten most critical causes of mental

health issues among university students include the following: self-esteem issues,

general health and well-being, body image concerns, friends’ relationship, familial issues,

financial responsibilities, and obligations, sleep quality, and rest, the pressure associated

with academic performance, post-graduation objectives and work or job-related factors

(Beiter et al., 2015, p91-92). Furthermore, it is often the case that university students

experience two to more stressors that combine to create a significant amount of anxiety.

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Dealing with this seemingly constant state of anxiety can itself lead to more serious mental

health diagnoses. A seemingly insignificant worry regarding a test, for instance, can lead

to anxiety about all the test-taking activities. In turn, incessant anxiety over test taking

activities can lead to performance anxiety and other related psychological distress. These

can eventually result in depressive episodes or clinical depression, anxiety, suicidal

ideation, and similar mental health issues.

A recent survey undertaken by National American College Health Association

reveals that an estimated 60% of all students report a high degree of anxiety, some 40%

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report a severe level of depression that inhibit proper social functioning and demand for

on-campus mental health services increased by as much as 40 % over the past few years
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(American College Health Association, 2020). Regardless of the exact figures, the need

for improved, more effective and more targeted mental health solutions on university
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campuses are quite clear.

2.2 Mental Health Service in Universities

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Mental health considerations are not just advisable for university administrators to

consider but critical areas of concern for them (Pedrelli et al., 2015, p.503-504). University

administrations are facing constant pressures that dictate the need to maintain enrollment

figures and meet federal financial aid requirements. Failure to do so means that the

university not only experiences a reduction in tuition revenues directly from students but

also in financial aid payments for student tuition. Additionally, administrators also risk

attracting and retaining quality students, which becomes much more difficult when student

mental health is not addressed adequately. Students are attracted to universities that

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have high graduation rates, equally high student satisfaction rates, and that consistently

award sufficient financial aid packages that allow students to complete their programs

(Avery &Hoxby, 2003).

Hence, mental health services in the university environment are a critical element

in any university’s overall operations. Therefore, most universities have their own mental

health counselors, staff, student mentors and mental health referral programs. Mental

illness has become such a problem that an estimated 88% of university counseling

centers state that more serious mental health diagnoses in the US have increased

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dramatically over much of the last decade, while as much as 75% of those university

students who do develop serious diagnoses develop them before the age of 25 (Xiao,
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2017). The result is such that if more improved mental health services on university

campuses are not a priority for college administrations, universities are certain to
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experience significant operational problems. These being problems such as higher

degree incompletion rates, higher drop-out rates, and poor academic performance
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outcomes (Hjorth et al., 2016). All of these in turn can negatively impact financial aid

distribution and allocations. Of course, such operational administrative problems pale in

comparison to the human cost associated with insufficient or inadequate mental health

services on university campuses.

Currently, the vast majority of such student counseling centers tend to follow the

same general format. This format typically involves maintaining some sort of counseling

facility that is capable of supporting walk-in services and visitation as well as outreach

programs both on and off campus.

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 This type of student counseling center is designed to promote success on student

academic performance and personal development; trained counselors and therapists will

help students coping with their psychological distress and try to hinder more serious

mental illness, suicidal attempts and other violent behaviors (Holm-Hadulla &

Koutsoukou-Argyraki, 2015, p.3). These mental health services from a vital nucleus in the

on-campus environment focused on positive student development. Yet, one important

issue with these types of facilities is that they tend to over-rely on students walking in to

seek services.

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Still, there is another element of these student service counseling centers relating

to their sophistication. Each university campus and associated student/faculty

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population is uniquely different. Therefore, counseling centers must account for the

unique mental health concerns that are associated with university environments and
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campuses. Research has demonstrated that each university campus is beset with its

own unique set of stressors in addition to the typical student stressors such as certain
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student body demographics, physical topography of the campus, or living characteristics

such as dorm constraints or commuter campus features (Xiao, 2017). In this regard,

student counseling centers may be too confined by this traditional walk-in, outreach

model that universities have relied on for many years. An expanded network of mental

health service providers is referred to as an “off-campus partnerships” in which the

university develops working partnerships with established community mental health

service providers such as family services, social workers, and local church and

community outreach programs (Oklahoma State Regents for Higher Education, 2020).

This type of expanded community network is, theoretically, meant to ensure that the

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university’s mental health services are able to stretch their safety net for at-risk

students.

2.3 Utilization of Mental Health Services

University students are aware that most, if not all, universities offer mental health

services. Despite this fact, students under-utilize such important resources. Research has

shown a high level of stress and a high prevalence of mental health issues on most

university campuses. Such prevailing stress on higher education campuses causes

university students to be less likely to seek professional mental health help for their

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concerns (Biddle et al., 2007). Thus, utilization of these mental health services is
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experiencing a disconnect between student awareness of them and willingness to access

them. Furthermore, the actual location of the services does not actually appear to be a
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significant deciding factor in their help-seeking behavior. Most universities have

significant off-campus students who commute to the campus for their course and other

matriculation needs. Therefore, off-campus mental health services offered directly by the
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university or through third-party service providers only make sense. The following figure

indicates that university students are almost just as inclined to make use of off-campus

mental health services as on-campus services:

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 Figure 1 - Students Usage of On-Campus/Off-Campus Mental Health Services

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（Sontag-Padilla et al., 2016, p.6）

As the figure above illustrates, more students do visit on-campus mental health
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services, but a sizable percentage also visit off-campus locations as well. Thus, it seems

apparent that the actual on or off campus location of mental health services does not

necessarily seem to be a deterrent to visitation and help-seeking behaviors.

There are several reasons that may ultimately contribute to the low utilization rate

of university mental health services and facilities on university campuses. Some of the

impediments to higher utilization rates among university students might be related to

access problems to the healthcare system in general, while other impediments might

involve transportation or financial concerns and so forth. Many students do not

necessarily know that the mental health services on campus are free to them. Thus,

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