Engagement, Use, and Impact of Digital Mental Health Resources for Diverse Populations in COVID-19: Community-Partnered Evaluation

Background The COVID-19 pandemic increased disparities for communities burdened by structural barriers such as reduced affordable housing, with mental health consequences. Limited data are available on digital resources for public mental health prevention during the COVID-19 pandemic. Objective The study aim was to evaluate engagement in and impact of free digital resources on the Together for Wellness/Juntos por Nuestro Bienestar (T4W/Juntos) website during COVID-19 in California. Methods A pilot evaluation of T4W/Juntos was performed, with partner agencies inviting providers, clients, and partners to visit the website and complete surveys at baseline (September 20, 2021, to April 4, 2022) and at 4-6–week follow-up (October 22, 2021, to May 17, 2022). Website use was assessed by three engagement items (ease of use, satisfaction, relevance), comfort in use, and use of six resource categories. Primary outcomes at follow-up were depression and anxiety (scores≥3 on Patient Health Questionnaire-2 item [PHQ2] and Generalized Anxiety Disorder-2 item [GAD2] scales). Secondary outcomes were post-pre differences in PHQ2 and GAD2 scores, and use of behavioral health hotlines and services the month before follow-up. Results Of 366 eligible participants, 315 (86.1%) completed baseline and 193 (61.3%) completed follow-up surveys. Of baseline participants, 72.6% identified as female, and 21.3% identified as lesbian, gay, bisexual, transgender, queer/questioning, and others (LGBTQ+). In terms of ethnicity, 44.0% identified as Hispanic, 17.8% as African American, 26.9% as non-Hispanic white, and 11.4% as other ethnicity. Overall, 32.7% had moderate anxiety or depression (GAD2/PHQ2≥3) at baseline. Predictors of baseline website engagement included being Hispanic versus other race/ethnicity (β=.27, 95% CI .10-.44; P=.002) and number of COVID-19–related behavior changes (β=.09, 95% CI .05-.13; P<.001). Predictors of comfort using the website were preferring English for website use (odds ratio [OR] 5.57, 95% CI 2.22-13.96; P<.001) and COVID-19–related behavior changes (OR 1.37, 95% CI 1.12-1.66; P=.002); receiving overnight behavioral health treatment in the prior 6 months (OR 0.15, 95% CI 0.03-0.69, P=.015) was associated with less comfort in website use. The main predictor of depression at follow-up (PHQ2≥3) was baseline depression (OR 6.24, 95% CI 2.77-14.09; P<.001). Engagement in T4W/Juntos was associated with lower likelihood of depression (OR 0.54, 95% CI 0.34-0.86; P=.01). Website use the month before follow-up was associated with a post-pre reduction in PHQ2 score (β=–.62, 95% CI –1.04 to –0.20; P=.004). The main predictor of GAD2≥3 at follow-up was baseline GAD2≥3 (OR 13.65, 95% CI 6.06-30.72; P<.001). Greater baseline website engagement predicted reduced hotline use (OR 0.36, 95% CI 0.18-0.71; P=.004). Conclusions Ethnicity/language and COVID-19–related behavior changes were associated with website engagement; engagement and use predicted reduced follow-up depression and behavioral hotline use. Findings are based on participants recommended by community agencies with moderate follow-up rates; however, significance was similar when weighting for nonresponse. This study may inform research and policy on digital mental health prevention resources.


Introduction Background
The COVID-19 pandemic increased disparities for communities burdened by structural barriers such as shortage of affordable housing or work opportunities, with mental health consequences [1]. Stressors related to COVID-19 include loss/grief, self-quarantining, physical distancing, social isolation, business and school closures, financial impacts, lack of access to basic needs, and stress, including that related to racial discrimination, with mental health consequences [2]. There is also documentation of provider stress such as burnout, fear of infection, and loss [3]. There are racial/ethnic disparities in prevalence and economic impacts, and disparities exist for other marginalized groups such as lesbian, gay, bisexual, transgender, queer/questioning and others (LGBTQ+), rural farm workers, and persons with mental health challenges [1,[3][4][5][6]. These impacts are noted across age groups, with concerns about school/work-related distress, substance use, suicidality, abuse/violence, and overall mental health consequences [7,8], highlighting the importance of public-facing interventions.
With advances in social media and digital technology, the importance of digital interventions for public health is clear; some countries use digital resources to promote mental health prevention, including in youth portals [9]. Such strategies may reduce the need for services, while increasing access to services for those in need [10]. There are limited data on the effectiveness of digital interventions for public mental health and in disasters [10]. Over the past decade, mental health care has been supplemented by mobile mental health apps and internet resources, ranging from meditation and mindfulness apps to symptom diaries and self-management tools such as cognitive behavioral therapy (CBT) [11]. While there is evidence for the efficacy of internet-based self-directed CBT and behavioral activation, evidence for many apps is limited, with inconsistent documentation of how apps are informed by evidence, as well as how they are accessible and tailored for underresourced groups [11][12][13]. Commentaries on next directions emphasize reframing tools as service enhancements and designing tools with end-user input, attending to the community and system contexts [14]. Some studies used consumer advisor input to tailor apps, such as sexual minority men to manage generalized anxiety and major depressive disorder [15] or consumer advisors' partnered digital resources for youth or underresourced communities, but with limited evidence on impacts [16,17]. A recent review suggested greater uptake and effectiveness of digital resources with human contact in some studies, including a few rigorous randomized trials, although some showed no significant added effects [18]. Commentaries emphasize "solution-focused" approaches to digital mental health, with attention to user experience and an intervention target of engagement (usefulness, usability, satisfaction, use, contacts with others), consistent with community-engaged approaches [19][20][21].

Digital Mental Health Tools and Together for Wellness Development
Given a history of partnered interventions, including those delivered during disasters [22,23], California Health Care Services Division of Behavioral Health included in its Federal Emergency Management Agency (FEMA)/Substance Abuse and Mental Health Services Administration (SAMHSA) a COVID-19 crisis counseling program, supporting free digital mental health resources (Together for Wellness/Juntos por Nuestro Bienestar [T4W/Juntos]) with partner input. T4W/Juntos features evidence-informed or evidence-based resources reviewed with lead agencies (Latinx, Black, Asian American, LGBTQ+, parent support for youths, older adults, persons with mental illness). The public website was developed iteratively, initially focusing on mindfulness, and adding resources vetted by community partners on coping with stress; grief; connecting to others; social justice issues such as racial discrimination; information on COVID-19; and resources for families with children, teachers, and older adults. Given the input, toolkits included visuals and videos, resources in multiple languages, and video orientations by provider and community partners; the initial partnered development process was previously described in a commentary [24]. This article describes further development of T4W/Juntos and results of a partnered evaluation, informed by principles of community-partnered participatory research (CPPR), including trust, respect, and two-way input [21]. The website and evaluation are informed by the technology acceptance model (TAM) and Behavioral Model for Vulnerable Populations, with COVID-19-related behavior changes [25][26][27]. The TAM explains use of technologies by professionals and patients, emphasizing reported engagement/satisfaction and comfort in use, contributing to actual use [25]. The Vulnerable Populations model emphasizes factors affecting underresourced groups [26], coupled here with COVID-19-related changes [27], to inform mechanisms of action (engagement, comfort in use) for promoting mental well-being, attending to the individual and system contexts [19,20].
The research questions for this study were as follows: (1) What are specific individual and social factors that promote engagement and use of the T4W/Juntos website?
(2) Does reported engagement in and use of T4W/Juntos reduce symptoms of depression and anxiety (primary), and use of crisis hotlines and behavioral health services (secondary)?
Based on input from community and policy partners, we hypothesized that individuals with higher need (greater depression, anxiety symptoms) and more COVID-19-related behavior changes (such as social distancing) and COVID-19-related stressors (such as loss or financial stress) would engage more in website use, and that engagement and use between baseline and follow-up would be associated with reduced depression, anxiety, and use of hotlines at follow-up, as evaluated by participant surveys.

T4W/Juntos Resources
The website was iteratively reviewed by community partners in group meetings (largely by Zoom) in English and Spanish. Meetings included representatives of 11 agencies, youth and older adult advisory groups, and involved interaction with investigators and technology design leaders. Resources were reviewed and updated. Suggestions led to modifications in design, addition of other languages, and others. Based on this feedback, 133 resources were selected for T4W/Juntos: websites (n=62), videos (n=18), YouTube links (n=2), PDFs (n=32), apps (n=10), and hotlines (n=9). The 6 main categories with examples are illustrated in Table 1. The website is available in 13 languages (videos in Mixteco were published in the summer of 2022). Once resources were made available on the website, we used an iterative process through focus group sessions (N=4) that consisted of youth (n=8) and older adult (n=10) advisors. Community partners were asked to provide feedback about their experience using the website and their review of resources. Each focus group was led by a moderator and notes were taken by members of the T4W/Juntos team. Feedback was communicated to the technology team and the website was revised/updated accordingly.

Evidence Basis
As shown in Table 1, most resources are evidence-informed or evidence-based for specific populations, rather than for public prevention. For example, there are studies of effectiveness of mindfulness on attentional and emotional self-regulation [28]; one study of community health promotion used a pre-post design [29] and another was a randomized trial for depressed English and Spanish adults, which was found to reduce depression [28].
Mindfulness is thus considered to be "evidence-informed" for public prevention. Some resources are based on CBT and mindfulness (such as Mindshift App and Sanvello), whereas others provide information (eg, on depression) with resources for subgroups (eg, children).

Design
The website evaluation was conducted in collaboration with 11 California community-based agencies representing diverse populations. Each agency gave input in planning meetings on survey measures and design, signed an agreement, and received US $1000 for their work to invite participants for the survey, including clients, partners, and staff, as groups impacted by COVID-19. For agencies with large lists of potential participants, random selection tools were provided. Assuming a 50% response rate, we encouraged the agencies to invite 80-100 individuals to ultimately enroll 30-40 per agency; that number was later expanded to 70 per agency to increase enrollment. The goal was to have 300-350 participants review the website and complete the baseline survey online; of these, 10% would be invited for a qualitative telephone interview 2 weeks later and all would be invited for a 4-6-week online follow-up survey. The goal was to apply the TAM/Vulnerable Population Model to describe engagement in website use [30], and predictors of engagement and anxiety/depression (Generalized Anxiety Disorder scale-2 [GAD2]/Patent Health Questionnaire-2 [PHQ2]), including demographics, services use, and COVID-19-related behavior changes and stressors [22,27,[31][32][33]. For the evaluation, we created a duplicate version of the entire public-access website that allowed us to track enrollment by the inviting agency. Potential participants were emailed invitations (with 1-2 reminders) and a link to the eligibility screener (participants needed to have online access, speak English or Spanish, be aged 18+ years). Eligible participants who consented online were registered, given a link to the duplicate website that they were asked to visit, and asked to complete a baseline survey after visiting the website. Those who completed the baseline survey and consented to follow-up were invited to participate online surveys 4-6 weeks later, and (if selected) to be contacted for a qualitative interview 2 weeks after baseline (10% of total sample). Surveys were provided in English or Spanish.

Ethics Approval
The study was reviewed and approved by the University of California, Los Angeles Institutional Review Board for Human Subjects (20-002163-AM-00008). All participants provided informed consent online and were advised that participation was voluntary, data would be deidentified, their contact information would be used for follow-up, and linking data (an ID code) would be stored on a secure server separately from study data. Informed consent was affirmed at follow-up assessments. For each participation event (survey, interview), participants received a US $25 electronic gift card. Inviting agencies were not informed of the participation of individuals.
The study team used the separately stored contact information to invite participants to follow-up. Participation in each activity was voluntary.  [22,[34][35][36]. Two mental health stigma items were also included at baseline (scored on 5-point Likert agreement scales plus "don't know") [22].

Baseline and Follow-up
Depression and anxiety screeners included responses to the PHQ2 and GAD2 (range 0-6; score≥3 considered moderate depression/anxiety) [32,33]. Services use was assessed for the prior 6 months in the baseline survey and for the prior 1 month in the follow-up survey, including any hotline use for behavioral health (any and number of calls) and any behavioral health services (emergency room, primary care, mental health, substance use visits; hospitalization, residential care) [22]. Pandemic-related stress at baseline was assessed according to an adapted version of the COVID-19 Stress Scale [37], including COVID-19-related behavior changes (nine items: no changes, social distancing, isolation, caring for someone at home, working from home, not working, change in health care services, following media coverage on COVID-19, and changing travel plans). The overall impact of the pandemic was assessed over five categories (plus decline to answer). COVID-19 stressors [19] included having COVID-19; fear of acquiring or spreading COVID-19; worrying about others; stigma or discrimination; financial, food, and home insecurity; frustration, depression, anxiety, alcohol, sleep, and sexual activity change; confusion about COVID-19; other difficulties (not contributing to greater good, having social/emotional support, having financial support from others). Additional items included were vaccination status (yes/no), vaccine acceptability (5-point Likert agreement plus don't know), date of survey completion, and racial/ethnic discrimination during the COVID-19 pandemic (assessed at baseline only: 6 items, 4-point Likert scale) [25,35].
The use of and engagement in the website at baseline were assessed according to website satisfaction, relevance of content, and ease of use, along with comfort in using the website (each with a 5-point Likert agreement scale plus "don't know"). At follow-up, use and engagement were assessed according to actual website use in the prior month, including any use (yes/no); frequency/download and use of any of the six main categories, each with five response options (did not use, used some, used and valuable, used and very valuable, used and would recommend to anyone); and if recommended website to others (yes/no), number of times and which resource categories were recommended [22,25,31].

Statistical Analyses
We performed descriptive analyses to describe the sample using means (SDs) for continuous variables, and counts and percentages for categorical variables. To describe predictors of engagement/use, we fit linear regression models for continuous variables (eg, mean engagement score) and logistic regression models for dichotomous variables (eg, used website). For preliminary bivariate analyses, predictors included demographics, need, stigma, COVID-19-related behaviors and stressors, and behavioral health services use (including predictors of follow-up nonresponse). The final regression model included predictors that were significant in preliminary models at P<.05.
For website use in the month before follow-up, we used logistic regression for any use and linear regression for total score of use across the six main categories. We examined predictors at follow-up of having PHQ2≥3 and GAD2≥3, and as sensitivity analyses, the post minus pre difference in PHQ2 and GAD2 scores. For secondary analyses, we examined predictors of hotline use and any behavioral health services use (outpatient, inpatient, rehabilitation, hotlines) in the month before follow-up; an imputed version of inpatient/rehabilitation was used for sensitivity analysis, assigning 0 if the items were skipped but other use items answered. We initially examined all measures as predictors in bivariate analyses, including predictors of follow-up nonresponse. We then fit regression models with significant predictors to inform final models. For final follow-up models, we conducted sensitivity analyses using inverse propensity weighting of data for predictors of nonresponse at baseline (age) and for follow-up after baseline [38,39].
Of the baseline participants, 72.6% were female, 21.3% self-reported as LGBTQ+, 44.0% were Hispanic, 17.8% African American, 26.9% non-Hispanic white, and 11.4% endorsed another ethnicity. The sample's mean age was 38.8 years with 110 (34.9%) aged 18-30 years and 18.5% had a high school education or less. Of the baseline participants, 32.7% screened positive for moderate anxiety or depression (GAD2/PHQ2≥3) and 61.2% had used behavioral health services in the prior 6 months. For COVID-19-related behavior changes, the mean number selected of the 9 listed was 3.9 (SD 2.0). For COVID-19 stressors, the mean selected of the 19 listed was 6.8 (SD 4.1) ( Table 2).

Website Engagement
Of all participants, 87.1% agreed the website was easy to use, 80.5% found the topics to be relevant, 85.9% were satisfied with the website, and 70.2% were comfortable using the website. Three items (ease, relevance, satisfaction) were averaged to obtain the mean engagement score with standard Cronbach α=.736; comfort using the website was considered a separate measure. In final regression analyses, predictors of higher baseline engagement included Hispanic versus other race/ethnicity (β=. 27

Follow-up Response and Predictors
Of the 315 participants completing the baseline survey, 193 (61.3%) completed follow-up surveys. Table 2 shows baseline factors in bivariate analyses that predicted follow-up survey completion (significance of differences between groups with and without follow-up response were evaluated with χ 2 tests for categorical variables and with t tests for continuous variables). In final logistic regression models, baseline predictors of follow-up survey response were: (1) (6) Need to Talk to Someone? (Helplines). For any use in the month prior to follow-up, unique baseline predictors in the regressions were: PHQ2 score (higher=more use), called hotline for behavioral health before baseline (higher=more use), and greater alcohol use during COVID-19; these predictors were also significant when weighted for nonresponse ( Table 3). The mean score of category use (1-5, from "no use" to "recommend to everyone") varied from a high of 2.30 (SD 1.45) for Soothe Anxiety and Stress to a low of 1.75 (SD 1.26) for Need to Talk to Someone; mean scores were significantly higher for Categories 1-3 and 5 than for 6; categories 1 and 2 than for 4 and 5; and category 2 than category 3 (all P≤.002). Predictors of higher total use summed across the six categories were: Hispanic ethnicity, baseline PHQ2 or GAD2 score ≥3, and caring for someone at home during COVID-19 (Table 3). COVID-19-related change in sexual activity was associated with reduced total use; these predictors were also significant with nonresponse weighting (Table 3). .002 -5.88 to -1.28 -3.58 COVID stressor, change in sexual activity a IPW: inverse probability weighting for nonresponse predictors at baseline and follow-up. b The effect is presented as the odds ratio for any website use and as β for use of 6 categories. c Analytical N=186 for main analysis, N=181 for sensitivity analysis.

Associations With Primary and Secondary Follow-up Outcomes
The main predictor of follow-up depression (PHQ2≥3) was baseline depression (Table 4). In addition, greater reported engagement in T4W/Juntos was associated with a lower likelihood of depression at follow-up (Table 4). PHQ2 scores can range from 0 to 6; for our sample, the baseline mean PHQ2 score was 1.6 (SD 1.5). Predictors of a post-pre change in the PHQ2 score included: (1) Caucasian/white versus other race/ethnicity, which was associated with an increase in PHQ2; (2) using the website resources in the month before follow-up, which was associated with a reduced post-pre PHQ2 score; and (3) having more COVID-19-related stressors at baseline, which was associated with a reduced post-pre PHQ2 score ( Table 4). The findings were similar when weighted for nonresponse. For GAD2≥3 at follow-up, the main predictor was baseline GAD2. For a post-pre change in the GAD2 score, the main predictors were non-Hispanic white versus other race/ethnicity, age, and COVID-19-related stressors; however, only COVID-19-related stressors and age were significant in the analysis weighting for nonresponse ( Table 4).
Predictors of using hotlines for behavioral health in the month before follow-up included: baseline depression or anxiety (PHQ2 or GAD2≥3) (P=.006) and use of hotlines prior to baseline assessment (P=.002). Greater baseline mean website engagement, greater comfort using the website at baseline, and greater mean total website use in the month before follow-up each predicted reduced hotline use at follow-up, which remained significant with nonresponse weighting (Table 5). For use of any behavioral health services (outpatient, inpatient, rehabilitation, hotlines) prior to follow-up, the main predictor in logistic regression was use of such services prior to baseline. Increased reported mean engagement with the website at baseline was associated with a borderline trend toward reduced probability of behavioral services use, which was significant when weighting for nonresponse (Table 5).

Principal Findings
This article presents an evaluation of engagement in and impact of free digital mental health resources developed with community advisor input to support well-being during COVID-19 in California. Informed by the TAM, Behavioral Health Model for Vulnerable Populations, COVID-19 stressors, and CPPR principles [21,[25][26][27], we hypothesized that individuals with higher need (depression, anxiety) and more COVID-19-related behavior changes and stressors would engage more in website use, and that higher engagement and use would be associated with reduced depression, anxiety, and hotline use at follow-up. Findings on predictors of website use were somewhat consistent with these hypotheses, but the details differed for baseline and follow-up. For main outcomes, findings were consistent with hypotheses for depression and hotline use, in that greater engagement or use before follow-up was associated with lower follow-up depression and greater reduction in depression from baseline to follow-up, but not reduced anxiety, for the overall sample. The main findings were consistent in sensitivity analyses weighting for nonresponse, and a borderline significant trend for baseline website engagement was significantly associated with reduction in any behavioral health service use when weighting for nonresponse.
These findings suggest that recruiting participants through community agencies can generate a diverse sample in race/ethnicity, age, gender identity, and sexual orientation [1,[6][7][8]. Baseline completers were somewhat younger than noncompleters, suggesting that more support for participation may be needed for older adults. Baseline website engagement was higher for those of Hispanic ethnicity, whereas comfort in website use was greater for people preferring English, suggesting that website modification or human support may be important for non-English speakers [18]. In addition, less comfort in use was associated with having a prior overnight behavioral health stay, which could reflect disability or need for support. Website use before follow-up was lower for those with greater alcohol use during the COVID-19 pandemic. Total website use across categories was higher for those caring for someone at home and was lower for those with a change in sexual activity during the pandemic. These findings highlight potential differences in website use patterns for specific COVID-19 changes, which is an area for future research. The main findings for depression and hotline use are largely consistent with policymaker goals for developing the website for prevention to reduce mental health needs and crisis calls.

Limitations
Limitations included that, as a nonrandomized study, the findings could reflect selection effects or reverse causality, although the main finding of website use associated with reduced depression was robust in analyses of end status and post-pre change with and without nonresponse weighting. Higher use of this website could be associated with use of other websites that could have had an unmeasured (confounding) effect on outcomes. Further, the study used a convenience sample recruited by partnering agencies in one state representing diverse populations rather than a general population sample during a specific period of the pandemic (September 2021-May 2022).
While effects of COVID-19 evolved over time, during this period, the date of survey completion was not significant and not included in final models. Future research may include experimental designs to clarify the causation and mechanisms of action. Further, the study had a moderate response at follow-up (61.3%). Predictors of response (non-Hispanic white, lower baseline engagement, greater number of COVID-19 stressors) were included as predictors in final models if significant, with weighting for nonresponse in sensitivity analyses. Recruited participants included clients, partners, and providers of partnering agencies, and we did not track participant roles; however, baseline education data suggest the sample included some nonproviders. In future research, it may be important to include demographic or cultural differences in stigma of mental health that may affect website use to inform the tailoring of resources, and it may be important to evaluate the added value of human support to enhance website use and survey response, particularly for non-English speakers or older adults [18].

Public Health Implications
Given the consistency of main outcome findings with hypotheses and policy consumer advisor goals for developing digital resources, the findings were considered by policy partners as encouraging for further website development and evaluation as next steps, including expansion to youth/young adults. Descriptive findings reinforce the importance of community agency partnerships to achieve a diverse sample. These findings also raise the issue of potential impacts for diverse populations of prevention-oriented, free digital mental health resources during COVID-19 to reduce depression and crisis hotline use, an important issue for future randomized trials or quality improvement initiatives with public health implications. The consumer advisor engagement in this study reinforces the public health value of a partnered participatory effort in intervention development and evaluation. The findings suggest next steps for research in public health, such as exploring human support for digital resources, especially for non-English speakers, even for a website available in 13 languages. Although this represents only a preliminary evaluation, given limited data on digital mental health for preventive public health goals [10], the findings may inform the next steps for development of resources and evaluation efforts to inform public mental health prevention.