Bridging the Digital Gap: A Content Analysis of Mental Health Activities on University Websites

: Mental health concerns are common among university and college students. Digital mental health resources and support are offered through university websites. However, the content and type of mental health activities of these institutions have not been analyzed. The aim of this study was to conduct a content analysis of mental health commitment and practices listed on Canadian postsecondary institutional websites. A 27-variable codebook was developed to map the content of all Canadian postsecondary institutions ( n = 90). Descriptive statistics were applied to provide a broad snapshot of current institutional wellbeing activities. Nearly all institutions offered crisis response options, and multiple mental health supports through various modalities. However, few institutions had a wellbeing framework (34%), engaged in recent campuswide anti-stigma campaigns (33%), tracked campus wellness activities (13%), monitored student mental health outcomes (13%), and solicited feedback through the wellness center webpages (14%). These outcomes were similar across all geographic regions but statistically signiﬁcantly different between small, medium, and large institutions. Findings suggest institutions need to address these gaps, provide smaller institutions with greater governmental support for building mental health capacity, and work towards developing a centralized hub for mental health that is accessible, navigable, and considers student needs and preferences.


Introduction
University and college students are at a high risk for developing mental health problems [1,2].A combination of stressors related to a transitionary period known as emerging adulthood, which often involves moving away from home, taking on additional responsibilities, academic challenges, new relationships, employment, and new-found independence may be contributors to the high prevalence of mental health concerns [1].Data from the American College Health Association from 1998 to 2022 show an increase in prevalence of mental health challenges, self-reported depression, and self-reported anxiety among postsecondary students over time [3].Additionally, findings from the Center for Collegiate Mental Health show increasing trends of counseling, students entering services with traumatic experiences, and self-harm between 2012 to 2021 [4].This same report revealed an 11-year increase in symptoms of student distress, social anxiety, generalized anxiety, and depression [4], suggesting an increased demand for these services.The COVID-19 pandemic has exacerbated ongoing mental health challenges in this priority population, with 72% of students seeking mental health services mentioning the pandemic had negatively affected their mental health in 2021 [4].The problem may not only be restricted to increased demand and COVID-19, but perhaps also a lack of early identification and treatment, and by extension, persistence of mental health problems among this group [1].Therefore, strategies focusing on early identification, treatment, and delivery of preventative mental health promotion activities across college and university campuses may be a feasible approach to better serve postsecondary students [1].
Digital mental health tools, interventions, and resources have seen an increase in the last few years and especially during the COVID-19 pandemic where barriers to access were widespread [5][6][7].The digital space and internet may be partially attributed as a mediator or moderator of some mental health problems among young adults, but these same technologies can and have been leveraged to overcome barriers and deliver mental health resources and services [8,9].A systematic review showed postsecondary students commonly used the internet to access mental health information and to seek support for mental health concerns [9].Another systematic review evaluating the effectiveness of digital mental health interventions demonstrated these interventions moderately improved psychological wellbeing, and reduced symptoms of stress, anxiety, and depression among students [10].However, research studies have highlighted the need to evaluate and ensure these digital health resources are developed appropriately, easy to use, equitable, available through multiple modalities (e.g., mobile apps, videoconferencing), and account for preferences and comfort of the populations using them [5,8,11,12].As the number and variety of services, programs, and activities increase to support the growing demand of postsecondary student mental health, there is also a need to evaluate the extent to which these institutions have adapted digitally.
Universities and colleges have been called on to take a more comprehensive and campuswide approach to health promoting activities [13,14].Many institutions in Canada have committed to actively promoting wellbeing and health across their campuses [15], and as a result, it is assumed there is a spectrum of mental health awareness, prevention approaches, promotion activities, treatments, and supports available to postsecondary students.In fact, students report trust in mental health-related digital resources provided by their universities and colleges, suggesting it is a promising avenue for campuses to deliver information [9].However, it is unclear the degree to which these institutional commitments have been translated to practice digitally, and whether institutional differences may be present.No study to date has identified and mapped Canadian postsecondary institutions' commitments to mental health and the publicly facing mental health activities viewed by students.There is a need to address this research gap.
The aim of this study was to conduct a content analysis of mental health commitments and practices listed on Canadian postsecondary institutional websites to determine whether these institutions are digitally capable to serve its student populations.The outcomes of this research can enable identification of gaps in institutional actions, determine the extent of online mental health activities, and provide recommendations for improving development of online wellness webpages hosted by higher education institutions.

Study Design
This study utilized a cross-sectional design with a basic content analysis approach [16].This analysis involves a systematic and quantitative description of content that is manifest (i.e., content which is overtly and literally present) [16].Content analyses have been successfully applied in research identifying and documenting the considerations, sensitivities, and gaps in best practices of mental health in websites [17][18][19].We adapted from these approaches and applied it to the postsecondary institution context.
The research question was: "What are the publicly reported mental health commitments, supports, and activities on Canadian postsecondary institutions' websites?".

Inclusion and Exclusion Criteria
All English-and French-language publicly recognized postsecondary degree granting institutions in Canada were eligible for inclusion based on the list of designated educa-tional institutions provided by the Government of Canada [20].We applied these eligibility criteria to make meaningful comparisons across institutions and findings applicable to Canadian university campuses.Therefore, private institutions, unaccredited schools, junior or community colleges, and technical institutes were excluded.We also excluded institutions outside of Canada, satellite campuses, and those which were not higher education institutions.In total, 90 institutions from 11 provinces and territories across Canada were included.

Codebook Development, Intercoder Reliability, and Application
The codebook was developed through: (i) consultation with members of the research team who have expertise in mental health research and advocacy, (ii) a scan of institutional websites to identify items of interest, and (iii) reviewing the Okanagan Charter, the American College Health Association (ACHA)'s healthy campus framework, and Canadian Association of College and University Student Services (CACUSS)' Systematic Approach to inform indicators of health promoting universities and colleges [14,15,21].
From this, a 27-variable codebook was developed containing key institutional characteristics (e.g., What is the student population?), campuswide practices (e.g., Does the institution have a wellbeing framework or mental health strategic plan?Does the institution provide students with crisis response resources?),and student wellness initiatives (e.g., Access to >1 support to address a variety of student needs that impact mental health?).Topics coded from the websites included the following domains: mental health policies, campuswide approaches, primary prevention, secondary prevention, tertiary prevention, and evaluation.Some enrollment data were not accessible through institutional websites, and thus, we retrieved these data from Universities Canada [22].Institution sizes were further categorized by using established classifications of very small (<1000 students), small (1000-2999 students), medium (3000-9999 students), and large (≥10,000 students) [23].The codebook went through several iterations and amendments before being finalized.The full codebook, its variable descriptions, and the coded dataset are available in the Supplementary Materials.
The reliability of the codebook was assessed by coding a randomly selected sample of institutions (n = 13) in duplicate (AT and JS).This has been considered a sufficient sample size for assessing intercoder reliability [24].Codebook questions and variables were revised, removed, or combined through discussion to reach a consensus on all codebook variables.The final intercoder reliability kappa agreement was 0.84, which indicated almost perfect agreement.Following this, the remaining institutional websites were visited and coded by two authors (AT and JS).All data collection was conducted during March and April 2023.Coding was completed using Microsoft Excel (Microsoft, Redmond, WA, USA).

Statistical Analysis
Most results were reported using descriptive statistics.Institution size and geographic region of the institutions were selected a priori for further analysis using Pearson's χ 2 tests and Fisher's exact tests to assess for statistically significant differences in the reporting of some mental health activities (α = 0.05).These activities included: application of wellbeing frameworks (yes/no), presence of campuswide anti-stigma activities (yes/no), provision of >1 wellbeing programming (yes/no), evidence of institution-community partnerships (yes/no), campuswide student engagement for wellbeing (yes/no), monitoring of wellbeing activities (yes/no), differentiation of mental health activities for equity-deserving groups (yes/no), invitation of ongoing community feedback for wellness services (yes/no), and acknowledgement of accommodations and accessibility for wellbeing (yes/no).For analysis, institution size was collapsed to three categories: large, medium, and small.Small and very small categories were combined due to low observations within some cells.Geographic regions were collapsed to four categories: Atlantic (New Brunswick, Prince Edward Island, Nova Scotia, and Newfoundland and Labrador); Central (Ontario, and Quebec); Prairie (Alberta, Saskatchewan, and Manitoba); and West and North (British Columbia, and Yukon).All statistical measures were calculated using StataSE 17.0 (StataCorp, College Station, TX, USA).

Compliance with Ethical Standards
This study was exempt by the Research Ethics Board at the participating institutions because the data were publicly available information, and this research did not involve human participants [25].

Institutional Characteristics and Mental Health Activities
Overall, 90 institutions were eligible for inclusion.Many institutions were from Ontario (27%) and were classified as large (44%) (Table 1).Regarding mental health activities, only a few institutions had: access to mental health services from the main landing page (38%), incorporated wellbeing or mental health within their mission statement (6%), reported any campuswide anti-stigma activities in the previous school year (33%), recognized some campuswide student engagement and commitment for mental health (34%), and had a wellbeing framework or strategic plan in place (34%) (Table 1).Most institutions provided information about crisis response options (90%), acknowledged accommodations and accessibility for psychological challenges (53%), provided tools to improve understanding of mental health challenges (84%), provided information for identification and responding to early warning signs (71%), self-management and identification of self needs (84%), access to multiple wellbeing programming activities (74%), and a wide variety of student mental health needs (79%) (Table 2).Regarding modality of mental health supports, telephone (90%), in-person (80%), internet (73%), and text-and app-based supports (72%) were the most frequently listed on the institutional websites (Table 2).Email (23%), audiovisual (16%), and print materials (1%) were less commonly reported on websites (Table 2).Regarding gaps, most institutions did not: have differentiated webpages or tabs for equity-deserving groups (51%), invite community feedback on wellness services or resource center (86%), or report tracking of wellbeing outcomes (87%) (Table 2).86.7 1 Values exceed 100% because some institutions had multiple option selections under this criterion. 2These groups were sometimes labelled 'racialized' or referred to specific groups (e.g., Black, South Asian). 3Options included: off-campus students (n = 2), women (n = 1), men (n = 1), first-generation students (n = 1), veterans (n = 1), and health care providers (n = 1). 4Some institutions did not have a wellness center (n = 2) or had an option for feedback, but it was not functional (n = 1).

Discussion
The present study used a content analysis to identify and map all available mental health supports and activities listed on Canadian postsecondary institution websites.Generally, most institutions reported multiple modalities of mental health supports, multiple wellness programming efforts, crisis response options, a demonstrated level of student engagement, and leveraged community mental health services and resources on wellness services webpages.Regarding resources and training, most institutions offered activities related to improving understanding of mental health, identifying, and responding to early warning signs, helping students identify their own wellbeing needs, and development of self-management skills.This suggests there was a spectrum of mental health activities catered to multiple student demographics.However, most institutions had several gaps related to presence of institutional wellbeing frameworks; monitoring and evaluations of student wellbeing and services; and general gaps across websites' online wellness services.We focus our discussion on these notable gaps, their implications for campuswide mental health promotion, and propose recommendations to improve digital spaces.
Our findings revealed fewer than half of the schools had an institutional mental health framework or wellbeing strategic plan in place, and of those that did, approximately onethird did not appear to have endorsement of these frameworks from senior leadership.The absence of wellbeing frameworks consequently resulted in the lack of written processes or plans for: tracking campus wellbeing outcomes; evaluating wellbeing services and programs; reviewing and developing all policies by considering mental health and wellbeing; and promoting a healthy campus culture.The Okanagan Charter is an international charter for health promoting colleges and universities, which states cultivating sustained health and wellbeing across a campus requires systems-level changes and embedding mental health into all aspects of the institution [13,14].The wellbeing frameworks identified from our study often recommended or applied elements of this charter, suggesting the value of institutional frameworks.It is possible some of these institutions examined in our study had frameworks in place but had not made them publicly available.The digital implications of this indicate demonstrating institutional commitment online can benefit all parties involved.A previously published study found students who perceived their university administration to care about their wellbeing had better mental health outcomes [26], and other research also reported institutional actions affected wellbeing outcomes among postsecondary students [27,28].Therefore, we recommend higher education institutions adopt the internationally recognized Okanagan Charter [14], develop campus-specific wellbeing frameworks, and share them publicly on their wellness services webpages to demonstrate institutional commitment to student wellbeing.Advocating for structural changes through the application of wellbeing frameworks can move campuses toward sustained culture of wellbeing and mental health promotion [13,14].
The primary end-users of campus mental health activities are postsecondary students.There is a need to consider the growing number of services, supports, programs, and resources that become available digitally [29].Further, consideration of user engagement and awareness of these tools are needed to make full use of often-limited institutional spending toward mental health [9].However, our study found most institutions did not solicit feedback on their wellness services webpages.Previously published work has indicated that community feedback forms are useful tools to identify changing user needs, and both strengths and weaknesses of websites and services [30][31][32].Additionally, most institutions in our study did not indicate monitoring or tracking wellbeing outcomes and did not have evaluation plans or processes for their institutional wellbeing activities.In fact, evaluations were mostly absent or opaque from institutional websites, and when present, were typically only recommended but not implemented.Evaluations are necessary to support the development of effective health promotion interventions in schools and integration of health promotion throughout all aspects of an institution [33].Many studies have recommended and expressed the benefits of both continuous monitoring of mental health outcomes of vulnerable populations and evaluations of digital mental health interventions and resources [9,29,[34][35][36].These strategies can help identify mental health activities that need increased promotion, work to eliminate barriers, ensure programs and services are effective, and improve user engagement with digital mental health tools and spaces [9,29,34].
Digital mental health tools and resources offer many advantages, such as accessibility, anonymity, greater likelihood of information disclosure, information availability, and time savings [37,38].However, we experienced several challenges during codebook development and coding due to a cross-institution variability in presentation of online mental health activities, resources, and tools.This was evident in our finding where many institutions from our study did not have dedicated webpages or sections for equity-deserving groups.Studies have recommended digital mental health-related content need to be personalized, accessible, and navigable [9,39].A pilot study found that the number of clicks to a specific webpage may not be as important as the flow of information [40], suggesting a need to explore students' perspectives and preferences of digital mental health webpages.Moreover, several studies have gone beyond this and identified a need for a centralized hub where users can access all wellness-related activities in one space (e.g., news, campaigns, community partnerships, student engagement) given there has been some indication of students experiencing information overload and difficulty finding relevant and credible mental health information online [9,[41][42][43][44].The implementation of a centralized online wellness hub that is up-to-date and considers student needs may contribute to a health promoting campus culture by increasing uptake of available supports by student populations and serving the campus community as intended [41,43,44].
Additional analysis disaggregating wellbeing activities by institution size and geographic regions revealed some noteworthy findings.Trends of mental health activities appear to be consistent across Canada.However, there were observed differences across institution size, with smaller institutions reporting fewer wellbeing activities.Smaller colleges and universities have smaller endowments [45,46]; capacity, staffing, and resource limitations [47,48]; and different teaching and research cultures compared to larger ones [46].The inherent challenges may require more equitable distribution of government funding to support smaller institutions [45], especially toward mental health.Furthermore, utilizing a socioecological approach to health with a focus on strengthening community action by connecting with the local community can help institutions leverage resources and collaborate on mental health promotions along with support the institutional values of community engagement [49,50].Therefore, equitable and sustainable government funding and an emphasis of institution-community partnerships may be a viable approach to overcome some of these health promotion gaps and resource limitations within smaller institutions.

Limitations
This investigation was not exhaustive.Earlier iterations of the codebook had nearly double the variables proposed to be coded, but issues related to subjectivity and interpretations that stemmed from the websites themselves led to the research team only prioritizing the final set of variables.Further, institutional websites varied greatly in the manner of presentation and organization of mental health-related content offered, which posed challenges during searching for content to be coded.Despite our best efforts to make this research reproducible, it is possible we may have missed some content.However, we reduced subjectivity and error during coding by pretesting our codebook multiple times with two independent coders and revising questions with members of the research team.Lastly, the nature of this investigation was to identify and determine publicly facing mental health activities across higher education websites.This may not be an accurate representation of the activities carried out by institutions.Content may lie behind login credentials (e.g., employee access), exist but not posted online, or only promoted physically on campus.Rather than this being a true limitation, these discrepancies instead highlight the need to make wellbeing activities easily accessible to student populations that higher education institutions serve.

Future Research Directions
To continue advancing knowledge in this area, we recommend the codebook be adapted and applied for community colleges (i.e., junior colleges), satellite campuses of large higher education institutions, and universities in other regions.Findings from these studies can improve our understanding on whether similar gaps exist in other higher education institutions and in regions outside of Canada.Secondly, most institutions included in this study did not incorporate wellbeing into their mission statements.This is unsurprising as previous research analyzing mission statements have not found health or wellbeing to be salient [51,52].To build on this, a closer examination of institutional values may be beneficial to identify whether mental health and wellbeing are integrated here.Finally, online mental health resources and activities are offered by institutions to support their student communities, and students' needs must be considered [5].Therefore, we recommend future research qualitatively explore postsecondary student preferences of university and college website content.These insights can be integrated with our results to inform best practices for website development, user interface, user engagement, and preferred technologies among students.

Conclusions
This content analysis successfully answered the research question of identifying the mental health commitments, supports, and activities on Canadian postsecondary institutions' websites.The study was the first of its kind to map online mental health activities in Canada's postsecondary settings.There were several strengths, including institutions offering multiple wellbeing programs, multiple modalities of mental health services (e.g., internet, text messaging, phone), resources that serve a spectrum of mental health topics, and information about crisis response options.Based on the findings from this study, institutions are advised to overcome existing gaps by establishing wellbeing frameworks; monitoring and disseminating student population wellbeing data; include an option for students to feedback online about wellness services; establish and promote student-institution partnerships; and engage in more campuswide mental health awareness campaigns.A combination of more equitable and sustainable funding for smaller institutions towards mental health and prioritizing partnerships with community organizations may overcome mental health program and services gaps digitally.
Our study was intended to descriptively map institutional mental health activities rather than establish any statistical associations or analyze disaggregated data through a granular approach.Therefore, these findings must be corroborated through other methods and analytical approaches and replicated in other regions.Specifically, we recommend future research investigate institutional core values to determine whether higher education prioritizes mental health and wellbeing.Investigations must also explore students' experiences interacting and engaging with schools' online wellness webpages to build on this study and identify areas to better serve this priority population digitally.

Table 2 .
Student mental health activities listed on Canadian postsecondary institution websites (n = 90).

Table 3 .
Disaggregated findings showing the variability of reported mental health activities by institution size (n = 90).

Table 4 .
Disaggregated findings showing the variability of reported mental health activities by geographic region of institution (n = 90).