Skill Enactment Among University Students Using a BriefVideo-Based Mental Health Intervention:Mixed Methods StudyWithin a Randomized Controlled Trial

Background: Mental health problems are common among university students, yet many students do not seek professional help.Digital mental health interventions can increase students'access to support and have been shown to be effective in preventingand treating mental health problems. However, little is known about the extent to which students implement therapeutic skillsfrom these programs in everyday life (ie, skill enactment) or about the impact of skill enactment on outcomes. Objective: This study aims to assess the effects of a low-intensity video-based intervention, Uni Virtual Clinic Lite (UVC-Lite),in improving skill enactment relative to an attention-control program (primary aim) and examine whether skill enactment influencessymptoms of depression and anxiety (secondary aim). The study also qualitatively explored participants'experiences of, andmotivations for, engaging with the therapeutic techniques. Methods: We analyzed data from a randomized controlled trial testing the effectiveness of UVC-Lite for symptoms of depressionand anxiety among university students with mild to moderate levels of psychological distress. Participants were recruited fromuniversities across Australia and randomly assigned to 6 weeks of self-guided use of UVC-Lite (243/487, 49.9%) or anattention-control program (244/487, 50.1%). Quantitative data on skill enactment, depression, and anxiety were collected throughbaseline, postintervention, and 3- and 6-month follow-up surveys. Qualitative data were obtained from 29 intervention-groupparticipants through open-ended questions during postintervention surveys (n=17, 59%) and semistructured interviews (n=12,41%) after the intervention period concluded. Results: Mixed model repeated measures ANOVA demonstrated that the intervention did not significantly improve skillenactment (F-3,F-215.36=0.50; P=.68). Skill enactment was also not found to influence change in symptoms of depression (F-3,F-241.10=1.69;P=.17) or anxiety (F-3,F-233.71=1.11; P=.35). However, higher levels of skill enactment were associated with lower symptom levelsamong both intervention and control group participants across time points (depression: F-1,F-541.87=134.61; P<.001; anxiety:F-1,F-535.11=73.08; P<.001). Inductive content analysis confirmed low levels of skill enactment among intervention group participants. Participants were motivated to use techniques and skills that were perceived to be personally relevant, easily integrated into dailylife, and that were novel or had worked for them in the past. Conclusions: The intervention did not improve skill enactment or mental health among students with mild to moderatepsychological distress. Low adherence impacted our ability to draw robust conclusions regarding the intervention's impact onoutcomes. Factors influencing skill enactment differed across individuals, suggesting that it may be necessary to tailor therapeuti skills and engagement strategies to the individual user. Theoretically informed research involving collaboration with end usersis needed to understand the processes underlying skill enactment in digital mental health interventions