Evaluating Knowledge Mobilization Sustainability Approaches for Stress Management in University Students

University students face heightened levels of stress and difficulties in coping with daily stressors (American College Health Association, 2023; Ribeiro et al., 2018). The transition to higher education can introduce a variety of stressors such as financial hardships, pressures of novel relationships, and the challenges of unfamiliar social environments, placing students at elevated risk for mental health difficulties (Arnett et al., 2014; Beiter et al., 2015; Ribeiro et al., 2018). Thus, there is a need to provide university students with evidence-based strategies to build their coping and stress management capacity during this exciting but challenging developmental period. As a result, universities are increasingly implementing complementary support services, such as digital self-guided supports (Benjet, 2023; Wang et al., 2023). Digital self-guided resources can be used completely independently (e.g., at the user's own convenience, in terms of time and location of use) and without real-time guidance from a professional or peer (Ahuvia et al., 2024; Edge et al., 2023). These self-guided approaches tend to be less resource-intensive while remaining effective in enhancing student well-being (Amanvermez et al., 2022; Harrer et al., 2019; Oey et al., 2023). Additionally, given university students' reported barriers to accessing mental health services, such as lack of time and a preference for self-management (Benjet, 2023; Dunley & Papadopoulos, 2019; Ebert et al., 2019), digital self-guided resources offer a potential first step for students who are reluctant to engage with traditional approaches to mental health support.

Although digital self-guided resources have been shown to be effective over short periods of time, what is less clear is how to ensure students' long-term use of the strategies being taught in these resources (Harrer et al., 2019; Heber et al., 2017). The majority of studies only examine the short-term effectiveness (i.e., three months or less) of digital self-guided resources (Harrer et al., 2019; Taylor et al., 2024; Wang et al., 2023; Yusufov et al., 2019). However, some studies suggest that users' sustained long-term use of self-guided resources, commonly defined as 3 months or more, is variable and generally low (Fleming et al., 2018; Lattie et al., 2019). In this literature review, the term "resource" is used to define the delivery mechanisms (e.g., mobile apps, infographics, online programs) that provide access to stress management content, while "strategies" refer to the specific coping techniques taught within these resources (e.g., breathing, mindfulness meditation). However, many studies do not differentiate between these terms and will report usage metrics without differentiating between participants' engagement with the resource itself, the strategies included, or both. As such, these terms have been used interchangeably throughout the literature review. Barriers related to long-term use include difficulties remembering to use the strategies and time constraints (Bamber & Schneider, 2022; Kaufman & Nemeroff, 2024; Lyzwinski et al., 2018; Renfrew et al., 2021; Stallman et al., 2020). Such findings highlight a need to expand research in this area by moving away from simply looking at short-term strategy effectiveness towards understanding sustainability approaches that promote long-term strategy use (Gan et al., 2021; Lattie et al., 2019; Taylor et al., 2024).

A common first step in understanding sustained strategy use, defined as ongoing or continued use of the strategies over time, is to consider adherence. Adherence typically refers to the extent to which users follow recommended guidelines for resource use, including the frequency, duration, and program completion (Achilles et al., 2020; Saleem et al., 2021). Measuring adherence is important, as it provides insight into whether students are engaging with interventions as intended (Achilles et al., 2020). However, focusing solely on adherence may not capture the broader and more nuanced patterns of how students continue using specific strategies in their day-to-day lives after initial exposure (Saleem et al., 2021; Taylor et al., 2024; Yusufov et al., 2019). To address this gap, researchers are increasingly exploring the concept of sustained strategy use, which focuses on long-term consistent engagement with specific coping methods beyond the initial intervention period (e.g., Borghouts et al., 2021; Melcher et al., 2022). Sustained strategy use may help students manage stress more effectively by encouraging consistent engagement with healthy coping methods. Particularly when no healthy strategies are perceived as effective or available, individuals remain motivated to alleviate their distress and may instead turn to unhealthy coping strategies; thus, students can be better equipped to manage difficult emotions (Stallman, 2020; Stallman et al., 2020). However, the literature remains unclear on the key areas to support long-term sustained strategy use, especially among university students.

Two key areas that have been suggested to contribute to sustained strategy use are: (1) sustainability supports and (2) the maintenance of behaviour change framework (Alkhaldi et al., 2016; Gan et al., 2021; Kwasnicka et al., 2016). Sustainability supports encompass a variety of approaches aimed at encouraging continued use of wellness strategies. These include providing psychoeducational information on habit formation, sending text or email reminders, and creating accountability groups (Alkhaldi et al., 2016; Gan et al., 2021). On the other hand, maintenance of behaviour change refers to psychological and environmental factors that promote long-term behaviour adoption, such as motivation, self-regulation, habit formation, availability of internal resources, and social/environmental factors (Kwasnicka et al., 2016). Thus, sustainability supports emphasize how to keep students engaged over time, while the maintenance of behaviour change framework focuses on why students continue using strategies in the long term.

The literature outlines a range of diverse sustainability supports, commonly offering information on habit formation (e.g., implementation supports and common barriers to strategy use; Borghouts et al., 2021; Gan et al., 2021; Saleem et al., 2021), fostering community through accountability groups or social support (e.g., peer support; Alkhaldi et al., 2016; Borghouts et al., 2021; Saleem et al., 2021; Vis et al., 2018), and sending text or email reminders (Achilles et al., 2020; Alkhaldi et al., 2016; Saleem et al., 2021). Offering information on habit formation has been suggested as an approach for sustained strategy use by providing psychoeducation and addressing common challenges in developing habits (Borghouts et al., 2021; Gan et al., 2022; Saleem et al., 2021). In university settings, this approach along with wellness services are frequently delivered in the form of workshops (Cho et al., 2024; Yuen et al., 2020), which allow trained facilitators to reach large numbers of students, provide support, and answer questions in real time. Another widely used approach to encourage sustained strategy use is incorporating community-based or peer support components, given the reported influence of social support on engagement (Achilles et al., 2020; Alkhaldi et al., 2016; Saleem et al., 2021). For instance, when participants perceive that an intervention fosters social engagement, whether through facilitator interactions or peer connections, they tend to show higher engagement with the resource and greater use of the strategies offered (Borghouts et al., 2021). Finally, strategy use reminders are also a commonly implemented approach due to their low resource intensity (Borghouts et al., 2021). Reminders have been recommended to support engagement and can be delivered either through SMS/text messages, email, or directly through the resource (i.e., app or gamification software; (Saleem et al., 2021; Zarski et al., 2016). Reminders have been used in several studies to promote strategy use and behaviour change(Clarke et al., 2009; Dryman et al., 2017; Morris et al., 2015; Zarski et al., 2016). Although there is variability in their effectiveness ranging from about 25% to 60%, generally they have been shown to be beneficial (Fry & Neff, 2009; Saleem et al., 2021). It is hypothesized that the variability in effectiveness is due to design and delivery of the interventions rather than the use of reminders themselves. However, to our knowledge, there is no research comparing the effectiveness of these sustainability supports both relative to one another and against an inactive control. As a result, student mental health services are often forced to make decisions without clear data on which approaches are most likely to support sustained strategy use over time.