A HOPE Online Community Peer Support Intervention for Help Seeking: A Randomized Controlled Trial

The COVID-19 pandemic has raised concerns about subsequent adverse mental health outcomes worldwide. Nearly half of American adults have experienced increased stress and worsened mental health (1). Furthermore, one-third of Americans have experienced an increase in anxiety and depression symptoms, and one in four Americans have experienced exacerbated trauma or stressor-related disorder symptoms (2).

Peer-led online support communities may assist in anxiety management through the psychology of social support (3). Online interventions, however, require high engagement for efficacy (4). Peer-led online interventions offer the advantage of a moderator who can encourage participation. Given the alarming rise in anxiety symptoms during the COVID-19 pandemic, peer-led online health interventions that previously showed beneficial effects (for other health outcomes) may be adapted to current and future public health problems.

The Harnessing Online Peer Education (HOPE) intervention has successfully led to behavior change across multiple geographic regions and medical conditions (5, 6). This intervention utilizes trained peer leaders, who have overcome personal health-related barriers, to provide support to others, and it may be adapted to help individuals experiencing high anxiety during the pandemic. In HOPE studies, peer leaders (who remain unknown to the participants) are tasked with engaging participants online through various modes of communication, including group walls, direct messaging, and real-time chat. Each peer leader was assigned a certain number of participants with whom to attempt to communicate at least three times per week. Discussion topics were primarily chosen by the peer leaders and ranged from friendly and supportive messages to messages regarding knowledge about COVID-19 and anxiety and how to address stigma (see the online supplement to this report).

This study tested the effectiveness of the HOPE peer-led social media intervention on anxiety, help seeking (i.e., requests for electronic resources [e-resources] about anxiety reduction), and online community engagement.

Methods

This randomized controlled trial was deemed exempt by the University of California, Irvine, Institutional Review Board.

Participants were recruited through online advertisements on Facebook, Google, and Reddit from March 15, 2020, to April 4, 2020. Advertisements targeted those with anxiety and invited them to complete surveys and join an online community (see online supplement). Participants were screened online for the following criteria: participants were 18 years or older, a U.S. resident, an English speaker, and not currently taking anxiety medication; used social media more than twice per week; accepted a group invitation from our Facebook page; and had moderate to severe generalized anxiety disorder based on scores of 10 or greater on the seven-item Generalized Anxiety Disorder scale (GAD-7) (7) in response to items about COVID-19 (i.e., participants completed a modified GAD-7 questionnaire in response to the question, “During the past 2 weeks, how often have you been bothered by the following problems related to the coronavirus?”).

Eligible and consenting participants were routed to the baseline survey, and after completion, they were randomly assigned to the intervention or control arm. Each arm consisted of five private and hidden Facebook community groups (CONSORT diagram available in the online supplement). Each group consisted of 30 participants. By March 31, 2020, a total of 300 participants were enrolled, randomly assigned to the intervention or control condition, and sent invitations to join their assigned online community group. The study officially started on April 5, 2020, once 300 participants were in their respective groups.

Twenty-nine peer leaders (to allow for four or five peer leaders per group based on prior studies) were recruited with online advertisements and referrals from mental health providers (6, 8, 9). Advertisements targeted people who reported being social online and had overcome health anxiety or COVID-19. Potential peer leaders were screened online for eligibility: they were 18 years or older, were a U.S. resident, had previously visited a health provider or paraprofessional for anxiety or recovered from COVID-19, were able to manage their anxiety, and were experienced with social media or willing to learn. Eligible peer leaders were called by our study team to gauge leadership skills and experience overcoming health anxiety or COVID-19. Peer leaders were excluded if they could not attend our training sessions. Enrolled peer leaders participated in three virtual training sessions of approximately 3 hours each (see online supplement). Peer leaders were compensated $20 per week in gift cards for attempting to communicate with participants each week. Peer leader weekly effort ranged from 30 minutes to 3 hours, depending on the amount of time they chose to commit.

Participants were each randomly assigned to one of 10 groups. Groups were randomly assigned to the intervention or control arm, and the participants were blind to the condition. Approximately five peer leaders were randomly assigned to each intervention group. Randomization was done by using a random number generator, with all possible assignments of individuals to groups being equally likely. Similarly, all possible peer leader assignments to the intervention groups were equally likely.

Participants in the intervention arm were assigned to a group with peer leaders, with each participant assigned to two peer leaders. Participants in the control arm were assigned to a similar group, but there were no peer leaders. The intervention took place over 6 weeks, from April 5, 2020, to May 17, 2020. Participants were told to use the group as they wanted and to continue using Facebook as they normally would. They were aware that there could be peer leaders but were not told who they were. The participants could use all the features of the online community, including wall posts, direct messaging, and chatting (see online supplement). Peer leaders were assigned to attempt to communicate with participants each week and were free to post or comment about whatever they wanted, although they were given guidance on weekly topics during training. Every 2 weeks through the end of the study, the participants in both conditions were invited to complete a survey and to e-mail us if they wished to receive information (e-resources) about cognitive-behavioral therapy and related resources for reducing anxiety (this announcement was posted in all Facebook groups). Participants were paid $15 in gift cards for each completed survey.

GAD-7 scores were used to assess anxiety (7). Participants’ requests for e-resources and online engagement (e.g., commenting on posts, posting content, or “liking” posts) were also recorded. Online engagement was measured every 2 weeks by recording whether a participant consistently commented on posts, posted, reacted to posts, or voted in their respective Facebook group.

Three regression analyses were conducted (with the standard error clustered by study group) to examine the odds of requesting self-coping e-resources in the intervention arm compared with the control arm at study week 6 (logistic regression), odds of consistent online engagement in the intervention arm compared with the control arm, and GAD-7 scores at study week 6 in the intervention arm compared with the control arm, after we controlled for baseline GAD-7 scores (ordinary least-squares regression). All analyses were conducted with Stata (SE), version 14.2 (10).

Results

Baseline demographic attributes are shown in Table 1. Tests of means and variance showed no statistically significant difference in baseline GAD-7 scores between the intervention and control arms. Mean±SD ages of the participants in the intervention and control groups were 39.0±13.1 and 39.3±12.4, respectively. In the intervention arm, 81% of the participants were female, and in the control arm, 82% of the participants were female. The week 6 survey was completed by 95% (N=143) and 98% (N=147) of the participants in the intervention and control arms, respectively (CONSORT chart available in the online supplement).

During the study period, GAD-7 scores dropped from 16.9 (95% CI=16.3–17.4) to 9.6 (8.6–10.5) in the intervention arm and from 17.5 (17.0–18.0) to 9.6 (8.7–10.6) in the control arm. The overall decrease in GAD-7 scores was statistically significant (t=–23.84, df=289, p<0.001), but the change in GAD-7 scores was not significantly different between study groups (see figure in the online supplement). The participants in the intervention arm were more likely than those in the control arm to request e-resources (OR=10.27, 95% CI=4.52–23.35) (see figure in the online supplement). Similarly, online engagement was more likely in the intervention arm than in the control arm (OR=2.8, 95% CI=1.70–4.76) (see figure in the online supplement).

Discussion

The HOPE intervention was found to be an effective platform for increasing mental health resource requests and led to significantly higher rates of engagement than found in a control group. Anxiety levels (GAD-7 scores) decreased in both groups; however, we did not find a group difference in GAD-7 score reductions. This may be because the intervention began at the peak of anxiety related to the COVID-19 pandemic (11), leading both groups to have reduced fear and anxiety about COVID-19 after this initial peak at the start of the study. Anxiety symptoms (including those associated with GAD) commonly fluctuate over time in the absence of treatment; as a combined result of the inclusion criteria for the study (requiring a minimum level of GAD symptom severity) and the greater tendency for people to seek help when their symptoms are more distressing, individuals may have joined the study during a particularly severe point in the course of their disorder and naturally experienced some degree of improvement over time. Future research may seek to replicate this study during times of less volatility around mental health. These findings, however, show promise as a potential first step toward initiating demand for mental health care in that help seeking is widely regarded as a key milestone toward improving mental health (12). Future studies will need to explore whether increased help seeking corresponds to greater contact with mental health care providers. We encourage future research to build upon our work and extend the evaluation to initiation of formal contact with mental health care professionals.

Prior research involving online mental health interventions has found that online engagement reduces perceptions of social isolation, which was a key psychological problem during the pandemic (13). Other studies have shown that engagement is key to effective online interventions (4). Taken together, these studies support the importance of the current research in which an online intervention was implemented with high rates of engagement and potential to influence mental health outcomes. Future research can expand on the methods in this study to further test ways to use online communities to reduce anxiety.

Strengths of this study include its randomized controlled design and use of a proven online intervention adapted to the COVID-19 pandemic. Because the study used self-reported data, the media outlook about the state of the pandemic could have influenced responses. Ensuring that participants remained blind to treatment was also difficult and may be difficult in real-world settings, in that participants may try to guess their condition or guess which participants are peer leaders. Other limitations included small samples from individual states and certain races and ethnicities, as well as overall low request rates from both arms (see online supplement).

Conclusions

The peer-led online HOPE intervention appeared effective in increasing help-seeking behavior. A future, larger study powered to detect differences in anxiety is warranted to assess efficacy in reducing anxiety.