In recent years, post-secondary students have reported increasing levels of mental health challenges including psychological distress and diagnosed conditions (e.g., anxiety, depression) (1). While the post-secondary years are often a period of self-exploration and interpersonal growth (2), they have also been associated with high stress, peer pressure, and greater responsibilities with reduced social supports (3, 4). For young adults, this period coincides with significant physiological, psychological, and social development (5, 6). In 2019, Canadian data from the National College Health Assessment (N = 55,284) showed that, within the last 12-months, most post-secondary students reported experiencing overwhelming anxiety (68.9%) and at least half reported functionally impairing depression (51.6%) (7). Among the sample, 16.4% of students endorsed active suicidal ideation in the last 12-months, compared to 2.5% of the general Canadian adult population and 6% of young adults (ages 15–24 years) that same year (8, 9). During the COVID-19 pandemic, the rate of mental health concerns escalated in the student population, one study (N = 1,388) reported a 30-day anxiety and/or depressive symptom prevalence of 75% among Canadian students during the pandemic's first-wave (up till May 2020) (10). Similarly, the Healthy Minds survey (N = 18,764) saw increased prevalence of depression and lower levels of resiliency among American students compared to pre-pandemic estimates (11). The pandemic has compounded psychological and social challenges (psychosocial stressors) (12, 13), magnifying an already severe campus mental health crisis (14).

Students experience individual- and system-level barriers that may impede timely access to age-appropriate care. Low mental health literacy, poor system navigation support, and service saturation (e.g., wait-times) all impede help-seeking (15–18). National Canadian standards for student mental health and well-being call for institutions to have early identification and preventative infrastructures (19), which can improve long-term mental health outcomes and timely connectedness into services (20). Universal mental health screening and navigational support tools can address challenges institutions experience with identifying mental health concerns and supporting connectivity to care. Such measures have been successfully integrated within post-secondary health systems (21–23). Digital screening tools may alleviate the need for in-person intake assessment/triaging and more seamlessly bridge in-person and digital resources (3, 24, 25). Digital self-reporting of psychosocial challenges also shows higher disclosure rates and may be preferred over clinician-administered or paper-based assessment (26–28), offering users privacy, time, and space to articulate needs.

Notwithstanding the potential of screening, existing scales often focus exclusively on common psychological issues, such as the PHQ-9 (depression), GAD-7 (anxiety), AUDIT (substance use), and SBQ-R (suicidality) (29–32). These tools are diagnoses-specific, have not been developed with student engagement, and generally lack comprehensive validity evidence in student populations (33–36). However, several instruments have been developed or adapted with students' unique contextual (e.g., academic stress, social autonomy) and clinical needs (e.g., emerging adulthood) in mind. Downs et al. (37) previously developed the 34-item Symptoms and Assets Screening Scale specifically for college students to self-screen on common mental health challenges (e.g., eating disorder, substance abuse, anxiety, depressive symptoms) and generalized distress (37). Similarly, Alschuler et al. (38) developed the 11-item College Health Questionnaire, which facilitates behavioral screening of psychological (e.g., anxiety, depression) and social concerns (e.g., academic problems, relationships, finances) (38). Other post-secondary-specific screening and assessment measures include the Counseling Center Assessment of Psychological Symptoms and the Mental Health Continuum model. However, these assessment tools lack an actionable, resource navigational component, which may support students' help-seeking and contribute to the utility of screening (39–41).

Our team has previously developed, validated, and implemented psychosocial instruments for the pediatric population. The clinical HEARTSMAP assessment and management guiding tool supports pediatric acute care providers with psychosocial interviewing and disposition planning (42). MyHEARTSMAP is a self-administered version allowing self-/proxy-screening, to facilitate universal screening by youth and parents (43). Both instruments have demonstrated evidence for strong psychometric properties (42–45), high clinical utility (46, 47), and user acceptability (48). These instruments expand on the seminal HEADSS psychosocial interview and history-taking tool (49, 50) and assess ten broad psychosocial sections: Home, Education and activities, Alcohol and drugs, Relationships and bullying, Thoughts and anxiety, Safety, Sexual Health, Mood, Abuse, and Professional resources. These psychosocial issues are clinically significant and theoretically supported within human development and socio-ecological models. According to Maslow's Hierarchy of Needs, individuals work up from physiological (e.g., Home, Safety) and psychological needs (e.g., “Relationships”) toward self-fulfillment-oriented needs (e.g., “Education and activities) (51, 52). Within socio-ecological models, these psychosocial areas demonstrate how youths' mental well-being is shaped through the interplay of individual (e.g., Mood, Thoughts and anxiety, Safety risk), interpersonal (e.g., Relationships, Abuse, Sexual Health), institutional (e.g., Education and activities), and community factors (e.g., Professionals and resources) (19, 53, 54). We provide further details on the HEARTSMAP tools' measurement model, assessment structure, and resource recommendation decision-making algorithm in Web-Appendix A.

Adapted specifically for post-secondary students, HEARTSMAP-U is a brief, digital self-administered psychosocial screening tool. Similar to previous HEARTSMAP versions, HEARTSMAP-U assesses ten psychosocial areas ranging from Housing to Abuse. For each section, students first score their concerns on a 4-point Likert-type scale ranging from 0 (no concern) to 3 (severe concern), using anchor descriptions for each scoring option. Second, student's score whether they have previously accessed services pertaining to this section (yes/no). After students have answered these questions for all 10 sections, their responses feed into a built-in algorithm, triggering urgency-specific resource recommendations for identified mental health needs (13, 16, 19).

The current paper describes the three-phase process by which previously developed HEARTSMAP tools were adapted into HEARTSMAP-U, a version that is fit-for-purpose for the post-secondary student population, to help students self-identify psychosocial support needs. Our study will serve as a foundational paper on the HEARTSMAP-U tool and its preliminary adaptation. We will collect multi-faceted evidence of instrument validity and reliability in an ongoing manner and report it in later studies.

Our tool adaptation process includes three phases and has been informed by established guidelines for developing patient-reported outcome measures in the literature (55–58), and expertise from diverse stakeholders including clinical experts and student end-users. We used an iterative, multi-method approach, outlined in Figure 1. For each phase we describe the design, study procedures, and analytic approach. We obtained approval from our institutional research ethics board for Phase two and three, in which research participants were recruited.

We document the multiphasic adaptation of previously developed pediatric psychosocial assessment tools into HEARTSMAP-U, a version fit-for-purpose for the post-secondary student population. In Phase one, the study team arrived at a prototype considered clinically and contextually suitable for post-secondary students. In Phase two, participants saw alignment between HEARTSMAP-U's content and their clinical experiences. Of those who offered constructive feedback, most called for a diagnostic level of content detail and specificity (28–41%), which may not be relevant for screening purposes. Between 23 and 39% clinicians provided modifications/feedback related to sectional content and severity coverage, as per the tool's intended use as a self-administered screener. In Phase three, students provided feedback for improving the content relevance and understandability. Modifications focused on creating a common language between tool users and researchers, as well as ensuring scoring options were realistic and distinguishable. Students did not propose novel psychosocial domains that HEARTSMAP-U does not already directly or indirectly measure.

Our tool adaptation process and methods built on existing screening literature and prior student-specific, rapid screening tools described in the literature. The Symptoms and Assets Screening Scale is a lengthier (34-item) instrument, and its content focuses mostly on psychological concerns. In the absence of more generalized psychosocial screening, students' resource needs may be underestimated or only partially understood. The College Health Questionnaire addresses these concerns and allows for multiple-domain screening. Both previous instruments display promising reliability and construct validity evidence. However, reporting of their development process is limited and describes a traditional “top–down” approach, with little mention of student and/or clinical expert (non-investigators) involvement. Engaging the target population has important implications in refining tool content, language, and instructions, which would contribute evidence toward the instrument's content validity, helping to ensure the measure reflects students' lived experiences and vernacular (63). While not intended for screening or assessing mental health issues, the Post-Secondary Stressor Index (PSSI) is an institution-facing tool that evaluates students' exposure to stress and supports targeted mental health intervention/programming (70, 71). In developing and evaluating the PSSI through an extensive process of student engagement, Linden et al. noted that their tool saw markedly stronger psychometric properties compared to similar tool's previously developed without involving students. The ISPOR Patient-Reported Outcomes Good Research Practices Task Force Report highlights the critical contribution that end-user engagement makes to the content validity argument of an instrument and its quantitative psychometric properties (72, 73). In line with this literature, HEARTSMAP-U's adaptation was closely informed by students, content experts of their own lived experiences and the collective experience of being a post-secondary student. While previously described measures have focused exclusively on assessment, scoring on HEARTSMAP-U feeds into a complex decision-making algorithm to generate severity and urgency-specific recommendations for both psychiatric and social/functional resources. The tool's action-oriented approach to assessment may help avoid “run-around” and potentially unnecessary referrals to already scarce psychiatric services.

During Phase two expert review, a fraction of clinician's (23–39%) identified opportunities to improve severity coverage across HEARTSMAP-U's sections, particularly of concerns that fit in-between “none” and “mild” scoring options. Capturing subthreshold and milder cases is a critical challenge with existing self-report measures (74). If transient and non-severe issues are not explicitly reflected in the scoring criteria, these cases may go underreported due to stigma and remain unmanaged until crisis situations. Recently, transdiagnostic clinical staging models of mental illness have received great attention as an improved means of characterizing the progression of mental disorders into adulthood. HEARTSMAP-U's symptomatic and functional characterization of low to high severity concerns may support its screening utility for mental disorders at their earliest stages, from non-specific to subthreshold symptoms (75). A sizable proportion of clinician's (28–41%) provided feedback more suited for their own practice and context of use (e.g., diagnostic-level probing), which would not be consistent with HEARTSMAP-U's intended use as a brief screener. These comments may reflect outstanding assessment needs and challenges in the post-secondary counseling settings, where validated, standardized intake procedures/measures are infrequently used, difficult to interpret, and can be time-consuming (76). A number of clinician's (18%) scored the tool's resource recommendations as underestimating the support needs of their fictional case. This may have been an artificial finding reflecting our online survey setup, where we asked participants to assess the appropriateness of each individual recommendation. By design, HEARTSMAP-U pairs intensive and lower tier resources, recognizing that multiple treatment and self-management modalities can help students cope with the long-wait times associated with scarcely available psychiatric resources (77). We believe that if clinicians had been asked to holistically assess the appropriateness of their case's service recommendations all-together (low tier and intensive options), support needs would have been perceived as sufficiently met. Future studies with a modified data collection instrument would help verify this was a methodological flaw.

In Phase three focus group sessions, student's felt the severity gradation (impairment, frequency, intensity) needed to be more distinguishable across scoring options. These comments are unsurprising given that internal, emotional states can be difficult to concretely self-score and numeric scales often have arbitrary scaling, with unclear distance between answer options (78). Student feedback also allowed us to revise tool language and build-in mechanisms (e.g., hover-overs, examples) to avoid assumptions and gender- and culturally-specific references, and use person first language where possible (79). Future validation studies will confirm whether students interpret and respond to tool content as intended.

Post-secondary student mental well-being is a growing national and international priority, with recent standards calling for the integration of student-centeredness within campus mental health strategies, to ensure responsiveness to students' perceived needs and experiences (19, 25). In striving toward these principles, our work demonstrates the development of early detection capacities built for, by, and with post-secondary students. Growing research demonstrates the potential for campus-based mental health screening interventions in helping students identify unmet support needs and initiate resource-seeking (33, 35, 80). Unfortunately, measuring what matters most to end-users/patients has not been traditionally prioritized in the psychological instrument development literature (81). Diverse student engagement was a key strength of the current study. Purposive sampling allowed us to ensure focus groups reflected student voices across a range of socially co-created realities, who may have differing experiences with respect to stigma, mental health literacy, barriers to care, and systemic challenges (e.g., oppression, discrimination). Another methodological strength is our use of vignettes during Phase two expert review, allowing us to interactively engage clinicians and elicit their feedback on tool content, given they could not self-administer the tool.

We note several study limitations. Phase one discussions and outputs may have been biased by the study team's proximity to the project. However, subsequent feedback and insights from clinicians and students offered additional perspectives and opportunities to further refine HEARTSMAP-U's content. In Phase two, we did not outline clear parameters for vignette development. As a result, no vignettes evaluated the tool's scoring criteria on severe “Alcohol and drug” and “Abuse” concerns. However, clinical investigators reviewed the tool's service provisions mapping to these severe scores, and found they matched current clinical safety protocols. Additionally, we restricted focus groups to students of a single, large-size post-secondary institution in Western Canada. Students from smaller institutions (e.g., community colleges, vocational schools), rural regions, and francophone communities may see the need for further tool content modification for alignment with their experiences and learning environment (82, 83). Still, our findings may be transferable to other similarly large, research-intensive institutions.

HEARTSMAP-U has undergone a rigorous, systematic, and multi-stage tool adaptation process with clinical experts and student end-users. Later validity investigations will report evidence of HEARTSMAP-U's measurement properties, which will be crucial in gauging the tool's suitability for universal screening utility and the early detection of students' mental health needs.

The datasets presented in this article are not readily available because the study participants did not agree for their data to be shared publicly, due to the nature of the research. Requests to access the datasets should be directed to Punit Virk, pvirk@bcchr.ca.

The studies involving human participants were reviewed and approved by University of British Columbia Behavioural Research Ethics Board. The patients/participants provided their written informed consent to participate in this study.

PV and QD contributed to conception and design of the study. PV and RA conducted data collection. PV, RA, and HB organized the database. PV performed the analysis and wrote the first draft of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.

This work was supported by The University of British Columbia Faculty of Medicine Strategic Investment Fund and The University of British Columbia Office of the Vice-President, Students. Funding sources had no involvement in study design, data collection, data analysis, writing report, or in the decision to submit for publication.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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