JMIR Publications

ABSTRACT

Background:

Digital mental health interventions (DMHIs) are increasingly proposed to address rising mental health problems among university students, yet their effectiveness is persistently constrained by low and heterogeneous engagement. Conventional metrics such as initiation and module completion rates fail to capture how students actually experience, appropriate, and integrate these tools into their daily lives, and may mask meaningful differences between delivery formats.

Objective:

This study aimed to characterize the lived experience and mechanisms of engagement with ETUCARE, an 8-week DMHI for university students in France, and to examine how online-only and hybrid delivery formats (combining digital modules with face-to-face workshops) shape distinct engagement pathways and configurations.

Methods:

This qualitative-led convergent mixed-methods study was nested within the ETUCARE trial, a three-arm randomized controlled trial evaluating the ETUCARE program and focused on the online-only and hybrid intervention arms. Approximately 1 month after the program, students were purposively recruited by email. Semistructured interviews conducted to capture variation in delivery format and engagement between May 2023 and October 2024 (N=23) were analyzed using reflexive thematic analysis. Behavioral indicators were collected directly from the ETUCARE online program platform logs, while experiential indicators (perceived quality, enjoyment, and usefulness) were self-reported by participants within the platform. Latent profile analysis examined these platform-use and experiential indicators among 97 participants. Associations between delivery format and profile membership were examined using the R3STEP procedure, and ANOVAs compared conditions on composite engagement scores. Findings were integrated using a joint display.

Results:

Reflexive thematic analysis generated six themes showing a central tension between engagement as self-chosen appropriation and engagement as externally structured participation. Online-only accounts emphasized autonomy, selective toolbox use, and discontinuous re-entry; hybrid accounts emphasized social safety and facilitator support while also describing workload, and obligation tensions. The quantitative strand identified four engagement profiles: engaged and satisfied (53.6%), engaged but dissatisfied (16.5%), low engagement (16.5%), and minimal engagement (13.4%). The findings were broadly consistent across strands. Hybrid participation was associated with higher odds of low rather than engaged-and-satisfied digital engagement (OR=3.51, 95% CI 1.07-11.52; p =.038) and with lower behavioral (ω²=.067) and experiential (ω²=.064) engagement with the digital component.

Conclusions:

Engagement with ETUCARE was multidimensional and heterogeneous. In this study, adding workshops did not correspond to greater engagement with the digital component; participants’ accounts suggest that social support and relational benefits coexisted with workload and obligation tensions. Because workshop engagement was not measured and the proposed mechanisms were not directly tested, these findings concern digital engagement within the hybrid format rather than overall intervention engagement. They support multidimensional, mechanism-informed approaches to designing and evaluating youth digital mental health programs. Clinical Trial: The trial was not prospectively registered.