JMIR Publications

ABSTRACT

Background:

Sexual and gender minority (SGM) populations experience significant mental health disparities, yet continue to face persistent barriers to care. Mental Health America (MHA) provides free, web-based screening and self-guided resources to millions of visitors, including tens of thousands of SGM visitors each year. Generally, digital mental health (DMH) can facilitate access to mental health resources; however, engagement remains a central challenge that limits effectiveness. MHA faces similar engagement challenges, with preliminary analyses indicating that most visitors exit the website without accessing substantive mental health content pages. The QT-Digital Mental Health Engagement (QT-DIME) Study used an iterative approach to develop and test strategies for improving engagement with DMH resources among SGM users.

Objective:

The current objective is to provide the rationale and protocol for an optimization-oriented micro-randomized trial (MRT) that tests theory-based engagement strategies embedded within the existing web infrastructure of a real-world DMH platform. The primary aim of the study is to evaluate whether delivering engagement strategies increases SGM visitors’ naturalistic engagement with MHA resources.

Methods:

Eligible participants will be MHA visitors who complete the PHQ-9 depression screening test in English and indicate on an optional post-screening survey that they: 1) live in the United States; 2) are aged 14 years or older, and; 3) identify as LGBTQ+. Participants will be randomized at two decision points embedded within the usual visitor flow of the MHA Online Screening Program, including the Screening Results Page and a targeted Next Steps Content Page. At each decision point, participants will be randomized with equal probability (0.2) to receive no engagement strategy or an engagement strategy targeting one of four HAPA behavioral determinants, including outcome expectancy, risk perception, self-efficacy, or SGM-specific barriers to engagement. The primary outcome will be proximal engagement with MHA content, operationalized at Decision Point 1 as click-through to a targeted Next Steps Content Page and at Decision Point 2 as click-through to any additional MHA page. The primary analysis will estimate marginal causal excursion effects of delivering any engagement strategy compared with control.

Results:

The protocol was approved by the University of Washington Institutional Review Board (STUDY00017726). Quality assurance testing on the MHA website began on March 12, 2026.

Conclusions:

This protocol describes an MRT designed to test theory-based engagement strategies embedded within a real-world DMH platform where disengagement can occur within seconds. Results will identify which strategies show promise for improving naturalistic engagement among MHA’s SGM visitors and inform future refinement of engagement strategies and adaptive decision rules for optimizing engagement with DMH resources. Clinical Trial: ClinicalTrials.gov NCT07278765