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A Qualitative Content Analysis of Online Public Mental Health Resources for COVID-19

The COVID-19 pandemic has far reaching potential public mental health impacts and is linked to higher levels of depression and anxiety. To address these in part, online information resources acted as mass interventions. It is vital to explore the content of these interventions, to consider the framing of the pandemic and to examine the extent to which their content is relevant. In March 2020, a qualitative content analysis was undertaken of 39 easily accessible online resources that offered advice, tips or guidance relating to mental health or mental wellbeing and COVID-19. Their content was compared to subsequent reports of the mental health impact of the pandemic. Resources frequently focused on anxiety. The content of intervention was typically of a cognitive-behavioral nature, with a significant focus on maintaining social contact. Typically, distress related to the situation was normalized and stigmatizing language was not seen. Data revealed a significant impact of the pandemic on depression as well as anxiety measures in the general UK population. A key recommendation is to ensure both depression and anxiety are addressed in these public mental health resources.


INTRODUCTION
The COVID-19 pandemic presented a major public health and public mental health challenge. At the start of the pandemic in March 2020, reviews of the impact of restrictions such as quarantine and COVID-19 itself pointed to an understandable effect on psychological wellbeing and mental health. Prior to COVID-19, research on the psychological impacts of epidemics and quarantine suggested high risk of potential distress including confusion, loss, anger, frustration, low mood, fear, stress, insomnia and boredom, with a minority of participants reporting high levels of depressive symptoms and anxiety (1)(2)(3)(4)(5)(6)(7). Given the impact on entire populations, often under protective measures that restrict their movement and interaction with others, even a minority of the population represents a significant number of people in distress and a significant challenge to the mental health services. UK data suggest that anxiety and depression levels "spiked" at the point at which the lockdown strategy was announced (8), prompting online public mental health information.
"Lockdown" and threat of illness are stressful. Stopping work, loss of routine, reduced physical social contact, a sense of isolation and loss of day-to-day activities are all identified as stressors, which can be addressed with coping and stress management techniques, problem solving, self-care, alleviation boredom, use of social networks, engagement with reliable information and re-iterating the purpose of isolation is to keep others safe (1,2,9). Sharing basic strategies to manage this distress has been recommended (10), alongside a need for online psychoeducation and self-management support, with selfdirected interventions (7,(11)(12)(13).
Numerous online resources offering support and guidance on how to manage one's mental health were published in March 2020, in the period where the pandemic rose to the public's awareness and protective measures were enacted in many nations. These were effectively mass interventions, to attempt to maintain psychological wellbeing or minimize adverse impact on mental health. Many online resources were produced, however for these to be useful, their content must be optimized. Some would argue that anxiety and distress in the face of this global health threat is entirely normal. However, it is also important to offer support and strategies to maintain wellbeing, and further intervention where people require more specialist mental health support.
The content of online resources intending to address mental health needs to be explored, to highlight any areas of omission in particular. This is important both at the time of the protective measures being put into place and subsequently, to learn from this pandemic and plan for the next. Indeed, future pandemics are thought to be "inevitable" (14). Mental health is key in their management: avoiding or treating depression and anxiety is important in its own right, but also as they may be linked to lower engagement in adaptive health-behaviors needed for COVID-19, as they are for many other health behaviors (15). The way in which these resources frame both COVID-19 and mental health is also important to understand and potentially improve. Excessive fear arousal or global descriptions of lack of personal control are likely to risk both mental health and adherence to public health infection reduction measures (16,17). Stigmatizing messages must be avoided, for both mental health and COVID-19 (1). This study aimed to complete a rapid content analysis of the easily accessible, online resources to elucidate their content, comparing these to subsequent data on the mental health impact of the pandemic.

Sampling of Resources
Google search for "COVID-19 mental health" was conducted (29/03/2020). The first twenty results that included guidance and advice were selected for analysis. An additional 10 novel results (i.e. disregarding duplicates from previous search) from a search for "COVID-19 mental wellbeing" were also selected. The searches were limited to results in English and was conducted from google.co.uk. This was augmented by Twitter searches using the same terms, selecting results not duplicating those from the Google searches. Snowballing was used to identify further resources from links within the online documentation. Links to other resources were all noted and these resources then analyzed.
Analysis began immediately with the Google search results, then Twitter results and snowballed results. Sampling was ceased when saturation was reached.

Evidence of the Mental Health Impact of COVID-19
The sampling of resources relating to the pandemic focused was conducted in the UK, and was limited to results in English. As such, the evidence we use to compare the impact of the pandemic on mental health uses UK focused data. The Office of National Statistics (ONS) is a UK government organization that collects, analyses and reports on relevant health, wellbeing, economic and population data. During the COVID-19 pandemic, they have collected and reported data relating to anxiety and depression symptom experience in adults. Data were collected using common measures-the Patient Health Questionnaire for depression (18) and the Generalized Anxiety Disorder assessment for anxiety (19). The measures provide an indication of those with probable clinical levels of depression or anxiety. These data were used to identify the estimated actual impact on the pandemic on mental health. An ONS report on depression provides data from pre-pandemic, 2020 and January-March 2021 (20). The report on anxiety uses data from the early pandemicfrom April to May 2020 (21). These are supplemented by a report presenting data from July-August 2021 (22).

Data Analysis
The content from each resource was downloaded. Qualitative content analysis was used inductively to code the data, as this approach allows analysis of both the explicit content and the latent meaning (23). Descriptions of the (a) type of data source, (b) type of resource, and (c) focus/topics were analyzed to create discrete categories addressing each factor. The details of the guidance itself were initially described with open-ended, descriptive responses. These were inspected to form inductive categories relating to each of the six areas outlined in the data collection (key message, diagnostic categories, responsibility, mechanism for change, normalization, claims). After analysis of 10 resources, initial categories were created and each resource rechecked for the presence of all categories. As analysis continued, with each new category, the previous resources were re-checked to explore whether this category was present. All data were first analyzed by one researcher, and then second coded by the other.
Coding continued until all the initially identified resources had been analyzed. During this process, it was noted whether each new resource was adding any new data. Saturation was used as the criterion as to whether it was necessary to seek further resources. Saturation was defined as resources being redundant, in that no new data advanced the conceptual categories (24,25). Forty percentage of the resource data were second coded, and inter-rater reliability was calculated (26), with the protocol that a kappa <0.90 would lead to second coding of all data.

RESULTS
The 30 resources identified from Google were supplemented with a further 19 identified from Twitter or snowballing. These included the resources published by Public Health England, UK National Health Service, World Health Organization, United States Center for Disease Control and several mental health charities. A list of the resources is given in Table 1. On close inspection, four of the resources identified from Google were excluded as they did not include novel guidance on mental health or wellbeing, and six of the resources identified from snowballing were also excluded for this reason. Analysis was conducted on 39 resources. No new themes or topics were identified at the end of the analysis of the identified resources, therefore no further sampling was conducted. Interrated reliability of kappa 0.94 was achieved for second coding of 40% of the resources. Table 2 provides a summary of the results, which are described in further detail below.

Framing of the Situation, Impact, and Resource
The COVID-19 pandemic was mostly referred to as "COVID-19 outbreak" or simply as "COVID-19" or "coronavirus." Almost all resources specifically named the situation, with the language of outbreak, virus name, pandemic or epidemic used. Just four resources did not use this language, instead referring to "lockdown, " "crisis, " or "social isolation." Potentially stigmatizing language of "Wuhan virus" or "Chinese virus" were not seen.
The impact of the situation on psychological wellbeing and mental health typically included significant attempts to normalize. Resources described the situation as having an impact on everyone, emphasizing universality. Worry and stress were described as "natural, " "normal" and "understandable." Many described that everyone would react differently. Some described examples of specific people's experiences, to exemplify potential reactions. Of the 39 inspected resources, nine did not offer normalization of psychological distress. Some of these were very brief resources, however four were resources, longer than a list of tips, from mental health charities. Most resources did not use diagnostic labels to describe people's experiences, and offer normalization of distress. Where diagnostic categories were used and where symptoms or difficulties were described, the focus was on anxiety.
Whilst resources described a range of potential emotional and psychological impacts, the majority focused on anxiety and its management, focusing on "worry, " "stress, " "anxiety, " "fear" and "uncertainty".
The resources were published by a range of organizations, as show in Table 1. The results reflect to some extent the geographical location of the authors, and cover international, national, and local sources, from governments, charities, businesses, and individuals. They are mostly lists of instructions, sometimes with text preceding these instructions. The intended aims or claims of what the resources could offer were commonly to "look after, " "help, " "support, " "take care, " "manage" and "protect." No resource made claims to remove distress or treat.

Content of Resources
The resources offered a range of strategies, detailed in Table 2. The majority of resources offered a list of tips or strategies. The resources then were frequently very brief, offering little detail on how to implement the suggested tips or strategies.
It was rare to see the likelihood of achieving these acknowledged, with just one resource explicitly suggesting "cut yourself some slack." Managing expectations of oneself was rarely acknowledged. The majority of advice did not acknowledge the other challenges that people may be facing, including lack of time owing to caring responsibilities, ongoing work expectations and challenges, potential ill-health, financial stressors, and difficulties in managing how to obtain everyday items such as food.
Social support was most commonly suggested. Self-care, management of media usage, maintenance of activities, and use of cognitive strategies were all advised. Several resources included content on focusing on what one can control as a cognitive strategy. Arousal reduction and emotional expression were also offered. Less commonly offered were advice relating to managing personal relationships and maintaining or altering one's physical environment. Within the cognitive focused advice, several resources offer prompts to consider the positives or solve problems, without offering further guidance on how this can be achieved. Some suggested the situation be reframed as an opportunity. An emphasis on kindness and gratitude was also seen.

Comparison of Resource Coverage to Mental Health Impact
Data from the ONS observed an increase in depression in the general population from pre-pandemic levels of around 10 to 19% in June and November 2020, and 21% in January-March 2021 (20). These data relate to those aged 16 or more.
Interestingly, depression was most common at 34% in the [16][17][18][19][20][21][22][23][24][25][26][27][28][29] year old age range (compared to just 10% in people aged at least 70 years). This age group are of course highly internet literate. For anxiety, in March-April 2020, at the very start of the pandemic in the UK and during a period of extreme uncertainty, 49.6% of people reported high anxiety (21). The mean score of the anxiety measure was 5.2/10, up from 3.0/10 at the end of 2019. Data from July-August 2021 show on ongoing higher than pre-pandemic level of depression, being 17% (compared to pre-pandemic levels of 10%) (22).

DISCUSSION
Analysis examined the framing and content of a variety of online resources aiming to support psychological wellbeing. The epidemic was referred to without using stigmatizing language for either the virus or the impact on mental wellbeing. Normalizing and contextualizing distress during a distressing situation is vital, as it can offer a sense of universality and not stigmatize what is understandable during this time of threat. Resources were found to be stating aims to help support mental wellbeing, which is an appropriate aim as these mass, online resources are not to replace therapy or interventions to treat mental health problems.
Overall the content of interventions could be broadly construed as including elements of cognitive-behavioral therapies, including elements of mindfulness and acceptance commitment approaches, such as thought defusion (27). The focus on maintaining activity and social contact address likely stressors of the situation. Practical strategies are frequently offered. These strategies can address both low mood and anxiety related difficulties as they form elements of behavioral activation (28). Cognitive intervention is overall less frequently offered, and again tends to focus on anxious thinking, however could be equally well applied to depressive rumination, for example techniques of reframing and defusing from thoughts may be useful for both types of difficulties (29). Control is a theme in nearly half the resources, typically with advice to focus on what you can control. This is highly relevant as appropriate control beliefs are linked to reduced anxiety (16). This is particularly important messaging to avoid fatalism, which may reduce protective health behaviors of handwashing and social distancing (15).
The data concerning the impact of the pandemic show a large increase in both depression and anxiety. A clear recommendation results from comparing this to the content of the resources. The majority of resources focused on anxiety related symptoms and strategies. It is vital ensure impact on depressive symptoms is also acknowledged, given preliminary findings of increased depression (8).
A number of additional recommendations arise from the findings. First, most resources were didactic information giving. These could usefully be augmented with guided activities, to increase engagement with the resources' advice. This could include links to activities to support people to problem solve, cognitively reframe, set goals and so on. Most people are likely to be able to spontaneously do these activities, however some may require further support. Second, the pandemic events are outside of personal control, potentially leading feelings of helplessness, which are linked to low mood and depression (30). More attention should be given in resources to reducing rumination, replacing both anxious and low-mood related thoughts with alternatives or defusing from thoughts. Third, the resources' content could potentially feel overwhelming itself: a single parent, struggling to manage a toddler at home and continue to work, experiencing financial difficulties and stress when trying to acquire food shopping may find a list suggesting great social contact and doing creative activities somewhat at odds with their personal experience. Noting the context is vital and recognizing this may be having a very significant impact may help some to feel more understood and the resources to feel more relevant. Fourth, and related to the previous recommendation, it may be important to include guidance on adapting ones' expectations of oneself. The current challenges may activate core beliefs about being not good enough, which may be further triggered by lists of activities to do. This could be simply acknowledging a need to shift one's expectations from normal level of achievement or activity to abnormal ones, given the abnormal situation. Fifth, resources could continue to emphasis the rationale of the restrictions to movement, emphasizing the shared experience; social cohesion and resilience; and collective responsibility to act, in the collective good (31,32).
Finally, two areas were commonly omitted. First, the importance of managing personal relationships was rarely mentioned. It is important to note that loneliness was observed in 27% of a UK sample in March-April 2020 (33). Addressing the maintenance of relationships during times of protective measures that restrict social interaction is then vital. In addition to the significant risk of increased domestic violence, the stress of confinement may affect many relationships within the home. Raising this issue and inclusion of basic guidance on communication skills may be beneficial (34). Second, greater awareness raising of the potential impact on mental wellbeing of home environment may be beneficial, particularly as this is an area over which many people will have some control (35).

Limitations
This study is limited by its sampling. Only resources written in English were included, limiting its coverage and generalisability, however resources from a range of sources were included. The limitation to resources written in English does also limit the underlying cultural assumptions and approaches offered. Only resources relating to a general population were included, advice for health-workers and children must also be made available to the highest standard. It is not possible to review the resources against existing evidence standards, as no such standards exist; rather we sought to summarize the content, consider its empirical basis, and highlight areas of omission.

CONCLUSION
In conclusion, the resources relating to public mental health addressed important topics. Supportive, comprehensive, empirically grounded resources can help maintain mental wellbeing for many, thus reducing future impact on mental health services, allowing them to focus on those with existing difficulties and high levels of distress. Such resources must address not only anxiety, but also depression. Given the high risk of future pandemics, the recommendations may inform future mass mental health support interventions.

DATA AVAILABILITY STATEMENT
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.