Mental health of young people demands the attention of both practitioners and policymakers, as adolescence is the period in which many mental health disorders are first detected. According to a review paper [1], research studies around the world show a prevalence of mental health disorders ranges from 8% to 27% among young people aged 24 and below. To prevent or mitigate the adverse impacts of mental health problems, service providers need to find ways to connect youths with mental health needs to mental health services to facilitate early identification and intervention. However, the range of barriers to mental health service access by this population [1] highlights the significant gap that exists between service needs and service utilization.

To reduce that gap, it is crucial that practitioners understand the influences on barriers to service use [2]. The various models used to explain patterns of service utilization adopt different perspectives to explain those barriers. For example, the behavioral model, which views healthcare decisions as a rational process [3], emphasizes the physical barriers to mental health service access, such as demographic factors (e.g., receiving a low level of education or being a member of an ethnic minority) and a lack of enabling resources (e.g., a lack of service information and inaccessible service locations) [4]. Another widely used model, the Health Belief Model (HBM), suggests that healthcare decisions are based on self-perception rather than an objective medical condition [5]. Therefore, the barriers to service utilization stem from subjective experiences and health beliefs. They perceived such barriers include a fear of treatment, lack of confidentiality, and the stigma associated with mental illness [6]. Different from the behavioral model’s assumption that individuals are rational decision-makers, some models assume that healthcare decisions can be influenced by peers and family members. According to the Network Episode Model (NEM) [7], for instance, service barriers are more likely to be influenced by social factors than individual factors. In addition, the Gateway Provider Model (GPM) extends the NEM to describe the role of the “gateway provider” in influencing service use by young people. Gateway providers direct youths toward and connect them with services, and the GPM thus highlights the important influence that helping professionals exert over service utilization [8].

Internet platforms may serve as gateway providers. A 2017 report by the International Telecommunication Union stated that 70% of the world’s youth are online. In developed countries, even 94% of young people aged 15–24 use the Internet [9]. In Hong Kong, where the current study was conducted, the household Internet penetration rate in that year was 82.8% [10]. The high global and local Internet penetration rates suggest that the provision of mental health services over the Internet may be a viable option, as it would reduce the physical barriers to service access via enhanced availability, accessibility, and affordability [11]. In addition, the Internet could offer a secure service channel, thereby reducing the psychological barriers to service access (e.g., stigma associated with mental illness) perceived by many young people [12].

According to both the behavioral model and HBM, Internet services can bridge the gap between youths’ mental health needs and service access because they reduce the physical and psychological barriers to such access. However, a danger is that the social influences that prevail in the cyber world may encourage them to seek inappropriate solutions to their problems. For example, young people engaged in sex work have formed strong collaborative networks online to share precautionary tips on sex-related problems through social media rather than seeking professional help [13]. Examples abound of social media serving as platforms for the spread of problem behaviors. For instance, online suicide groups on social media that provide detailed descriptions of suicide methods may encourage suicidal thoughts and even promote suicidal acts [14]. However, social media could also serve as a platform for helping professionals to develop proactive engagement and health promotion strategies and encourage youths to seek professional help [15].

To date, helping professionals’ involvement in social media-based mental health interventions has been minimal, which researchers have attributed to the low adherence rate to such interventions [16]. Although there is a long history of online counseling services, those services have not reached out to vulnerable young people [17]. To the best of our knowledge, there is only one evaluation study on Internet outreach services providing HIV screening for LGBT youths [18], and yet their service needs remain undetermined. The GPM suggests that online helping professionals can be proactive gateway providers that identify young people experiencing problems and recommend them to services [19]. The study reported herein was to investigate the possibility of reaching youths who need help via various Internet platforms (e.g., social media, Internet forums).

The study’s specific aims were to (1) better understand the behavior of young people disclosing their distress on the Internet; (2) elucidate the characteristics of youths who make such online disclosures to allow helping professionals to identify and engage with them; and (3) examine the differences between those who are at risk but do not seek help and those who do seek help. Its results will help professionals to devise a more strategic outreach approach [20]. The study was a response to the call for research examining whether Internet platforms such as social media can serve as a substitute for traditional face-to-face psychosocial services and connect at-risk youths with such services.

To the best of our knowledge, this is the first study to investigate help-seeking behavior through possible means of Internet engagement and to examine the online expression of distress by young people using a representative sample of Chinese youths. Its results indicate that young female students aged 18 to 24 with strong online and personal networks are the most likely to express emotional distress online, which is helpful information for helping professionals seeking to identify the population of youths most likely to view the Internet as an emotional outlet. With the strong personal and well-developed online networks, these professionals may be able to increase their influence by attempting to connect with youths and their friends online and/or promoting their services online or making them accessible via the Internet. For instance, helping professionals could recruit volunteers to serve as Internet ambassadors to safeguard the online space to promote a more caring Internet culture. These volunteers could visit online forums or Facebook groups to leave caring messages and offer words of kindness to those who appear to be in distress.

The study’s results also suggest that professionals should view those who have either never sought help or sought informal help alone as targets for engagement. In this research, respondents who were distressed had a higher prevalence of several risk behaviors compared with their non-distressed counterparts. More importantly, approximately 20% of the distressed youths surveyed (i.e., members of the “Did not seek help” group) had sought neither formal nor informal help despite expressing their distress online. According to the GPM, helping professionals can act as gatekeepers to identify youths who make negative expressions online and offer them formal services. The distressed youths in the current study were divided into groups on the basis of their help-seeking behavior (see Fig 1). Relative to the “Did not seek help” group, the “seek informal help” group exhibited a stronger tendency to express distress via online platforms. However, the former agreed that online platforms are a good venue for retaining anonymity. These findings shed light on what professionals can do to earn trust and build rapport during the engagement process. The adoption of the Internet as an outreach platform opens up a new range of possibilities and areas for discussion for the providers of youth services.

This study has several limitations that must be acknowledged. First, as it involved a telephone-based survey based on randomly generated mobile phone numbers, youths who do not use a mobile phone were excluded. Second, the response rate was less than ideal, possibly because of the relatively extensive length of the survey questionnaire. Third, the survey comprised only self-report items, which are known to be prone to recall bias, and there is thus no way to verify how accurately the findings reflect the true Internet behavior of Hong Kong youths. Finally, one important issue has been left unaddressed by our study, that is, the question of whether young people are likely to search online for health or risk behavior information prior to their disclosure of distress online. If so, knowledge of what kinds of websites they browse (e.g., sites discussing suicide methods) would be helpful for professionals seeking to better target their outreach efforts [25]. Further research in this area is necessary.

To the best of our knowledge, there has been only few evaluative studies to date concerning an online outreach intervention restricted to a specific population (i.e., Chinese men who have sex with men) [18], which implies that online outreach has the potential to be expanded to other problem areas (e.g., cyberbullying and youth social withdrawal) [26–27]. Researchers should consider cooperating with social media companies (e.g., Facebook, Google, Baidu) to make relevant information accessible to those who need it. Social media platforms play a supplementary role to existing youth services, providing a substitute means of engagement. Youth service providers should take note of the nature of online engagement and consider providing timelier, more accessible services to youths at risk of mental health problems. Advanced technologies can also be utilized to improve the online detection of at-risk youths [28–30]. All of these strategies should be incorporated into future deliberations on youth service provision in the Internet era. If their features are used properly, social media can be an effective means to connect with the previously disconnected.

(Please refer to Fig1.tif for Fig 1. Categorization of the four groups for DV2 and Fig2.tif for Fig 2. Pyramid model of the survey.)