JMIR FORMATIVE RESEARCH

Kruzan et al

Original Paper

Young Adults’ Perceptions of 2 Publicly Available Digital
Resources for Self-injury: Qualitative Study of a Peer Support App
and Web-Based Factsheets
Kaylee Payne Kruzan1, PhD; Janis Whitlock2, PhD; Julia Chapman2, MSW; Aparajita Bhandari2, MSc; Natalya
Bazarova2, PhD
1

Department of Preventive Medicine, Northwestern University, Chicago, IL, United States

2

Department of Communication, Cornell University, Ithaca, NY, United States

Corresponding Author:
Kaylee Payne Kruzan, PhD
Department of Preventive Medicine
Northwestern University
750 N Lakeshore Drive
Chicago, IL, 60611
United States
Phone: 1 312 503 3114
Email: kaylee.kruzan@northwestern.edu

Abstract
Background: Digital resources have the potential to bridge the gaps in mental health services for young people who self-injure.
Most research on digital resources for this population has involved observational studies of content in web-based communities
or formative studies focused on the design and early evaluation of new interventions. Far less research has sought to understandyoung people’s experiences with publicly available digital resources or to identify specific components of these resources thatare perceived to be of value in their recovery.
Objective: This study aimed to understand young people’s experiences with 2 publicly available digital resources for self-injury—apeer support app and web-based factsheets—and to disentangle potential explanatory mechanisms associated with perceived
benefits and harms.
Methods: Participants were 96 individuals (aged 16-25 years) with nonsuicidal self-injury behavior in the past month, whorecently completed a pilot randomized controlled trial designed to assess the efficacy of a peer support app as compared with
web-based factsheets to reduce self-injury behavior. The trial showed that participants using the peer support app reported lessself-injury behavior relative to those receiving the web-based factsheets over 8 weeks. In this study, we used a conventional
approach to content analysis of responses to 2 open-ended questions delivered at the end of the trial with the aims of exploring
participants’ overall experiences with these resources and identifying the qualities of these resources that were perceived to bebeneficial to or harmful for participants’ recovery.
Results: Overall, participants were more likely to report benefits than harms. Participants who used the peer support app reported
more harms than those who received the web-based factsheets. In the open coding phase, clear benefits were also derived fromrepeated weekly surveys about self-injury. Key benefits across digital resources included enhanced self-knowledge, reduction in
self-injury activity, increased outreach or informal conversations, improved attitudes toward therapy, improved mood, and feelingsupported and less alone. Key challenges included worsened or unchanged self-injury activity, diminished mood, and increased
barriers to outreach. The most prominent benefit derived from the web-based factsheets and weekly surveys was improved
self-understanding. However, the way this manifested differed, with factsheets providing insight on why participants engage inself-injury and the function it serves them and surveys making the frequency and severity of participants’ behaviors more apparent.
The benefits perceived from using the peer support app were general improvements in mood and feeling less alone.
Conclusions: Findings contribute a nuanced understanding of young people’s experiences with these digital resources and have
implications for the optimization of existing platforms and the design of novel resources to support individuals who self-injure.
(JMIR Form Res 2023;7:e41546) doi: 10.2196/41546

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KEYWORDS
nonsuicidal self-injury; self-harm; digital mental health; mobile app; design; intervention; peer support; psychoeducation

Introduction
BackgroundNonsuicidal self-injury affects approximately 13% of young
adults [1] and as much as 37% of adolescents [2]. Nonsuicidal
self-injury refers to self-inflicted damage of body tissue, without
suicidal intent. For simplicity, in this paper, we will use theterm self-injury to refer to nonsuicidal behavior. As a leadingrisk factor for future suicidal ideation and attempts [3,4], earlyand effective intervention for self-injury is a public healthpriority. There are several efficacious treatments for self-injury,
but many people do not disclose their self-injury or seek
treatment, which limits their access to support and resourcesthat could help [5]. When individuals seek help, it is often
through informal supports such as friends or peers in web-based
communities [6-8]. Some studies have shown that approximately
one-third of young people with a history of self-injury report
web-based help seeking, and those engaged in web-based help
seeking were younger, endorsed more frequent and recent
self-injury behaviors, and reported significantly more suicidal
thoughts than those who had not sought help on the web [9].
Thus, digital resources designed for and disseminated in
web-based spaces where people engage in self-injury help
seeking have the potential to reach a highly distressed and at-risk
population [10].
Web-based and mobile digital interventions offer accessible,
low-cost, and potentially efficacious ways of bridging the gaps
in services for individuals who self-injure and who are not intreatment [11-13]. Although research in this area is nascent,studies support the acceptability and feasibility of digitalinterventions for self-injury, with some providing preliminary
support for their efficacy to reduce the behavior [14]. For
example, a pilot trial of an app focused on delivering cognitive
behavioral strategies (BlueIce) found that >70% of users
reported having stopped or decreased self-harm behavior after
3 months of use [15]. Similarly, Emotion Regulation Individual
Therapy for Adolescents—a web-based program focused on
the development of emotion regulation strategies—was
associated with 69% reduction in self-injury over a 14-weekpilot trial [16]. Similar to BlueIce and Emotion Regulation
Individual Therapy for Adolescents, most digital interventions
incorporate the structured delivery of psychoeducation andstrategies or skills grounded in cognitive and behavioral
treatment models [14,17,18]. Although the growing evidencein support of self-injury digital intervention is promising, mostof the digital interventions developed and rigorously examined
are not broadly available to the public. Moreover, little empiricalattention has been given to understanding the value of existing
publicly available digital resources for self-injury. Resourceson the internet are often less focused on the structured deliveryof evidence-based strategies and more on psychoeducation,
through blogs, websites, peer support, and web-based
communities. Whether these existing resources are beneficial
for self-injury recovery remains as an open question.

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Psychoeducation—an evidence-based intervention focused onincreasing a person’s understanding of, and ability to cope with,a condition—is a core component of self-injury prevention andintervention [19-21]. Many websites with self-injury
psychoeducation provide basic information on the behavior,possible treatments, and ways of managing the behavior.
However, studies focused on how young people perceive andmake use of existing web-based psychoeducational materials
are sparse, which limits both our ability to draw conclusions
about the benefits of such content and to identify any unmet
needs that could be addressed through the design anddissemination of digital interventions embedded in spaces wherethese resources are encountered.
In contrast, web-based communities (eg, forums, social media,
and message boards) are a category of digital resources that hasreceived a lot of attention. Studies have shown that people sharedetails about their mental health status and symptoms with peers
in web-based communities to obtain support, advice, andvalidation [22-24]. Studies have also shown that relationships
developed between peers in these spaces can decrease feelingsof isolation, increase feelings of being understood and accepted,
and lead to a great sense of purpose—all factors that are known
to contribute to improved mental health and recovery [25,26].
Although many people reap benefit from this exchange of
support, observational studies also highlight several risks,
including the potential for normalization of the behavior [27,28],
narrative reinforcement [29], and exposure to triggering content[8,30,31]. Even with community moderation efforts, people canbe exposed to harmful images, texts, or narratives [22,31].
However, these harms are not well understood from theperspectives of individuals actively involved in thesecommunities and are often inferred from static content. Thus,
there is a need for studies focused on understanding the specificattributes of web-based communities that are perceived to bebeneficial or harmful from the viewpoints of their members.
A study upon which this paper draws aimed to address thesegaps in the literature through a small-scale randomized
controlled trial of web-based psychoeducation (in the form offactsheets) and an app-based peer support community [32].
Findings showed that participants using the peer support app
reported less frequent self-injury and greater confidence tochange their behavior over an 8-week period relative to those
who received the web-based factsheets. This work provided
preliminary support for the value of the peer support app in
reducing self-injury behavior. However, what exactly
contributed to participants’ experiences with these digital
resources and how they perceived these resources to bebeneficial or harmful in the context of their recovery remains
largely unknown.

Objectives
This study aimed to understand the relationship between uniqueintervention components and self-injury behaviors, through theanalysis of participants’ experiences with, and perceptions of,

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these 2 publicly available digital resources for self-injury. We
asked the following research questions (RQs):

participants were asked to post or comment at least 3 times a
week.

•

Web-Based Factsheets•

RQ1—What are the perceived benefits and harms ofengaging with the peer support app and web-based
factsheets?
RQ2—Which features or interactions are perceived to be
central to users’ experiences and the benefits and harms
derived from use?

Methods
Overview
In this study, we analyzed open-ended feedback fromadolescents and young adults (aged 16-25 years) regarding theirexperiences with using the peer support app or receiving
web-based factsheets following a 2-month, 2-arm, pilot
randomized controlled trial. A detailed description of trial
procedures is published elsewhere [32]. In brief, 131 participants
were involved in the trial. Half (67/131, 51.1%) of theparticipants were asked to use the peer support app, TalkLife,
which allowed users to make a profile, post, and comment onothers’ posts. The other half (64/131, 48.9%) received
web-based factsheets, which were publicly available throughacademic websites on recovery from self-injury, through theiremail. In addition to engaging with 1 of these 2 digital resources
over the course of 2 months, all participants (131/131, 100%)
were asked to respond to weekly surveys sent via email to assess
their self-injury frequency, urges, and potential mechanisms ofchange (eg, stigma and sense of belonging). All (131/131, 100%)
participants were invited to provide feedback in an opentext–based format through the final trial survey. Open-ended
prompts were intentionally broad, asking participants about
their experiences with using the peer support app or receiving
the factsheets, to allow them to comment on any aspect of theirexperience that was salient. In total, 73.3% (96/131) of theparticipants responded to at least one open-ended prompt andwere included in the present analyses. This included 47%(45/96) of the participants who used the peer support app and
53% (51/96) of the participants who received the web-based
factsheets.

Digital Resources
Peer Support App
The first group of participants was invited to use TalkLife (thepeer support app), which is publicly available for download
across app stores. TalkLife is an existing mobile app, notdesigned by the research team, and is intended to connect young
people to exchange support and share stories on topics related
to well-being and mental health. The functionality of the peer
support app resembles that of other popular web-based
communities and social media sites. For example, the app itself
has a relatively simple format, allowing users to post andcomment on a live feed and encourage peers through 1-click
reactions (eg, likes, supports, and hugs). Furthermore, the app
allows users to select categories for their posts (eg, self-harm,
eating disorders, and relationships), which they can use to seek
specific advice or filter the content they receive in their main
feed. To ensure engagement during the course of the trial,
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The second group of participants received a series of self-injury
factsheets once weekly through their email. Similar to the peer
support app, the factsheets are publicly available resources
hosted on 2 websites devoted to self-injury education, advocacy,and outreach: The Cornell Research Program on Self-Injury
and Recovery [33], which is led by JW, and The Self-Injury
Outreach and Support [34], which is led by Dr Stephen Lewis.
Factsheets were chosen by the research team to represent avariety of content from key domains associated with recovery
from self-injury. Each included self-injury psychoeducation
through noninteractive infographics and information briefs
covering topics about self-injury such as self-injury functions,common myths, how to seek help, and how to cope with urges.
Participants could open these weekly factsheets on the web or
download them for offline use and sharing. Importantly, theseresources were selected by the research team because they were
publicly available, were free, and may be encountered naturally
by those seeking self-injury information on the web. Links to
the factsheets are available in Multimedia Appendix 1.

Recruitment and Participant Eligibility
Participants were recruited via the web through self-injury
information websites, professional networks, social media
outlets (such as Facebook or Twitter), listservs, and theuniversity recruitment system. Potential participants completed
a web-based survey to determine eligibility based on thefollowing criteria: individuals aged between 16 and 25 years,
with current (within 3 months) and chronic (>6 episodes in thepast year) self-injury history were eligible to participate.
Exclusion criteria included the following: recent history ofpsychosis (>2 weeks of institutionalization in the past year) or
current suicidality (operationalized as suicidal thoughts orplans). All individuals who completed the eligibility survey
received contact information for the National Suicide Prevention
Lifeline (NSPL) call center and chat line. Participants who werescreened as ineligible were provided with a message thanking
them for their willingness to get involved, letting them knowthat they were ineligible based on their responses, and containing
a link to resources on the Cornell Research Program for
Self-Injury website and NSPL contact information. Participants
who reported elevated suicidal ideation or plan received an
additional pop-up message encouraging them to reach out tosomeone for support, with hyperlinks to the NSPL embedded
within the message for easy access. Eligible participants received
an email from the research team, providing them with key
information about their participation. Those who provided
consent via the web were randomly assigned to engage with thepeer support app or the web-based factsheets for the study
duration. During onboarding, participants received a welcome
email containing several videos explaining the expectations per
week, how to register on the platform (where applicable), anddetails about how and when they would receive compensation.
In total, participants were eligible to receive US $90 in the formof Amazon gift cards for completion of weekly surveys
throughout the 8-week trial and were compensated based on the
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number of weekly surveys submitted. Participants received US$10 for the week-8 survey, which was the data set used in thepresent analysis. More details on the trial methodology are
published elsewhere [32].

Ethics Approval
This study was approved by Cornell University’s institutional
review board (approval number 1807008133), with a waiver ofparental consent approved for individuals aged 16 to 17 years.
All participants provided informed assent or consent before
participating in the study activities. Additional questions werebuilt into the web-based assent procedure to ensure thatadolescents understood who they could reach out to if theyexperienced distress (including contact information for the
study’s principal investigator [PI] and national crisis resources),what types of activities they would be asked to engage in, andthat they had the right to discontinue the study.

Data Management
The types of data collected as part of this study were also
described in detail in the assent and consent form. This included
data from activity on the peer support app and survey responses
at baseline, during the trial, and at follow-up (which we usedin this study). Participants’ privacy and confidentiality werepriorities in our study design. As part of the large study, only
the research PI and research coordinator had access to
information linking participants to their contact information
and unique identifier. All identifying information was kept
separate from survey and use data in a password-secured
computer that was accessible only to the PI and study
coordinator. All data presented in this paper were deidentified
before analysis. Participant safety was also a priority. All
potential participants were provided with a list of mental healthresources (mentioned previously) during the eligibility
screening. Enrolled participants were provided with theseresources at the beginning and end of the study and after eachweekly survey.

Data Analysis
We used a mixed methods analytical approach in this study.
We present quantitative analyses mainly to provide a descriptive
overview of our participant sample and a general distributionof our codes. We report on participants’ demographics, mental
health history, and previous experiences with mental
health–focused apps. Qualitative methods were then used toanalyze responses to 2 open-ended prompts aimed at eliciting
overall impressions about and experiences with the digital
resources after 2 months of engagement. As mentioned
previously, although there were 131 participants in the original
trial, our sample for the present analysis was limited toparticipants who responded to at least one of the open-ended
questions on the week-8 survey. Complete responses were
provided by 73.3% (96/131) of the participants (45/96, 47% of
the participants who engaged with the peer support app and
51/96, 53% of the participants who engaged with the factsheets).
As the open-ended responses to these questions were meant tosolicit general comments about user experience, they weremerged at the participant level during open coding.

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We used a conventional approach for qualitative content
analysis, as described by Hsieh and Shannon [35]. Consistent
with this approach, codes were defined during the data analysis
process. First, 2 authors independently read excerpts line byline and applied open codes to the transcripts, with the 2 RQs
in mind. The authors then met to settle on an initial code
structure. This involved discussing the applied codes andremoving codes that were not often used. Next, an author anda research assistant familiarized themselves with the data andmet to discuss the initial code structure. These 2 coders thenapplied codes independently to a randomly drawn sample of 20
texts to test for general congruence and allow for further
discussion and refinement. Again, infrequent codes werereduced, and several codes were combined. The coders thenapplied the code structure to the remaining data. All coding
discrepancies were discussed by coders in detail until consensus
was reached. Finally, coders met to organize the codes in ahierarchical structure and to choose and extract example quotes
for the presentation of findings. Quantitative analyses wereconducted using SPSS (version 25; IBM Corp) [36], andqualitative analyses were conducted using the Dedoose coding
software (Dedoose).

Results
Participant Characteristics
Demographics
In total, 96 participants aged between 16 and 25 (mean 20.26,
SD 2.51) years provided feedback on their experiences with thepeer support app or web-based factsheets after 8 weeks of use.
Of the 96 participants, most (n=64, 67%) identified as women,
whereas 21 (22%) participants identified as men, 8 (8%)
identified as nonbinary, and 3 (3%) identified with other gender
identities (transmasculine, 2-spirit, and questioning). Of the 96
participants, most were from North America (n=66, 68%), 13(14%) were from the United Kingdom, and 17 (18%) were fromthe European Union.

Mental Health Characteristics
Participants reported diverse mental health histories. As
self-injury commonly co-occurs with other mental healthconditions, we assessed for common diagnoses, indicators oflifetime self-injury severity, and traumatic life events througha survey at the beginning of the trial. Of the 96 participants, 70(73%) reported injuring themselves >50 times in their lifetime,
whereas 19 (20%) reported injuring between 21 and 50 times
and 7 (7%) reported injuring ≤20 times. Of the 96 participants,
90 (94%) reported having another mental health condition. The
2 most prevalent comorbidities were depression (85/96, 89%)
and anxiety (69/96, 72%). Finally, 95% (91/96) of theparticipants reported at least one other distressing or traumatic
life experience (eg, emotional abuse, sexual abuse, physicalabuse, death of loved one, or familial divorce).

Technology Use for Mental Health and Their Perceived
Efficacy
Participants were asked whether they had engaged with anyother digital resources for mental health including apps,
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web-based communities, or seeking information through otherweb-based channels. More than half (61/96, 64%) of our sample
reported having used other digital resources. Of the 96
participants, 61 (64%) participants reported using web-based
communities and 53 (55%) reported using mobile apps formental health or well-being, when they entered the trial. Of
those reporting use, 48% (46/96) and 22% (21/96) of theparticipants reported sharing or exchanging information about
self-injury, respectively. While interacting through theseplatforms, approximately one-third of the participants reported
some degree of anonymity (eg, not using real name or photo;
38/96, 40% for web-based communities and 30/96, 31% forapps). Commonly reported web-based communities were Reddit(25/96, 26%), Discord (8/96, 8%), Facebook Groups (10/96,10%), and Tumblr (6/96, 6%). Commonly reported apps were
Mood path (7/96, 7%), Calm Harm (11/96, 11%), and 7 Cupsof Tea (7/96, 7%). On a scale of 1 to 100, participants rated theoverall satisfaction with web-based communities (mean score21.37, SD 26.24) and apps (mean score 20.49, SD 28.61) asquite low.

Qualitative Findings
Overview
To understand participants’ experiences with these digital
resources, we first examined codes and their general distribution
across groups. It became evident in our early open coding thatthe weekly surveys on self-injury activity, which were received
by all participants throughout the trial period, were also
perceived to be beneficial in fostering reflection. As
self-monitoring is a common feature of digital mental healthinterventions, we chose to include surveys in our coding of
benefits and challenges. Findings are organized in two key
sections corresponding to our RQs: (1) perceived benefits andchallenges associated with the use of digital resources and (2)specific factors or features influencing experience andacceptability.

Perceived Benefits and Challenges Associated With theUse of Digital Resources
Overview
Participants identified several ways in which the digital
resources affected them and their self-injury behavior over the
2-month period. Benefits included references to how the digital
resources were perceived to be helpful in their self-injury
self-management and included (1) enhanced self-knowledge,(2) reduction in self-injury activity, (3) increased outreach or
informal conversations, (4) improved attitudes toward therapy,(5) improved mood, and (6) feeling supported and less alone.
Challenges referred to ways in which the digital resources wereless helpful or even harmful to participants’ self-injury
self-management. These included experiences of (1) worsenedor unchanged self-injury activity, (2) diminished mood, and (3)increased barriers to outreach.
To provide a high-level overview of the distribution of codes
within our sample, we performed chi-square analyses comparing
the benefits and challenges across participants interacting withthe peer support app and factsheets. We found that participants
who used the peer support app were less likely to mention
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benefits (odds ratio 0.41, 95% CI 0.17-0.97; P=.04) and more
likely to report challenges encountered (odds ratio 5.29, 95%
CI 1.06-26.43; P=.04), when compared with the group thatreceived factsheets. However, overall, participants reported
more benefits than challenges. Of the 96 participants, 36 (38%)
noted at least one benefit, whereas 10 (10%) noted challenges,
across both groups. Of the mentions of benefits, 20% (7/35)
were attributed to the peer support app, 40% (14/35) were
attributed to the psychoeducational materials, and 39% (13/35)
were attributed to the weekly surveys. Of the challenges
mentioned, 81% (9/12) were attributed to the peer support app,
whereas approximately 9% were attributed each to web-based
factsheets (1/12) and weekly surveys (1/12). Of the challenges
mentioned, 81% were attributed to the peer support app, whereas
approximately 9% were attributed each to web-based factsheets
and weekly surveys. A more detailed qualitative report ofparticipants’ reflections on their experiences with each digital
resource is provided in the following sections.
Peer Support App
The most mentioned benefits identified among participants who
used the peer support app were improved mood and feeling lessalone. Regarding improved mood, participants described thatbeing able to connect with others through the app helped them
to better self-regulate and improve their mood. For example, aparticipant noted the following:
It was really helpful to be able to talk to people online
when I was feeling down. [Participant 28]
This participant described that in-the-moment use of the app
was helpful in managing difficult moods, whereas otherparticipants noted that using the app helped them to get a better
sense of how their emotional state shifted over long periods. A
participant described that the app helped them “get a better
image of my emotions over the last few weeks” (Participant11). Both in-the-moment mood boosts and developing a deep
awareness of emotional patterns were reflected upon as key
benefits across participant experiences.
Another commonly mentioned benefit among participants using
the app was feeling less alone in their struggles. A sense ofconnection was derived from interactions with peers on the app
and through reading content from peers with shared experiencesor characteristics. For example, a participant described thefollowing:
I’ve met some nice people on [the app] and they makeme feel less alone. [Participant 12]
Many participants attributed feelings of validation and relief toknow that they are not alone to their experience on the app. For
example, another participant noted the following:
It really helped me to understand there are people
who relate to my struggles. [Participant 13]
However, not all participants described that their experienceswith peers on the app were beneficial. The most common
challenges attributed to the use of the peer support app were its
impact on participants’ self-injury behavior and worsened mood.
Regarding the impact on self-injury behaviors, a participant
described that they felt “like my recovery was less likely after
spending any significant portion of time on the app” (Participant
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14). This participant, and others, described that being exposed
to harmful content and peers’ distress made them feel lessinclined toward or hopeful about their ability to recover. Other
participants described a more agnostic experience with the app
and the impact it had on their self-injury. A participant noted
the following:
It didn’t feel like [the app] actively hurt anything, but
I’ve relapsed during the course of this survey, so I
don’t think it helped either. [Participant 63]
In addition, despite some participants describing improved moodowing to engaging with the peer support app, a comparable
proportion of users commented on how experiences within theapp had harmful effects on their mood. Most of these comments
were related to the effects of community negativity. For
example, a participant wrote the following:
Most times I felt worse after using the app.
[Participant 74]
Another participant elaborated upon the following idea:
The toxic community on the app had a very negative
effect on my time management and mental health.
[Participant 14]
Although the fact that there are both benefits and harms
perceived from app use is consistent with the existing literature
on web-based peer support for self-injury, it is interesting tonote how nuanced these effects are, with some participants
reporting both benefits and harms after a relatively short periodof use.
Web-Based Factsheets
The most common perceived benefits of the web-based
factsheets were enhanced self-knowledge, reduction in
self-injury behaviors, increased outreach, and improved attitudes
toward therapy. When participants described improvements in
self-knowledge, they commonly referenced factsheets that
helped them to explain why they injured themselves or the way
self-injury was related to coping. For example, a participant
wrote the following:
Learning about why people self-injure helped me gain
focus on my coping methods and how compulsive it
has become for me when I’m upset. [Participant 16]
Similarly, another participant wrote the following:
I liked understanding why self-harm made me feelbetter and how to change. [Participant 30]
This participant also went on to describe how factsheets about
the recovery process and readiness to change self-injury
behaviors helped to change their perspective on their existing
coping strategies:
I feel a lot more normal in coping with urges andunderstand my thought process in theprecontemplation stage in a new light. [Participant
30]
Participants also commented on the relationship between thefactsheets and their self-injury behavior. Mostly, these comments
were regarding the use of new coping skills during the study

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and how this helped them to reduce their weekly self-injury
frequency. For example, a participant wrote the following:Some of those tips helped me not to injure myself.
[Participant 18]
Other participants described how simply having new resources
made them feel more capable of stopping injury over time andthat this was a catalyst for change. Regarding this aspect, aparticipant wrote the following:It’s definitely helped me to take the steps towards
stopping self harm for good, as I have new coping
mechanisms. [Participant 68]
Although most comments on the benefits of the factsheets
focused on the materials referencing new coping skills, there
were also comments on information about help seeking. Several
participants noted that the help-seeking materials focused on
how to seek help and improved their attitudes and receptivity
toward formal treatment. A participant described the following:
I think the pushes for therapy in this study were wellplaced, because truly, professionals can help those
who are troubled better than they can themselves. I’mlooking for therapy at the moment. [Participant 19]
Another participant similarly noted that materials motivatedthem to try treatment:
They’ve also helped me be open to begin online
therapy, which I will start tomorrow. [Participant 30]
In terms of challenges, only 1 participant described how thepsychoeducational factsheets did not support their efforts toward
recovery from self-injury. In particular, they wrote that afactsheet describing “how to disclose to others” made them feel
discouraged about engaging in further outreach, writing that it“made me feel like I was a burden to the only friend I tell about
myself injury” (Participant 55). Although most participants
described positive experiences with factsheets, this finding
underscores the potential harms that come from delivering evenwell-intentioned materials through a format that lacks context
and does not easily facilitate direct paths for follow-up andclarification.
SurveyAlthough we did not set out to explore the survey as a catalyst
for benefits and challenges, many participants made explicit
reference to the role the weekly survey played in theirexperience with digital resources. Given the extensive literatureon the value of self-monitoring [37-40] and personal tracking
in human-computer interaction [41-43], we chose to includecomments related to experiences with the survey as they could
shed further light on how repeated measurements can bebeneficially incorporated into future digital interventions.
Similar to the factsheets, the most common benefits attributed
to surveys were enhanced self-knowledge, reduced self-injury
activity, and improved attitudes toward therapy. Many
participants across both groups described that the weekly
surveys promoted self-reflection. For example, a participantreferred to the survey as a useful check-in:

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I liked [the] survey because it gave me an idea of
where I was at by the end of every week and allowed
me to reflect on my behavior. [Participant 19]
Another participant described that the surveys made some of
their behavioral patterns more salient:
I liked this survey because it opened my own eyes tosome behaviors I hadn’t originally recognized.
[Participant 57]
In some cases, this enhanced self-awareness motivatedparticipants to make changes to stop or reduce their self-injury
behavior. Some participants described a mental shift in how
they thought about their self-injury frequency or severity. For
example, a participant wrote the following:

Kruzan et al
It definitely opened my eyes to see how much I
probably need to be in counseling. Having the samequestions repeated helped me see how I was growing
as well as how I am being held back. [Participant 29]
Similar sentiments were evident in another participant’s
reflection:
I have never tried therapy, but have contemplated it
for a while. These surveys have made me feel, moreso than ever, that I should at least try to take the firststep. [Participant 40]
Although most comments related to the survey were focusedon benefits, several participants noted that the survey may haveworsened their mood. A participant wrote the following:

The survey helped me pinpoint what could be holding
me back from letting go of my addiction to cutting. I
felt like I didn’t need to cut as much as normal during
this study. [Participant 35]
Other participants described that the surveys made them realizethat change was needed. For example, a participant wrote thefollowing:

I felt somewhat depressed when I answered yourquestions, but I was okay. It just reminded me of all
the things that happened. [Participant 25]
Notably, this participant reported that they had seen
improvements in their self-injury leading up to the study;
therefore, the weekly reflections on self-injury activity may nothave been as helpful for them at this point in their recovery.

Answering the “how often have you been self harming
this week” was very helpful in getting me to realizethat I needed to cut back on self harming and/or stop
altogether. [Participant 21]
Similarly, participants felt empowered to make changes by this
newfound awareness. A participant described the following:

Factors and Features Influencing Experience andAcceptability

The questionnaire is very insightful. I found myself
asking questions that get me out of complacency. I
gotta start making moves for myself. [Participant 22]
Participant 20 wrote that the survey helped them “to reflect on
my behaviours and seek active steps and resources to challenge
and positively change my behaviours over time.”
Several participants also mentioned improved attitudes toward
therapy because of the continuous reflection on the frequencyof their self-injury behavior that these surveys provided. For
example, a participant wrote the following:

Overview
In the next section, we delve more deeply into the specificfeatures or interactions that contributed to the benefits andchallenges described previously. We present participant quotes
in tables and elaborate on particularly novel findings in text.
Table 1 includes app features that contributed to perceived
benefits, Table 2 includes app features that were associated withchallenges, and Table 3 refers to specific content preferencesin the factsheets. Participant comments on the factsheets were
overwhelmingly positive; therefore, we did not include further
reflection on the challenges for this resource. In addition, no
corollary comments were made in reference to specific featuresof the survey. We expand on subthemes with relevance for
future design in the following sections.

Table 1. Features associated with peer support benefits.
Features

QuotesInteractions with supportive “I felt fairly supported by responses to any posts or comments I made. I liked the feature where you could react inpeers
several different ways alongside commenting, as this was more accessible and the combination helped more people toshow support to each other.” [Participant 20]
Sense of shared experience“Some of the people would comment on my posts and tell me their stories similar to what I would be talking about.
Knowing that there are people older than me that understand what I’m going thru really helps and then knowing how
their life changed even with the same past also made me feel supported.” [Participant 32]

Space for venting“Shouting into the void is therapeutic in itself.” [Participant 34]

Immediacy of support“The fact that there’s almost always a quick response to a post and the responses in general being kind and wholesome
added to that feeling of being supported.” [Participant 78]

Anonymity“It was nice to vent anonymously.” [Participant 36]

Reduced stigma“Being able to interact with a community of fellow self-harmers without fear of being judged proved itself beneficial
to be.” [Participant 40]

Provision of support“I liked being able to help other people with their problems.” [Participant 39]

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Table 2. Features associated with peer support challenges.
Features

QuotesCommunity negativity“It made me uncomfortable and felt like an echo chamber of negativity along with people giving instructions
on how to cut the ‘right’ way.” [Participant 44]

Interactions with unsupportive peers “Many of the users on the app made the experience less enjoyable.” [Participant 74]
Perceived inauthenticity of otherposters“Everything feels completely impersonal, and the times I was in crisis and needed help I only really got platitudes
in response.” [Participant 63]

Exposure to triggering content“It can be a very triggering app, yes there are nice people on it that just want to talk but it upset me reading allthese upsetting posts.” [Participant 58]

Preference for therapy or in-person “I feel like in person connection is more effective than anything online can be.” [Participant 33]
support
Perceived difficulty in intervening“It did make me feel less alone but it was not worth having to read through all the other stuff people have goingon, I don’t know these people so it makes me sad that they feel like that and there’s not a lot I can do.” [Participant
58]

Table 3. References to specific factsheets.
Features

QuotesCoping strategies“Learning about why people self injure helped me gain focus on my coping methods and how compulsive it has become forme when I’m upset.” [Participant 16]

Pain offset relief“Understanding that it is a pain offset not onset that actually helps me feel better.” [Participant 35]

Disclosure“I liked the guide to self-disclosing about one’s self-injury and I think this is something that will inform future interactions.”[Participant 17]

Science and statistics“I liked getting science backed info to make it more real.” [Participant 31]

Stages of change“The last materials in week 8 regarding the different stages and the guide to coping with urges were without doubt the mosthelpful. I found it helpful for my own identification of struggles with where I’m at now and learned what I could do aboutit.” [Participant 23]

Factors or Features Associated With Peer Support App
Benefits
When reflecting on the benefits of using the peer support app,
participants generally commented on design features that madethe sharing of support possible and qualities inherent in thecommunity of peers. Factors that contributed to benefits included(1) interactions with supportive peers, (2) sense of sharedexperience, and (3) space for catharsis or venting. Participantsalso made explicit reference to (1) immediacy of support, (2)anonymity, (3) lack of stigma, and (4) being able to provide
support to others to a lesser degree. Table 1 contains quotes
corresponding to each of these subthemes.
Consistent with the findings on benefits and challenges related
to experiences with the peer support app, participants commonlydescribed characteristics of peers that made them feel accepted
and less alone (eg, shared experiences and lack of stigma).
Participants similarly appreciated being able to show and receive
support in a variety of ways through 1-click responses (eg, likes
and hearts) and through commenting on peer posts openly via
the main feed and privately via direct messaging. As mentioned
previously, participants commonly used the app to obtain
feedback or support in moments of distress and thus appreciatedbeing able to receive feedback from peers quickly during thesetimes.

venting, they also expressed dissatisfaction with the experience
as a whole. For example, a participant wrote the following:
It is a well-intentioned but likely ineffective app. It’sa good place to vent and send something off into space
for the sake of being seen, but often the interactions
with others leave much to be desired. [Participant 52]
Another participant described the following:
It can be cool I guess if you just wanna vent or talkto people who are going through similar things asyou, but there’s way too much negativity there for it
to be useful to actually get better. [Participant 42]
These participants seemed to feel as if there was a benefit
inherent in being able to express themselves openly, but that
this may not outweigh exposure to negativity. Similarly,
although several participants referred to the benefits of providing
support, the balance between support provision and receipt was
not always equal. A participant noted the following:
I felt like I supported more people than who supported
me. [Participant 58]
As is clear in these participants’ experiences, there appears to
be a personal cost-benefit analysis undertaken to determine theoverall value of the resource for their well-being.

Interestingly, participants described mixed feelings about both
venting and provision of support. Although several participants
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Factors or Features Associated With Peer Support App
Challenges

experiencing intense urges [11,13]. For example, a participant
wrote the following:

Participants also described the elements that contributed tochallenges or harmful interactions on the app. These elements
included (1) community negativity, (2) interactions with
unsupportive peers, and (3) perceived poster inauthenticity.
Participants also mentioned (1) exposure to triggering content,(2) preference for therapy or in-person support, and (3) perceived
difficulty in intervening. Quotes corresponding to thesesubthemes are presented in Table 2.

The alternative coping skills have been helpful.
However, I still struggle to implement them in
moments of very intense frustration, and I still don’tquite know what to do about that. [Participant 17]
Factsheets that focused on scientific evidence such as pain offset
relief and those including statistics were particularly compelling
and appreciated largely because they increased
self-understanding and made participants feel as if they wereless alone in their struggles.

In contrast to factors that were helpful, many comments about
negative or potentially harmful experiences were related tocontent, rather than design features, and how participants
perceived peers (eg, authentic vs inauthentic). Comments fallingunder interactions with unsupportive peers or community
negativity were differentiated by their reference to isolated
incidents resulting in negative interactions with individuals
versus a general sense of negativity at the community level. In
addition to the quotes in Table 2, there were several references
to harassment and trolling. For example, a participant wrote thefollowing:
Whenever I would post I would have people privately
message me and try to hit on me. It seems completely
inappropriate for this type of app. [Participant 55]
Participants also described a perceived inability to effectively
intervene while navigating the app, and this led to a sense ofhelplessness when reading distressing comments from peers.
Although many of these comments referred to limitations thatparticipants perceived in their ability to help, there were alsocomments on the perceived lack of moderation. For example,
a participant noted the following:

In addition to the utility of learning about how to disclose,
several participants described the factsheets as being catalysts
to conversations with others. Overall, 10% (5/51) of theparticipants described sharing factsheets with family or friends.
A participant noted that sharing the factsheets made them feel
further supported by their significant other:
My boyfriend has been helping me through a lot of
my mental health problems. I discussed some of thearticles with him and that made me feel heard andsupported. [Participant 30]
Another participant described that they opened up to their sister
about their self-injury:
I spoke with my sister about what I was learning
regarding [self-injury]. I was surprised to find little
judgment from her and that alone made me feel better
about myself. [Participant 19]
In these cases, the materials led to valued offline conversations.

I understand that everyone should be able to express
their feelings, but I feel like if the app itself could
somehow catch and delete inappropriate or triggering
responses that are meant to be mean to the person,that would be really nice. [Participant 54]
Though the app has several layers of moderation, including theability for users to flag or block harmful peers and administrative
moderators that can remove harmful content, this reflects theimperfect nature of top-down and automated moderation efforts
on peer support platforms—particularly those devoted tosensitive topics such as self-injury.

Overall, our findings suggest that there were elements of value
in both digital resources, but that they were characterized bydifferent effects and experiences. Several factors were identified
as contributing to positive experiences with the peer support
app; however, there was also significant variability in theperceived value of features across participant experiences.
Individual differences in the types of psychoeducational
factsheets that were most valued and useful were also
apparent—despite the relative agreement on the importance oflearning coping skills. These findings reflect the high level ofnuance that individuals perceive when describing theirexperiences with digital resources and the multifaceted natureof the effects derived.

Preferred Web-Based Factsheets

Discussion

Participants who received weekly web-based factsheets
described specific topic areas that they found to be particularly
helpful. Materials related to coping strategies (including
distraction techniques) were the most referenced, followed byinformation on pain offset relief, information on how to disclose,
and resources addressing the science behind self-injury andstatistics. Quotes corresponding to these content areas arepresented in Table 3.
Many participants saw value in factsheets related to coping
strategies; however, as in other studies, participants expressed
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Principal Findings
Many of the previous studies on digital resources for self-injury
have focused on whether the use of digital interventions leads
to more or less of the behavior, with less attention on other typesof effects that may be relevant to individuals’ experiences ofself-injury and recovery. This study explored the benefits andchallenges perceived by young people who engaged with 2
publicly available digital resources for self-injury. Althoughmany of our findings align with the existing literature on therisks and benefits of web-based activities [8,44], most of thisliterature has inferred these effects from content publishedwithin web-based communities and without direct user insight
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on perceived impacts. Our study makes a novel contribution bydirectly soliciting impressions from adolescents and young
adults after 2 months of engagement with these digital resources.
We also begin to disentangle the specific elements and featuresof these resources that were most valued by users. Collectively,
our findings demonstrate that young people perceived benefits
from the peer support app, web-based factsheets, and therepeated web-based surveys. All 3 digital resources have thepotential for direct and collateral benefits; however, perceptionsof their value and limitations differed considerably.
In general, participants were more likely to mention benefits
than challenges; however, these varied according to digital
resource. Our findings suggest the highest and most consistentsatisfaction with the web-based factsheets containing
psychoeducation on self-injury and treatment. This finding is
not without precedent, as psychoeducation is a core componentof self-injury prevention and intervention [19-21,45]. However,in this study, the psychoeducational materials were relatively
simple and static, suggesting that even brief factsheets areperceived to be useful. We note that this finding may also reflect
the relative simplicity of the factsheets in contrast to the dynamic
nature of interactions on the peer support app. For example,
there were 58 specific references to features of the peer support
app as compared with 29 for the psychoeducational materials(19 for the survey). Engaging in an interactive platform withmany affordances and human actors is a very different
experience than receiving factsheets directly to your email, tobe opened and read at one’s leisure. That is, it may be that thepeer support app had potential for more engagement and, thus,
greater overall positive and negative impact.
Participants articulated several direct benefits from theirexperience with the web-based factsheets, with the dominantbenefits focused on improved self-understanding, increased
motivation to use other coping techniques, and improved
attitudes toward additional support. Interestingly, similar
benefits were supported through experiences with the survey.
However, participants’ reflections on how the survey improved
self-knowledge differed from their reflections on the factsheets.
Benefits derived from the survey focused on how weekly
reflections or check-ins made the frequency and severity ofparticipants’ behaviors more apparent. Heightened awarenessof their self-injury behavior appeared to increase participants’intentions to get additional help and engage in coping strategies
to reduce self-injury. In contrast, the factsheets appeared tocontribute to self-knowledge by providing further explanation
for why participants may engage in self-injury and how the
behavior serves a particular function. This knowledge itself was
helpful for participants and appeared to lead to a newfoundunderstanding of their personal emotional and behavioral
patterns. Participants also expressed clear content preferences,with factsheets related to (1) coping, (2) the way self-injury
assists in reducing emotional arousal, (3) tips and techniques
for productive disclosure, and (4) review of basic science andstatistics being the most referenced and perhaps most likely tohave an impact on future intervention design.
Both the benefits from the survey and factsheets on
self-knowledge resonate with principles of behavioral
approaches to self-injury treatment, which emphasize a
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Kruzan et alfunctional understanding of self-injury and involves tracking
antecedents (or triggers) and consequences of the behavior overtime. This appreciation of features that allow users to monitor
patterns is also consistent with findings from design work on
self-injury self-management [11,46] and the large body ofliterature on the value of self-monitoring in behavior change[40,47,48]. Momentary assessments and passive sensing areincreasingly being integrated into mental health interventions[49,50], and our findings suggest the potential of both
psychoeducation and regular active or passive monitoring in
future digital resources aimed at supporting recovery for
individuals who engage in self-injury.
Another possible benefit from the weekly surveys may havebeen the perceived presence of an empathetic listener. We mustacknowledge that the weekly surveys were sent by the study
research assistant, and although the emails were meant to be
simple reminders, participants may have benefited from regularcontact with someone who was responsive and expressed interestin their experience. The potential benefit of having someone
bear witness to personal experience was clearly present incomments about the peer support app, and it may have similarly
played a role in the surveys. Empathy through repeated contact
with someone invested in patient wellness is a criticalcomponent of the caring contacts program for suicide
prevention. For example, in caring contacts, a clinician sends
a series of repeated asynchronous messages to patients following
acute care, and this simple intervention has been associated with
reduction in suicidal ideation and attempts [51]. Empathetic
listening is also a key feature of crisis lines [52]. It may be
worthwhile for future digital interventions to consider integrating
nonintrusive, low-intensity contact with users, such as throughcoaching or other automated means [53]. Future studies should
explore user comfort with low-intensity contact and the digitalformats that are most suitable for this type of intervention.
The main benefits of the peer support app differed from thoseof the factsheets and weekly surveys and were instead focusedon general improvements in mood and feeling less alone.
Experiences of interacting with peers seemed to increase thesalience of mood and mood shifts for some participants. Other
participants mentioned using the app when their mood wasparticularly low. This finding is consistent with other studies
on peer support for self-injury, in that it is common for people
to navigate to these apps or communities in moments of distressfor just-in-time support [8,27,54,55]. The sense of feeling lessalone in one’s struggles through connecting with peers whoshare their experiences with self-injury was also noted and isaligned with previous studies [56]. However, it is notable that
there was little mention of improved self-knowledge or strategies
to manage self-injury as a result of using the peer support app.
When young people are in a web-based community where they
are exposed to others who are in distress without strategies tomanage that distress, this may result in negative consequences,including emotional contagion, making them ultimately feelworse [57,58].
Participants described negative effects on mood and interactions
or exposure to content that increased or did not help theirself-injury behavior. There was significant variability inreferences to app features, such that some features were
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JMIR FORMATIVE RESEARCH
identified as being both positive and negative across participants.
Examples include anonymity—a feature that was identified asallowing for positive supportive exchanges, while also being asource of negative interaction and perceived inauthenticity ofpeer exchanges, as in other studies [59,60]. The unique alchemyof the app itself along with individual user characteristics makes
assuring that all users have a uniformly positive experience on
the platform challenging. Many participants commented on how
community negativity outweighed the benefits of sharing
experiences with others—describing a cost-benefit analysis
inherent in their evaluation of the peer support app. In summary,the challenges that participants experienced with the peer
support app underscore the need for additional features andfunctionality that can mitigate user challenges and amplify user
benefits.

Implications for Developing Future Digital Resources
Overview
Most participants reported previous use of digital resources formental health (eg, web-based communities and apps), suggesting
general receptivity to these resources and digital interventionsin this population. However, participants also reported low
satisfaction with historical use of these resources, indicating aclear need to improve upon existing spaces where individuals
seek information and support. Our study contributes additional
insights for designers to consider when working to build andimprove digital resources for this population. In this section,
we outline several implications for design and future studies.

Blending Psychoeducation and Peer Support to Amplify
Benefits and Reduce Harms
The overall positive experience participants described with the
web-based factsheets was notable because many existing
websites include psychoeducational content. However, publicly
available web-based communities for self-injury do not often
include active or structured psychoeducational components.
Our study suggests that the integration of psychoeducational
components within web-based communities may increase theirperceived value and diversify the benefits gained. Web-based
communities that include psychoeducation through existingbanks or toolkits often do so as an additive that is optional tousers. For example, 7 Cups of Tea, a digital platform thatdelivers self-help tools and on-demand emotional supportdelivered by trained volunteers, has self-help guides withmaterial such as understanding self-harm behavior [61]. Other
communities, including TalkLife, provide tips for managing
self-injury through their blog feature. However, it is not clear
how often users access this information, and none of theparticipants in our study mentioned the presence or use of theseofferings as part of their experience with the app. It may be thatthe current integration of psychoeducation in these web andmobile spaces is not well marketed or prominently displayedor that the materials are not attuned to young users’ needs.
Therefore, we suggest a more structured delivery ofpsychoeducational content.
A way to increase awareness of and engagement withpsychoeducation within web-based peer support communities
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encourages or reminds users to perform beneficial actions (eg,read psychoeducation or watch content). We should underscorethat there was likely value in receiving materials directly througha prompt (such as email) and with some regularity in this study
versus needing to seek out such resources. This may beespecially true for individuals with comorbid conditions that
affect motivation (eg, depression). In the self-monitoring
literature, push elements are frequently more useful and used,
relative to pull elements (where users must seek out content)[62,63]. Many of our participants seemed surprised by thebenefits they derived from reading the materials, and they may
not have had the drive to track this information on their own.
Related to this, studies have shown that even among young
people who seek information about self-injury on the web, it
can be a challenge to access high-quality information groundedin evidence-based practice [64,65]. Therefore, it will be criticalfor designers to ensure that they are incorporating high-quality
psychoeducation within web spaces that are frequently used byyoung people already, such as web-based communities. Several
questions about this integration remain unanswered. For
example, before incorporating push elements within an existing
web-based community, we need to explore and understand theethical considerations of such changes and assess community
needs. Studies using a user-centered design approach withindividuals with lived experience of self-injury and previous
experience in using digital resources can help move this line ofimportant research forward.
In addition to making high-quality psychoeducation accessible
to individuals engaged in web-based communities, we mustalso ensure that these materials are relevant and resonate with
their experiences [66]. Our study points to several content areasthat were particularly valued by participants and helpful inimproving self-knowledge and increasing receptivity toadditional help, including content on self-injury functions,
coping strategies, and available supports (including outreachefforts and therapy). A compelling way to ensure the relevanceof psychoeducational content for a diverse set of users may be
to use machine learning or decisional logic to tailor the deliveryof content to match users’ needs [67,68]. For example, manysocial platforms send support messages to individuals in crisis
based on keyword use, and a similar model may be leveraged
to deliver brief psychoeducational interventions. Individuals
who post about self-injury may be further prompted with options
to receive daily or weekly psychoeducational materials throughthe platform itself or via email or SMS text message. Individual
tailoring could be explored, so that materials are appropriate
for users’ existing knowledge, goals, and preferences. For
example, early efforts to implement a brief intervention for
self-injury through the social media site, Tumblr, have shownthat it is feasible to integrate psychoeducation into web-based
community spaces [69]. In a study, Tumblr users received ashort psychoeducational intervention aimed at decreasing
self-injury by targeting self-criticism and hate [69]. Although
the results did not show reduction in self-injury behavior, there
was evidence for reduction in self-hate and increase in desire
to stop self-injury. It may be that cognitive behavioral strategies
such as behavioral activation or goal setting may be paired withpsychoeducation to increase the likelihood of putting new
knowledge into action, thus reducing behavior. In summary,
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adding value to existing platforms is a worthwhile endeavorbecause these spaces are already frequently visited by young
people who engage in self-injury, many of whom are nototherwise engaged in mental health services.

Integrating Peer Presence in Digital Resources for
Self-injury
The lack of overlap in benefits perceived across the peer support
app, web-based factsheets, and survey suggests the unique ways
these resources contribute to recovery. The main benefits of thepeer support app appeared to be the sharing of stories, ability
to express oneself, and connection to individuals with sharedexperiences. However, being able to derive benefits wascontrasted with harms such as exposure to community negativity
that exacerbated mood and self-injury symptoms. This potential
for harm may be especially amplified once the novelty of sharing
and hearing similar stories wanes. A way to leverage thebeneficial qualities of peer support in a different digital context
may be to present peer stories alongside psychoeducational
programs. Enabling young people to gain exposure to peer
experiences in a structured context may circumvent some of theharms inherent in an open (often unmoderated) peer support
community, while still providing beneficial qualities to reduceloneliness. Peer narratives are becoming a prominent feature inseveral brief digital interventions targeting youth mental health[66], including the brief intervention discussed previously [69].
Another way in which these brief interventions leverage peer
support is by allowing users who engage in the intervention toshare parts of their personal history such as coping strategies,
which can have a direct therapeutic benefit, and they can thenchoose to share this story with future participants. In this way,interventions can crowdsource peer advice and allow young
people to learn about others who have a shared experience ofself-injury, without being exposed to content that may lead tofurther distress. Although other psychoeducational websites for
suicide and self-injury include peer stories through short video
clips, most psychoeducational content that individuals comeacross on the internet do not include or prominently feature peer
stories representing another opportunity to augment existing
resources.
In addition to using peer stories as part of digital intervention,
researchers and designers should also consider new and safe
ways for young people to interact with one another to exchange
support. An option may be to build peer pairing or referral
systems that connect peers based on a set of characteristics.
Creating a structured exchange between 2 individuals may allow
users to develop deep connections, while also reducing the
likelihood of them being exposed to negative or harmful content.
For example, similar to the Alcoholics Anonymous [70]program, peers earlier in their recovery could be paired withpeers later in their recovery. Peer pairing would provide users
with a dedicated empathetic listener and could be mutually
beneficial because studies have shown that being able to help
others who have a shared struggle promotes psychological
growth [71,72]. Future digital interventions could consider waysof building elements of copresence within interventions—even
if it is through a chatbot or low-intensity human support.

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Promoting Self-knowledge and Encouraging Action
Through Design Features
Finally, one of the most consistent benefits that participants
derived from the digital resources was an increased sense of
self-knowledge. Although this was most apparent in participants’reflections on their experiences with the web-based factsheets
and the survey, it was also highlighted in comments regarding
increased awareness of mood patterns while using the app.
Given the importance of tracking self-injury behavior using
chain and functional analyses in formal treatments for
self-injury, it is important to consider ways of improving
self-knowledge and increasing awareness through interactions
with digital resources. A way to promote awareness is throughsimple self-report monitoring, such as check-ins that ask users
to reflect on a series of questions over a period. Alternatively,
passive monitoring can be used to detect patterns and provide
a brief report for users along with suggested strategies or
activities to improve mental health and reduce in-the-moment
distress. Although passive monitoring can relieve the user
burden as it does not require participants to input additionaldata, more active approaches that require users to input data
may increase the salience of patterns and allow for more
opportunities for self-reflection. To account for different userneeds, an ideal design may allow users to switch back and forth
between periods of passive and active monitoring (eg,semiautomatic tracking) depending on their needs (as described
elsewhere [73]). An intervention incorporating both active andpassive monitoring may be especially useful for young people
who self-injure because self-injury patterns are not always
constant or consistent and long periods can pass between
self-injury episodes. A combination of repeated measurements
for monitoring can also be leveraged to initiate in-the-moment
and tailored interventions.

Limitations
This study should be considered in the context of several
limitations. Although participants were encouraged to respondto open-ended responses honestly, it is important to note that
we analyzed self-report data in a study examining the efficacy
of a digital intervention. Therefore, desirability bias may playa role in participant responses; however, we feel that the rangeof positive and negative responses we received is reassuring.
In addition, participants’ characteristics may make them willingand interested in using digital resources for self-injury. Ourparticipants may have been more likely to use these resources,
given their history of using digital resources and their desire toparticipate in our trial. This may limit the generalizability of
our findings to other populations with less experience with orinterest in digital resources and in the context of natural use(outside of a trial). In addition, although we believe thatsustained use of the digital resources for 8 weeks is a strengthof our study, our results may not extend to more naturalistic useof these resources over long periods. Finally, our results should
be interpreted with the understanding that we used a specific
set of psychoeducational materials developed by researcher
advocates and a peer support platform that was developed as acommunity for mental health.

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Conclusions
The potential to leverage web spaces to provide resources tosupport young people who engage in self-injury is an area ofincreased research interest and practical importance. The uniquenature of our study enabled us to focus on the perceived valueof 2 publicly available digital resources. In doing so, we
discovered details on what is and is not perceived to be helpful
for individuals with self-injury history. The general congruence

Kruzan et alof our findings with themes from other studies exploring thetypes of services and design features that are valued byindividuals with lived experience of self-injury (eg, distraction
and coping) provide a clear direction forward for future researchand design. Although there is certainly merit in designing newtechnologies to support individuals who self-injure, there is alsoa need to improve and augment existing platforms that are
already frequently used by these individuals.

Acknowledgments
The authors would like to thank the participants for contributing their perspectives to this study. This work was supported by theUnited States Department of Agriculture's (USDA) National Institute of Food and Agriculture, Hatch project 1004268 and theCornell Center for Social Sciences. KPK received support from the National Institute of Mental Health (T32 MH115882) while
completing final drafts of this manuscript. The content is solely the responsibility of the authors and does not necessarily represent
the official views of the National Institutes of Health.

Data Availability
The data sets generated and analyzed during this study are available from the corresponding author upon reasonable request.

Conflicts of Interest
None declared.

Multimedia Appendix 1
Web-based factsheets on self-injury.
[PDF File (Adobe PDF File), 290 KB-Multimedia Appendix 1]

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Abbreviations
NSPL: National Suicide Prevention Lifeline
PI: principal investigator
RQ: research question

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Kruzan et al

Edited by A Mavragani; submitted 29.07.22; peer-reviewed by K Rodham, K Dingwall, J Waite-Jones; comments to author 14.11.22;
revised version received 05.12.22; accepted 12.12.22; published 12.01.23
Please cite as:
Kruzan KP, Whitlock J, Chapman J, Bhandari A, Bazarova N
Young Adults’ Perceptions of 2 Publicly Available Digital Resources for Self-injury: Qualitative Study of a Peer Support App and
Web-Based Factsheets
JMIR Form Res 2023;7:e41546
URL: https://formative.jmir.org/2023/1/e41546
doi: 10.2196/41546
PMID:©Kaylee Payne Kruzan, Janis Whitlock, Julia Chapman, Aparajita Bhandari, Natalya Bazarova. Originally published in JMIR
Formative Research (https://formative.jmir.org), 12.01.2023. This is an open-access article distributed under the terms of theCreative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution,and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The
complete bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright andlicense information must be included.

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