A Feasibility Study of the WHO Digital Mental Health Intervention Step-by-Step to Address Depression Among Chinese Young Adults

Background: Chinese young adults experience barriers to mental health treatment, including the lack of treatment providers and stigma around treatment seeking. Evidence-based digital mental health interventions are promising and scalable alternatives to face-to-face treatment for this population, but lack rigorous evidence to support scale-up in China. Aim: The study was a feasibility study for a large-scale RCT of Step-by-Step, a behavioral activation-based, mental health intervention to address depression and anxiety symptoms in Chinese young adults. It sought to assess feasibility of recruitment and of delivery of Step-by-Step in a University setting, to assess acceptability of the intervention, and to examine potential effectiveness. Method: An uncontrolled, feasibility trial was conducted to assess the feasibility and acceptability of Chinese Step-by-Step for Chinese University students with elevated depressive symptoms (PHQ-9 scores at or above 10) in Macao, China. Data was collected at two different time points (i.e., baseline and 8-weeks after baseline), administered via questionnaires embedded in an interventional mobile application. Participation rate and dropout rate were measured. Depressive and anxiety symptom severity, well-being, and self-defined stress were assessed. Satisfaction with the program was assessed using qualitative interviews. Results: A total of 173 students were screened, 22.0% (n = 38) were eligible, and 63.2% of them (n = 24) started the intervention. The dropout rate by post-test was 45.8%. Results from completers showed that Step-by-Step was potentially effective in reducing depressive and anxiety symptom severity, and self-defined stress. Students were generally satisfied with the program, but also offered suggestions for continued improvement. Qualitative feedback was reported within the RE-AIM framework, covering recruitment, effectiveness, adoption, implementation, and maintenance. Amendments to the program were made according to the feedback (e.g., adding notification for new session, modify the time zone). Conclusion: A minimally guided Step-by-Step protocol and the study procedure were successfully pilot tested for use for Chinese University students. The intervention was acceptable and no adverse events were reported. The results support the potential effectiveness and feasibility of a large-scale evaluation of the program

“We Live Just Like a Normal Family”: Exploring Local Renderings of the Global HIV Normalisation Discourse Among Serodiscordant Couples in Papua New Guinea

The contemporary global discourse of “HIV normalisation” is intimately linked to the scientific consensus that, with effective antiretroviral therapy, an “undetectable” viral load renders HIV “non-infectious” and “untransmittable” between sexual partners. Beyond this correlation, HIV normality is rarely defined, leaving the impression that it is an objective and universally applicable phenomenon. But what does normality mean in settings where these concepts are not widely known or part of local understandings of HIV? Our research in Papua New Guinea with “serodiscordant” couples (one partner has HIV, but not the other) found that while HIV normality was a widespread narrative, it pivoted on culturally specific values and expectations, not on undetectability. We argue that narrow assumptions of what constitutes “HIV normalisation” limit our capacity to understand how global discourses can translate and manifest in local contexts and with what consequences for personal lives, relationships, and the epidemic

A protocol for a type 1 effectiveness-implementation randomized controlled trial of the WHO digital mental health intervention Step-by-Step to address depression among Chinese young adults in Macao (SAR), China

Background Among Chinese college students, the burden of depression is considerably high, affecting up to 30 % of the population. Despite this burden, few Chinese students seek mental health treatment. In addition, depression is highly comorbid with other mental health disorders, such as anxiety. Scalable, transdiagnostic, evidence-based interventions are needed for this population. Objective The study will evaluate the effectiveness of a World Health Organization transdiagnostic digital mental health intervention, Step-by-Step, to reduce depressive and anxiety symptoms and improve well-being compared with enhanced care as usual and its implementation in a Chinese university community. Methods A type 1 effectiveness-implementation two-arm, parallel, randomized controlled trial will be conducted. The two conditions are 1) the 5-session Step-by-Step program with minimal guidance by trained peer-helpers and 2) psychoeducational information on depression and anxiety and referrals to local community services. A total of 334 Chinese university students will be randomized with a 1:1 ratio to either of the two groups. Depression, anxiety, wellbeing, and client defined problems will be assessed at pre-intervention, post-intervention, and 3-month follow-up. Endline qualitative interviews and focus group discussions will be conducted to explore SbS implementation among service users, university staff, and stakeholders. Data will be analysed based on the intent-to-treat principle. Discussion Step-by-Step is an innovative approach to address common mental health problems in populations with sufficient digital literacy. It is a promising intervention that can be embedded to scale mental health services within a university setting. It is anticipated that after successful evaluation of the program and its implementation in the type 1 hybrid design RCT study, Step-by-Step can be scaled and maintained as a low-intensity treatment in universities, and potentially extended to other populations within the Chinese community. Trial registration ChiCTR2100050214

Young and Positive

Young & Positive is a series of short documentary films about three young women living with HIV in Papua New Guinea. Collectively and individually they share their experiences of the diagnosis, treatment, fear of death, pregnancy and parenthood, TB, education and making a future, and the possibility of living a normal life. Their inspirational stories weave together the importance of others, family members, children and health care workers who show kindness, love, and support to remain on their HIV treatment. Young & Positive addresses the issue of adolescents staying on HIV treatment and better understanding the challenges they might face. By documenting stories of young women who have overcome these challenges the films form an important advocacy and education component of the national HIV response in Papua New Guinea

Resource Extraction, Gender and the Sexual Economy in Hela Province, Papua New Guinea: 'Everything has Changed'

Due to the wealth flowing from a large new liquefied natural gas extraction project, Hela Province has undergone immense socio-cultural changes. Many of these changes are well documented, but those pertaining to gender and sexuality have largely been overlooked. Our research used photovoice and interviews to examine how the local sexual economy has been affected by money flowing from the project. This methodology allowed the participants to creatively visualise and document their lived experience of the changes occurring. The research findings illustrate the complex and diverse ways in which one instance of resource extraction is impacting on people at the margins of large-scale developments and how this is shaping both gender relations and sexual relations.</p

Loss to follow up of pregnant women with HIV and infant HIV outcomes in the prevention of maternal to child transmission of HIV programme in two high-burden provinces in Papua New Guinea: a retrospective clinical audit

Introduction Despite early adoption of the WHO guidelines to deliver lifelong antiretroviral (ARV) regimen to pregnant women on HIV diagnosis, the HIV prevention of mother to child transmission programme in Papua New Guinea remains suboptimal. An unacceptable number of babies are infected with HIV and mothers not retained in treatment. This study aimed to describe the characteristics of this programme and to investigate the factors associated with programme performance outcomes.Methods We conducted a retrospective analysis of clinical records of HIV-positive pregnant women at two hospitals providing prevention of mother to child transmission services. All women enrolled in the prevention of mother to child transmission programme during the study period (June 2012–June 2015) were eligible for inclusion. Using logistic regression, we examined the factors associated with maternal loss to follow-up (LTFU) before birth and before infant registration in a paediatric ARV programme.Results 763 of women had records eligible for inclusion. Demographic and clinical differences existed between women at the two sites. Almost half (45.1%) of the women knew their HIV-positive status prior to the current pregnancy. Multivariate analysis showed that women more likely to be LTFU by the time of birth were younger (adjusted OR (AOR)=2.92, 95% CI 1.16 to 7.63), were newly diagnosed with HIV in the current/most recent pregnancy (AOR=3.50, 95% CI 1.62 to 7.59) and were in an HIV serodiscordant relationship (AOR=2.94, 95% CI 1.11 to 7.84). Factors associated with maternal LTFU before infant registration included being primipara at the time of enrolment (AOR=3.13, 95% CI 1.44 to 6.80) and being newly diagnosed in that current/most recent pregnancy (AOR=2.49, 95% CI 1.31 to 4.73). 6.6% (50 of 763) of exposed infants had a positive HIV DNA test.Conclusions Our study highlighted predictors of LTFU among women. Understanding these correlates at different stages of the programme offers important insights for targets and timing of greater support for retention in care

"I Was Attracted to Him Because of His Money': Changing Forms of Polygyny in Contemporary Papua New Guinea

Substantial economic transition in Papua New Guinea (PNG) is giving rise to increased wealth, rapid social change and changing cultural practices. Polygyny practices in PNG have come under increasing domestic attention in recent years, especially as pertains to reinforcing patriarchy and exacerbating gender inequality. Based on qualitative research with women, we identify a new emerging polygyny' that is located in women's and girls' choices, decisions, experiences and actions, and which contrasts with other research documenting polygyny from men's perspectives. Narratives from female participants described young women and girls who actively seek polygynous relationships with men who have disposable income and other assets, with the aim of gaining access to economic wealth as co-wives. In the context of public and legal debate about the status of polygyny in PNG, these findings illustrate the need for a more balanced discussion about polygynous relationships, located within an understanding of women's lived experiences

A WHO digital intervention to address depression among young Chinese adults: a type 1 effectiveness-implementation randomized controlled trial

Abstract Common mental disorders among young people are rising globally. Current university-based interventions are inadequate to address the need for evidence-based interventions. We investigated the effectiveness and implementation of Step-by-Step (SbS), a WHO digital intervention to address depression, among Chinese university students with depressive symptoms. In this paper, we report a type 1 hybrid effectiveness-implementation randomized controlled trial conducted between September 2021 and September 2022. The control condition was enhanced treatment as usual (ETAU, psychoeducation). The primary outcome was improvement in depression symptoms. Secondary outcomes were improvements in psychological well-being, anxiety symptoms, and self-identified psychosocial problems. Effectiveness of the intervention was evaluated using generalized linear mixed models. Implementation outcomes were evaluated by thematic analysis of participant interviews. A total of 371 participants were enrolled to two treatment conditions in a 1:1 ratio. SbS resulted in a greater reduction in depressive symptoms at posttreatment (p = 0.004, Hedges’ g = 0.35), but no significant difference between SbS and ETAU was observed at three-month follow-up (p = 0.179, Hedges’ g = 0.16). The treatment effect was larger among those who adhered to the treatment (Hedges’ gs = 0.59 and 0.30). Subjective well-being also improved for SbS at both time points (Hedges’ gs = 0.31 and 0.30). In addition, SbS resulted in more improvement in anxiety symptoms at posttreatment (p = 0.029, Hedges’ g = 0.26), but not at three-month follow-up (p = 0.265, Hedges’ g = 0.13). The qualitative results demonstrated that the intervention was well-implemented as a self-help mental health service, with minimal support from peer supporters. In conclusion, Step-by-Step, a digital intervention developed by WHO, was effective in reducing depressive symptoms in the short term and improving psychological well-being in a longer term. The sustained effect on depression needs further investigation. Improving uptake and engagement in the program is needed for its scale-up implementation as a university-based mental health service for Chinese young adults. Trial registration: ChiCTR2100050214

Sexual risk behaviour, marriage and ART : a study of HIV-positive people in Papua New Guinea

Background: The prevention of intimate partner transmission of HIV remains an important component of comprehensive HIV prevention strategies. In this paper we examine the sexual practices of people living with HIV on antiretroviral therapy (ART) in Papua New Guinea (PNG). Method: In 2008, a total of 374 HIV-positive people over the age of 16 and on ART for more than two weeks were recruited using a non-probability, convenience sampling methodology. This accounted for around 18% of adults on ART at the time. A further 36 people participated in semi-structured interviews. All interviews were thematically analysed using NVivo qualitative data analysis software. Results: Less than forty per cent (38%) of participants reported having had sexual intercourse in the six months prior to the survey. Marital status was by far the most important factor in determining sexual activity, but consistent condom use during vaginal intercourse with a regular partner was low. Only 46% reported consistent condom use during vaginal intercourse with a regular partner in the last six months, despite 77% of all participants reporting that consistent condom use can prevent HIV transmission. Consistent condom use was lowest amongst married couples and those in seroconcordant relationships. The vast majority (91.8%) of all participants with a regular heterosexual partner had disclosed their status to their partner. Qualitative data reinforced low rates of sexual activity and provided important insights into sexual abstinence and condom use. Conclusions: Considering the importance of intimate partner transmission of HIV, these results on the sexual practices of people with HIV on ART in PNG suggest that one-dimensional HIV prevention messages focussing solely on condom use fail to account for the current practices and needs of HIV-positive people, especially those who are married and know their partners' HIV status.12 page(s