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

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

Mapping the availability of translated versions of posttraumatic stress disorder screening questionnaires for adults: A scoping review

Background: The most used questionnaires for PTSD screening in adults were developed in English. Although many of these questionnaires were translated into other languages, the procedures used to translate them and to evaluate their reliability and validity have not been consistently documented. This comprehensive scoping review aimed to compile the currently available translated and evaluated questionnaires used for PTSD screening, and highlight important gaps in the literature. Objective: This review aimed to map the availability of translated and evaluated screening questionnaires for posttraumatic stress disorder (PTSD) for adults. Methods: All peer-reviewed studies in which a PTSD screening questionnaire for adults was translated, and which reported at least one result of a qualitative and /or quantitative evaluation procedure were included. The literature was searched using Embase, MEDLINE, and APA PsycInfo, citation searches and contributions from study team members. There were no restrictions regarding the target languages of the translations. Data on the translation procedure, the qualitative evaluation, the quantitative evaluation (dimensionality of the questionnaire, reliability, and performance), and open access were extracted. Results: A total of 866 studies were screened, of which 126 were included. Collectively, 128 translations of 12 different questionnaires were found. Out of these, 105 (83.3%) studies used a forward and backward translation procedure, 120 (95.2%) assessed the reliability of the translated questionnaire, 60 (47.6%) the dimensionality, 49 (38.9%) the performance, and 42 (33.3%) used qualitative evaluation procedures. Thirty-four questionnaires (27.0%) were either freely available or accessible on request. Conclusions: The analyses conducted and the description of the methods and results varied substantially, making a quality assessment impractical. Translations into languages spoken in middle- or low-income countries were underrepresented. In addition, only a small proportion of all translated questionnaires were available. Given the need for freely accessible translations, an online repository was developed

A Men Who Have Sex With Men-Friendly Doctor Finder Hackathon in Guangzhou, China: Development of a Mobile Health Intervention to Enhance Health Care Utilization.

BACKGROUND: Mobile health (mHeath)-based HIV and sexual health promotion among men who have sex with men (MSM) is feasible in low- and middle-income settings. However, many currently available mHealth tools on the market were developed by the private sector for profit and have limited input from MSM communities. OBJECTIVE: A health hackathon is an intensive contest that brings together participants from multidisciplinary backgrounds to develop a proposed solution for a specific health issue within a short period. The purpose of this paper was to describe a hackathon event that aimed to develop an mHealth tool to enhance health care (specifically HIV prevention) utilization among Chinese MSM, summarize characteristics of the final prototypes, and discuss implications for future mHealth intervention development. METHODS: The hackathon took place in Guangzhou, China. An open call for hackathon participants was advertised on 3 Chinese social media platforms, including Blued, a popular social networking app among MSM. All applicants completed a Web-based survey and were then scored. The top scoring applicants were grouped into teams based on their skills and content area expertise. Each team was allowed 1 month to prepare for the hackathon. The teams then came together in person with on-site expert mentorship for a 72-hour hackathon contest to develop and present mHealth prototype solutions. The judging panel included experts in psychology, public health, computer science, social media, clinical medicine, and MSM advocacy. The final prototypes were evaluated based on innovation, usability, and feasibility. RESULTS: We received 92 applicants, and 38 of them were selected to attend the April 2019 hackathon. A total of 8 teams were formed, including expertise in computer science, user interface design, business or marketing, clinical medicine, and public health. Moreover, 24 participants self-identified as gay, and 3 participants self-identified as bisexual. All teams successfully developed a prototype tool. A total of 4 prototypes were designed as a mini program that could be embedded within a popular Chinese social networking app, and 3 prototypes were designed as stand-alone apps. Common prototype functions included Web-based physician searching based on one's location (8 prototypes), health education (4 prototypes), Web-based health counseling with providers or lay health volunteers (6 prototypes), appointment scheduling (8 prototypes), and between-user communication (2 prototypes). All prototypes included strategies to ensure privacy protection for MSM users, and some prototypes offered strategies to ensure privacy of physicians. The selected prototypes are undergoing pilot testing. CONCLUSIONS: This study demonstrated the feasibility and acceptability of using a hackathon to create mHealth intervention tools. This suggests a different pathway to developing mHealth interventions and could be relevant in other settings

Evaluating the Implementation of a Mental Health App for Overseas Filipino Workers in Macao China: A Mixed-Methods Study of Stakeholders’ Perspectives

Background: Overseas Filipino workers (OFWs) is one of the largest communities of international migrant workers. They face systemic barriers to fulfilling their health needs. The COVID-19 pandemic worsened this condition and provided a context to evaluate the utility of a digital mental health intervention delivered within a stepped-care model to address OFW mental health. Using an implementation science framework, this study aimed to evaluate stakeholders’ perspectives on the implementation of Kumusta Kabayan, a mobile phone-based mental health app, for OFWs in Macao. Methods: A mixed-methods convergent design was used by conducting two parallel steps, including quantitative and qualitative measures. The quantitative data was collected from Filipino team members and local non-governmental organization (NGO) staff members (N = 12). The qualitative data were gathered from interviews with OFWs in Macao who used the app (N = 25; 80% females, 76% domestic workers). Results: From the online survey, the staff members of the local partner NGO and the Filipino team members strongly perceived that their organization could adapt Kumusta Kabayan to their program and generally evaluated that Kumusta Kabayan achieved its goal and was received well by OFWs. In the interviews, the OFW app users shared their experiences in using Kumusta Kabayan, which was thematically organized into six aspects of the participants’ experience: (1) promotional channel and expectation; (2) when to use the app and in what language; (3) lessons learnt; (4) memorable aspects; (5) key facilitators and barriers; and (6) suggestions. Conclusion: Kumusta Kabayan was well accepted and shows potential to be integrated into the existing support services for OFWs in Macao. This app has the promise of being scaled-up for OFWs in other countries by collaborating with local and overseas stakeholders. Lessons learnt from this evaluation could also be implemented in wider digital mental health services in different settings

A Network Analysis Investigation of the Comorbidity Between Sleep Dysfunction and PTSD Symptomatology Among Filipino Domestic Workers in Macao (SAR) China

Posttraumatic stress disorder (PTSD) is highly comorbid with sleep dysfunction. This association was previously explained based on cognitive and emotional dysfunction. The current study extends this literature by investigating the symptom level comorbidity of sleep dysfunction and DSM-5 PTSD utilizing a network approach. Participants were trauma-exposed female Filipino domestic workers (N = 1241). Network analysis was applied to 23 items: 18 items from PCL-5 measuring PTSD (Community 1) and 5 items from PSQI assessing sleep dysfunction (Community 2). The results showed that the symptoms within each community had the strongest correlations. Bridge connections were identified between the sleep dysfunction and PTSD symptom communities. Symptoms with the highest bridge strength were concentration difficulties, recklessness, irritability, and sleep disturbance. This is among the first studies investigating the comorbidity between PTSD and sleep dysfunction from the network approach. Future interventions may be developed that emphasize the bridge symptoms to address comorbidity among trauma exposed migrants

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

Alcohol use among adolescents in Macao during COVID-19: a latent class analysis

Objective: the objective of this study was to estimate the prevalence of past alcohol use and to evaluate patterns of alcohol use among Chinese adolescents.Methods: 1,707 students from 11 high schools in Macao (SAR) China self-reported their alcohol use measured by the Alcohol Use Disorder Identification Test (AUDIT). Latent class analysis and multinomial logistic regression were conducted to examine patterns of drinking and their correlates with alcohol-related use problems.Results: the prevalence of past alcohol use and problematic alcohol use (AUDIT ≥8) was 26.0% and 3.2%, respectively. Latent class analysis demonstrated that a five-class model best fit the participants’ alcohol use patterns, including a heavy consumption group, two moderate consumption groups and two light consumption groups. Compared with the light consumption group, adolescents over the age of 15 (vs. 15 years or younger) were more likely to be classified into the moderate consumption group with mild negative consequences, and adolescents who smoked were more likely to be classified into all other groups vs. the reference group.Conclusion: the results suggest a high prevalence of alcohol use and several sub-groups were at increased odds of alcohol related harms.</p

Crowdsourcing to design a marketing package to promote a WHO digital mental health intervention among Chinese young adults

Background: Digital mental health is an emerging field that can leverage technology and mobile apps to deliver mental health treatment to populations in areas with limited mental health services. Despite widespread availability of these apps, uptake remains low. Enhanced marketing is necessary to increase public engagement. There is growing recognition that mental health intervention beneficiaries should be engaged in all phases of treatment development, adaptation, and delivery. Crowdsourcing – consulting the public to solve problems and sharing the solutions – can foster community-informed ideas for public health, but has yet been applied to digital mental health marketing. Objective: With the goal of engaging potential intervention beneficiaries in digital mental health dissemination, the current project implemented a digital mental health crowdsourcing designathon for Chinese college students in Macao SAR, China and evaluated the feasibility of the contest and the products. The contest asked participants to design marketing packages for Step-by-Step, a scalable WHO digital mental health intervention focusing on depression. Methods: Designathon participants, recruited from a global health class, were sorted into teams with balanced areas of expertise. Two judging panels – one of experts in relevant fields and another of Chinese college students – evaluated the marketing packages and selected finalists. The designathon was held in-person over four days and involved debriefing, workshops, a contest, and an awards ceremony. A parallel mixed-methods approach was applied, including qualitative feedback from judges and participants alongside quantitative data on participant satisfaction and depressive symptoms to enrich our understanding of the event. Additionally, based on judges' feedback given to participants, the communication packages of the contest were ranked. Results: 49 participants (8 teams of 6–7 members each) were involved in the designathon. Using a cutoff score of 10 on the Patient Health Questionnaire-9 (PHQ-9), 11.4% of participants had moderate or higher depressive symptoms. All teams successfully produced complete digital mental health marketing packages. Four finalists' packages were selected quantitatively with judges' scores and the top finalist's package was described by judges' comments as simple, thoughtful, and appealing, although not informative enough. Participants were overall satisfied with the designathon, but some mentioned that time was insufficient and that organization/instruction clarity could have been improved. Conclusions: The designathon is a novel, feasible strategy to collect crowd input for the dissemination of a mental health intervention. Compared with traditional communication strategies, this bottom-up approach included and engaged potential intervention beneficiaries to take an active role in creating digital mental health marketing communication. Future contests should allow participants more time and reconsider aspects of event organization

Mapping the availability of translated versions of posttraumatic stress disorder screening questionnaires for adults: A scoping review

Background: The most used questionnaires for PTSD screening in adults were developed in English. Although many of these questionnaires were translated into other languages, the procedures used to translate them and to evaluate their reliability and validity have not been consistently documented. This comprehensive scoping review aimed to compile the currently available translated and evaluated questionnaires used for PTSD screening, and highlight important gaps in the literature. Objective: This review aimed to map the availability of translated and evaluated screening questionnaires for posttraumatic stress disorder (PTSD) for adults. Methods: All peer-reviewed studies in which a PTSD screening questionnaire for adults was translated, and which reported at least one result of a qualitative and /or quantitative evaluation procedure were included. The literature was searched using Embase, MEDLINE, and APA PsycInfo, citation searches and contributions from study team members. There were no restrictions regarding the target languages of the translations. Data on the translation procedure, the qualitative evaluation, the quantitative evaluation (dimensionality of the questionnaire, reliability, and performance), and open access were extracted. Results: A total of 866 studies were screened, of which 126 were included. Collectively, 128 translations of 12 different questionnaires were found. Out of these, 105 (83.3%) studies used a forward and backward translation procedure, 120 (95.2%) assessed the reliability of the translated questionnaire, 60 (47.6%) the dimensionality, 49 (38.9%) the performance, and 42 (33.3%) used qualitative evaluation procedures. Thirty-four questionnaires (27.0%) were either freely available or accessible on request. Conclusions: The analyses conducted and the description of the methods and results varied substantially, making a quality assessment impractical. Translations into languages spoken in middle- or low-income countries were underrepresented. In addition, only a small proportion of all translated questionnaires were available. Given the need for freely accessible translations, an online repository was developed. HIGHLIGHTS We mapped the availability of translated PTSD screening questionnaires. The quality of the translation and validation processes is very heterogenous. We created a repository for translated, validated PTSD screening questionnaires