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Traditional in-person psychotherapies are incapable of addressing global mental health needs. Use of computer-based interventions is one promising solution for closing the gap between the amount of global mental health treatment needed and received.
Although many meta-analyses have provided evidence supporting the efficacy of self-guided, computer-based interventions, most report low rates of treatment engagement (eg, high attrition and low adherence). The aim of this study is to investigate the efficacy of an adjunctive treatment component that uses task shifting, wherein mental health care is provided by nonspecialist peer counselors to enhance engagement in an internet-based, self-directed, evidence-based mindfulness intervention among Chinese university students.
From 3 universities across China, 54 students who reported at least mild stress, anxiety, or depression were randomly assigned to a 4-week internet-based mindfulness intervention (MIND) or to the intervention plus peer counselor support (MIND+), respectively.
For both conditions, participation in the internet-based intervention was associated with significant improvements in mindfulness and mental health outcomes. The pre-post effect sizes (Cohen
This study provides new insights into effective ways of leveraging technology and task shifting to implement large-scale mental health initiatives that are financially feasible, easily transportable, and quickly scalable in low-resource settings. The findings suggest that volunteer peer counselors receiving low-cost, low-intensity training and supervision may significantly improve participants’ indices of treatment engagement and mental health outcomes in an internet-based mindfulness intervention among Chinese university students.
Approximately 1 in 5 adults in the United States experiences mental illness annually [
Traditional psychotherapy training models (ie, 2-7 years of graduate school) and psychotherapies (one-on-one and in-person sessions) are incapable of singularly closing the global mental health gap in LMICs. Fundamentally, new approaches are needed to increase access to effective mental health care in an economic, feasible, and scalable manner to address global needs [
Mindfulness- and acceptance-based interventions have been successfully used to address clinical dysfunction across a range of physical and mental health disorders. Specifically, systematic reviews and meta-analyses have demonstrated mindfulness and acceptance to be beneficial in treating physical health conditions, such as chronic pain [
Although technology-based mindfulness interventions can be effective, treatment engagement is a key barrier to the implementation of these approaches. High attrition and low adherence rates are commonly observed in research and practice. Nonadherence can diminish the effectiveness of interventions [
Adherence is especially relevant in mindfulness training because regular practice is thought to be essential for developing mindfulness skills. In their meta-analytic review of web-based mindfulness interventions, Spijkerman et al [
Although many web-based mindfulness interventions have been shown to be effective, about half of the published studies did not report treatment engagement outcomes, and of those that did, most reported low engagement (high attrition and low adherence). Researchers have repeatedly noted that in spite of the effectiveness of web-based interventions, it is a consistent challenge to reliably measure the amount and quality of mindfulness practice with which people engage [
Previous research indicates that providing therapist support has a positive influence on adherence and enhances the effectiveness of web-based psychological interventions [
Task sharing or
The aim of this study is to examine whether an adjunctive, task-shifting component (MIND+) enhances treatment engagement in a mindfulness intervention for stress and depression among Chinese undergraduate and graduate students. Individuals were randomly assigned to a brief (4-week), self-guided, web-based, mindfulness intervention (MIND), or the intervention plus support from nonspecialist peer counselors (MIND+). Peer counselors were instructed to engage in brief (15-20 minutes) weekly meetings with MIND+ participants via text or phone call during the course of treatment, with the intention of supporting and encouraging participants to complete the internet-based intervention. It was hypothesized that at posttreatment, participants randomly assigned to MIND+ (vs those assigned to MIND) would show (1) less attrition (higher completion rates of assessment), (2) greater adherence (higher percentage of course completion), (3) greater reductions in stress and depression levels, and (4) greater increases in mindfulness.
Participants were 54 currently enrolled university students (undergraduate, master’s, and doctoral programs) from 36 universities across China. Their mean age was 23.5 years (SD 3.17), and 74% (40/54) identified as female. Out of the 54 participants, 29 (54%) were master’s students, 21 (39%) were undergraduate students, and 4 (7%) were doctoral students. All participants reported having passed an English proficiency test: 11% (6/54) reported passing the College English Test (CET; level 4); 72% (39/54), the CET (level 6); and 17% (9/54), the Test of English as a Foreign Language. All participants denied currently receiving formal mental health treatment; 80% (43/54) reported no history of mental health treatment, 11% (6/54) reported formerly receiving therapy, 4% (2/54) reported formerly receiving medication, and 6% (3/54) reported formerly receiving both treatment and medication. Out of the 54 participants, 47 (87%) reported no previous mindfulness training, and 3 (6%) reported practicing mindfulness meditation in the past year.
Participants were recruited via WeChat blogs, student club listservs, and university websites’ listing of available jobs and research opportunities. Interested individuals completed a web-based screening assessment. Eligible students were contacted by the study coordinator, who conducted phone interviews and orientation to the study procedures. Students who provided proof of student status and emergency contact information received a link to the baseline assessment measures. Students who completed the web-based baseline assessment measures were randomly assigned to a brief, 4-week internet-based mindfulness intervention (MIND), or to the intervention plus peer counselor support (MIND+). The inclusion and exclusion criteria have been provided in
Is currently enrolled in a university in China (undergraduate, graduate, or doctoral)
Has a smartphone and regular access to the internet
Demonstrates the ability to read and understand Mandarin
Reports passing at least College English Test (level 4)
Experiences at least mild depression and anxiety
Is aged <18 years
Does not provide proof of current student status and emergency contact
Currently experiences manic or psychotic symptoms
Expresses suicidal or homicidal ideation during the intake phone interview
Peer counselors included 4 currently enrolled female students at 3 different universities in Beijing. At the time of recruitment, their mean age was 27.5 years (SD 6.8), including 1 undergraduate (psychology), 1 master’s (business), and 2 doctoral (nursing) students. None of the peer counselors reported formal training or experience in mindfulness practice or the provision of mental health services. All participants reported having passed at least the CET (level 6).
Web-based advertisements were posted on university research, student club, and mindfulness listservs. A total of 56 candidates responded to the web-based survey, expressing interest in participating in the study as peer counselors. Those who met the inclusion criteria were contacted via telephone to screen for the exclusion criteria and confirm their understanding of the study and willingness to participate in the in-person training and orientation. Volunteer peer counselor candidates who met all the inclusion criteria were invited to the in-person training and orientation. After this training, participants were contacted via telephone to once again assess their willingness to engage in the study. We selected 4 individuals as peer counselors based on their English proficiency, reported level of enthusiasm for the project, and the researchers’ assessment of their nonspecific factors. Each individual was given access to the internet-based intervention and a 6-week period to complete the course. After completing the course, peer counselors were paired with study participants who were randomized to the MIND+ group. The inclusion and exclusion criteria for peer counselors have been illustrated in
Is currently enrolled in a university in Beijing (undergraduate, graduate, or doctoral)
Has a smartphone and regular access to the internet
Demonstrates the ability to read and communicate in Mandarin and English
Is willing to provide brief (15-20 minute) peer-support chats per week per participant
Is willing to participate in web-based group supervision for 1 hour per week
Is willing to complete the internet-based mindfulness intervention
Is aged <18 years
Reports previous or current format training in mindfulness or psychotherapy
Reports current treatment (psychotherapy or medication) for a mental health problem
Is unable to attend the day-long, in-person training in Beijing
The in-person training took place for 8 hours in Beijing. All lectures and discussions were conducted in Mandarin. Peer counselor candidates listened to lectures on topics related to peer counseling and the current research project. The candidates were given opportunities to practice using the skills in dyads and to receive coaching and feedback from the first author and research assistants.
Training was didactic and experimental and included (1) mindfulness theory and practice (2 hours), (2) orientation to the study and role of a peer counselor (1.5 hours), ethics, confidentiality, and mandated reporting (30 minutes), (4) lunch break and personal introductions (1 hour), (5) fundamentals of counseling listening skills (30 minutes), (6) validation techniques (1.5 hours), and (7) motivational interviewing (1 hour).
Weekly group supervision was attended by the research coordinator (MR), 2 research assistants, and the 4 peer counselors. Meetings were conducted in Mandarin and via a videoconferencing software (Zoom; Zoom Video Communications) after peer counselors were matched with their first participant. The structure of the supervision meetings was modeled after the elements of dialectical behavior therapy consultation team meetings [
The
When this study was conducted in May 2018, the
Chapter and title | Content | Materials and homework assignments |
Before; Getting Started | Orientation to the course and format | 3 videos (>6 min total); assignments: stress assessment, reflection on goals, and motivation for practicing |
Week 1; Stepping out of Automatic Pilot | Introduction to the concept of mindfulness | 4 videos (>12 min total); 1 audio file (30 min); assignments: events diary, body scan, routine activity, and mindful meal |
Week 2; Reconnecting with Body and Breath | Awareness of thoughts and feelings | 3 videos (>17 min total); 2 audio files (19 min total); assignments: difficult thoughts checklist, event awareness, mindful movement, and mindful breathing |
Week 3; Working with Difficulties | Acknowledging difficult thoughts and emotions without judgment or attachment | 3 videos (>9 min total); 1 audio file (22 min); assignments: stress awareness, sitting meditation, and breathing space |
Week 4; Mindfulness in Daily Life | Awareness of (1) personal patterns, (2) associations to changes in mind and body, and (3) stress indicators | 3 videos (>11 min total); assignments: list of four helpful and unhelpful strategies, activity awareness, breathing space, and chosen practice |
After; Going Forward | Reflecting on lessons learned | 3 videos (>5 min total); assignments: stress assessment, letter to yourself, and review additional resources |
Participants were compensated for completing the baseline questionnaire packet, posttreatment questionnaires, and for responding to each daily assessment; the total amount that the participants could make from this course was approximately US $28. This study received institutional review board approval from the Psychology Research Ethics Committee at the Beijing Institute of Technology, and all participants electronically signed a digital informed consent form.
Participants randomized to the MIND+ condition (n=27) completed the same procedures as those in the MIND condition (n=27). However, those in the MIND+ condition were informed by the study coordinator via email that they were paired with a peer counselor who would provide them support and encouragement. Participants were instructed to contact their peer counselor within a week to schedule a time to chat. Peer counselors were instructed to contact their participants if they did not hear from them within 5 days. Peer counselors were encouraged to provide brief (15-20 minutes) weekly meetings to support and encourage participants in their completion of the internet-based intervention.
Daily assessments were completed using the Qualtrics software. Participants rated their state mindfulness and mood (stress, depression, and happiness) on a 5-point Likert scale (1=
A self-report questionnaire packet was completed at screening, baseline, postintervention, and at the 1-month follow-up after the end of the intervention.
The Demographic Data Survey-Modified is a self-report measure used to obtain demographic information (gender, age, university, year in school, and field of study), as well as self-report data about the patient’s English proficiency, meditation experience (previous training and current practice), psychiatric diagnostic and treatment history, and emergency contact information.
The 7-item Generalized Anxiety Disorder (GAD-7) questionnaire is a 7-item measure of the severity of anxiety symptoms in the last 2 weeks [
The Patient Health Questionnaire-9 (PHQ-9) is a 9-item measure of the severity of depression symptoms in the last 2 weeks [
The Five-Factor Mindfulness Questionnaire (FFMQ), originally developed by Baer, is a 39-item measure of trait mindfulness that is organized into 5 subscales (Observing, Describing, Nonjudging of inner experience, Nonreactivity to Inner Experience, and Acting with Awareness), with 7 or 8 items in each subscale [
The Depression Anxiety Stress Scale is a 21-item measure comprising 3 subscales (Depression, Anxiety, and Stress) of 7 items each, which provide indices of depression [
Perceived Stress Scale (PSS) is a 14-item measure of perceived stress in the last month [
All analyses were conducted in SAS (version 9.4, SAS Institute).
To capture any nonlinear changes across the study, the phases were coded as follows:
First, a chi-square analysis was used to test the hypothesis that participants randomly assigned to MIND+ (vs those assigned to MIND) would show less attrition as indicated by higher completion (vs noncompletion) rates of posttreatment assessment (yes or no).
Second, independent samples, two-tailed
Three multilevel models (identical to those used for the number of minutes of mindfulness practice mentioned above) were used to test the hypothesis that the randomization to the MIND+ condition would result in a greater increase in mindfulness across the trial, and greater decrease in depression and stress levels across the trial. Time was also alternatively defined by examining contrasts of the beginning of the study (days 1-11) with both the middle (days 12-23) and end (days 24-35) of the study.
Model fitting was accomplished using the −2 log likelihood model to determine model fit. Random slopes were retained when this improved the model fit. Person-standardized daily values (today’s value minus overall person mean, divided by overall person SD) were used for graphical depictions of continuous outcomes to depict only the within-person changes in the outcome across the study, consistent with multilevel modeling results.
The size of group differences in each outcome, or change over time in each outcome, was estimated using Cohen
The randomization sequence was sourced through random.org [
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow chart.
Descriptive statistics in the full sample and by condition (N=54).
Variable | Total sample (N=54) | MIND (n=27) | MIND+ (n=27) | Comparisons | ||
Sex (female), n (%) | 40 (74) | 18 (67) | 22 (81) | |||
Age (years), mean (SD) | 23.53 (3.17) | 23.77 (3.72) | 23.29 (2.56) | |||
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Previously practiced | 4 (7) | 2 (7) | 2 (7) |
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Currently practice | 3 (6) | 3 (11) | 0 |
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Never practiced | 47 (87) | 22 (81) | 25 (93) |
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CETb level 4 | 7 (13) | 6 (22) | 1 (4) |
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CET level 6 | 38 (70) | 16 (59) | 22 (81) |
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TOEFLc or IELTSd | 9 (17) | 5 (19) | 4 (15) |
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Pretreatment | 10.63 (5.0) | 9.70 (4.7) | 11.56 (5.3) | ||
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Posttreatment | 7.11 (4.8) | 7.42 (5.4) | 6.78 (4.2) | ||
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Pre-to-post change | −3.23 (5.29) | −2.38 (5.08) | −4.13 (5.46) | ||
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Pretreatment | 8.65 (4.1) | 8.33 (4.0) | 8.96 (4.2) | ||
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Posttreatment | 5.96 (4.2) | 5.83 (3.3) | 6.09 (5.1) | ||
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Pre-to-post change | −2.77 (3.97) | −2.62 (3.69) | −2.91 (4.32) | ||
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Pretreatment | 6.45 (3.8) | 5.73 (2.8) | 7.15 (4.6) | ||
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Posttreatment | 3.96 (3.0) | 3.79 (3.0) | 4.13 (3.1) | ||
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Pre-to-post change | −2.40 (3.84) | −2.62 (3.69) | −2.87 (4.32) | ||
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Pretreatment | 6.38 (3.2) | 6.19 (3.1) | 6.56 (3.4) | ||
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Posttreatment | 4.72 (2.7) | 4.79 (3.0) | 4.65 (2.3) | ||
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Pre-to-post change | −1.47 (3.44) | −1.29 (3.26) | −1.65 (3.22) | ||
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Pretreatment | 8.91 (3.4) | 8.31 (3.5) | 9.48 (3.3) | ||
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Posttreatment | 6.70 (3.6) | 6.33 (2.9) | 7.09 (4.3) | ||
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Pre-to-post change | −2.17 (3.79) | −2.0 (3.78) | −2.34 (3.86) | ||
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Pretreatment | 115.46 (10.3) | 116.27 (8.9) | 114.65 (11.6) | ||
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Posttreatment | 119.96 (14.8) | 121.63 (12.8) | 118.22 (16.7) | ||
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Pre-to-post change | 4.87 (13.18) | 6.04 (9.84) | 3.59 (16.21) | ||
Completed course, n (%) | 23 (43) | 7 (26) | 16 (59) | |||
Percentage of course completion, mean (SD) | 61.66 (39.37) | 50.74 (37.40) | 72.59 (38.88) | |||
Number of log-ins, mean (SD) | 15.72 (12.35) | 13.92 (9.30) | 17.51 (12.39) |
aφ=phi coefficient (ie, mean square contingency coefficient).
bCET: College English Test.
cTOEFL: Test of English as a Foreign Language.
dIELTS: International English Language Testing System.
eDASS-21: Depression Anxiety and Stress Scale.
Hypothesis 1 predicted that participants randomly assigned to MIND+ (vs those assigned to MIND) would show less attrition, as indicated by a greater likelihood of completing the posttreatment assessment (as a dichotomous, between-person variable). A chi-square analysis comparing dichotomous condition assignment (MIND vs MIND+) and posttreatment assessment (completed vs not completed) revealed a greater number of completers in the MIND+ condition (χ21=6.1;
Hypothesis 2 predicted that participants randomly assigned to MIND+ (vs MIND) would show greater program adherence, as indicated by a higher percentage of course completion as a continuous, between-person variable. An independent samples
Hypothesis 3 predicted that participants randomly assigned to MIND+ (vs those assigned to MIND) would show more robust improvements in stress, depression, and mindfulness levels across the trial (as continuous, daily within-person variables). The results of the multilevel models testing this hypothesis are presented in
Covariance parameters for the interactive effect of condition and time (study day) predicting daily self-reported stress.
Parameter | Estimate (SE) | Z valuea | |
Intercept | 0.513 (0.192) | 2.68 | .004 |
Covariance (I,S)b | −0.006 (0.005) | −1.18 | .24 |
Study day | 0.000 (0.000) | 2.20 | .01 |
Residual (VCc) | 0.556 (0.029) | 19.19 | <.001 |
aThe Z value represents the test value of the z distribution on which statistical significance is determined for this analysis.
bCovariance between the random parameters for intercept and slope in the multilevel model.
cVC: variance component (method for structuring the covariance matrix).
Fixed effects for the interactive effect of condition and time (study day) predicting daily self-reported stress.
Effect | Estimate (SE) | ||
Intercept | 2.998 (0.185) | 16.24 (34.1) | <.001 |
Conditiona | −0.279 (0.268) | −1.04 (35.2) | .30 |
Study day | −0.022 (0.006) | −3.90 (39.4) | <.001 |
Condition X study day | 0.009 (0.008) | 1.08 (40.3) | .29 |
aCondition is coded as a dichotomous variable, where 0=MIND only and 1=MIND+.
Covariance parameters for the interactive effect of condition and time (study phase) predicting daily self-reported stress.
Parameter | Estimate (SE) | Z valuea | |
Intercept | 0.460 (0.112) | 4.12 | <.001 |
Study phase (3 vs 1) | 0.340 (0.036) | 9.55 | <.001 |
Residual (VCb) | 0.601 (0.031) | 19.53 | <.001 |
aThe Z value represents the test value of the z distribution on which statistical significance is determined for this analysis.
bVC: variance component (method for structuring the covariance matrix).
Fixed effects for the interactive effect of condition and time (study phase) predicting daily self-reported stress.
Effect | Estimate (SE) | ||
Intercept | 2.580 (0.167) | 15.48 (62.4) | <.001 |
Conditiona | 0.118 (0.230) | 0.51 (62.2) | .61 |
Study phase (2 vs 1) | −0.268 (0.111) | −2.42 (360) | .02 |
Study phase (3 vs 1) | −0.285 (0.112) | −2.54 (272) | .01 |
Condition X phase (2 vs 1) | 0.093 (0.151) | 0.62 (344) | .54 |
Condition X phase (3 vs 1) | −0.234 (0.113) | −2.07 (266) | .04 |
aCondition is coded as a dichotomous variable, where 0=MIND only and 1=MIND+.
Covariance parameters for the interactive effect of condition and time (study day) predicting daily self-reported depression.
Parameter | Estimate (SE) | Z valuea | |
Intercept | 0.566 (0.191) | 2.97 | .002 |
Covariance (I,S)b | −0.007 (0.005) | −1.49 | .14 |
Study day | 0.000 (0.000) | 2.19 | .01 |
Residual (VCc) | 0.505 (0.027) | 18.92 | <.001 |
aThe Z value represents the test value of the z distribution on which statistical significance is determined for this analysis.
bCovariance between the random parameters for intercept and slope in the multilevel model.
cVC: variance component (method for structuring the covariance matrix).
Fixed effects for the interactive effect of condition and time (study day) predicting daily self-reported depression.
Effect | Estimate (SE) | ||
Intercept | 2.439 (0.189) | 12.94 (38.1) | <.001 |
Conditiona | −0.160 (0.273) | −0.59 (39.1) | .56 |
Study day | −0.013 (0.005) | −2.40 (39.2) | .02 |
Condition X study day | 0.008 (0.008) | 1.01 (40.1) | .32 |
aCondition is coded as a dichotomous variable, where 0=MIND only and 1=MIND+.
Covariance parameters for the interactive effect of condition and time (study phase) predicting daily self-reported depression.
Parameter | Estimate (SE) | Z valuea | |
Intercept | 0.422 (0.104) | 4.08 | <.001 |
Study phase (3 vs 1) | 0.359 (0.035) | 10.29 | <.001 |
Residual (VCb) | 0.544 (0.028) | 19.30 | <.001 |
aThe Z value represents the test value of the z distribution on which statistical significance is determined for this analysis.
bVC: variance component (method for structuring the covariance matrix).
Fixed effects for the interactive effect of condition and time (study phase) predicting daily self-reported depression.
Effect | Estimate (SE) | ||
Intercept | 2.164 (0.160) | 13.55 (61.5) | <.001 |
Conditiona | 0.117 (0.221) | 0.53 (61.3) | .60 |
Study phase (2 vs 1) | 0.025 (0.106) | 0.23 (362) | .82 |
Study phase (3 vs 1) | −0.063 (0.108) | −0.58 (271) | .56 |
Condition X phase (2 vs 1) | −0.162 (0.145) | −1.12 (347) | .26 |
Condition X phase (3 vs 1) | −0.280 (0.128) | −2.19 (265) | .03 |
aCondition is coded as a dichotomous variable, where 0=MIND only and 1=MIND+.
Covariance parameters for the interactive effect of condition and time (study day) predicting daily self-reported mindfulness.
Parameter | Estimate (SE) | Z valuea | |
Intercept | 0.395 (0.134) | 2.95 | .002 |
Covariance (I,S)b | −0.006 (0.004) | −1.64 | .10 |
Study day | 0.000 (0.000) | 2.49 | .006 |
Residual (VCc) | 0.526 (0.025) | 21.09 | <.001 |
aThe Z value represents the test value of the z distribution on which statistical significance is determined for this analysis.
bCovariance between the random parameters for intercept and slope in the multilevel model.
cVC: variance component (method for structuring the covariance matrix).
Fixed effects for the interactive effect of condition and time (study day) predicting daily self-reported mindfulness.
Effect | Estimate (SE) | ||
Intercept | 2.561 (0.164) | 15.61 (40.5) | <.001 |
Conditiona | 0.007 (0.237) | 0.03 (42.0) | .98 |
Study day | 0.002 (0.005) | 0.30 (41.2) | .76 |
Condition X study day | 0.007 (0.008) | 0.93 (42.1) | .36 |
aCondition is coded as a dichotomous variable, where 0=MIND only and 1=MIND+.
Covariance parameters for the interactive effect of condition and time (study phase) predicting daily self-reported mindfulness.
Parameter | Estimate (SE) | Z valuea | |
Intercept | 0.300 (0.073) | 4.13 | <.001 |
Study phase (3 vs 1) | 0.211 (0.037) | 5.75 | <.001 |
Residual (VCb) | 0.565 (0.027) | 21.26 | <.001 |
aThe Z value represents the test value of the z distribution on which statistical significance is determined for this analysis.
bVC: variance component (method for structuring the covariance matrix).
Fixed effects for the interactive effect of condition and time (study phase) predicting daily self-reported mindfulness.
Effect | Estimate (SE) | ||
Intercept | 2.732 (0.139) | 19.69 (69.6) | <.001 |
Conditiona | −0.142 (0.191) | −0.74 (69.3) | .46 |
Study phase (2 vs 1) | 0.023 (0.100) | 0.23 (405.0) | .82 |
Study phase (3 vs 1) | 0.123 (0.099) | 1.24 (324.0) | .22 |
Condition X phase (2 vs 1) | −0.084 (0.136) | −0.62 (383.0) | .54 |
Condition X phase (3 vs 1) | −0.053 (0.136) | −0.39 (314.0) | .69 |
aCondition is coded as a dichotomous variable, where 0=MIND only and 1=MIND+.
Daily (A) and phase (B) means for outcome daily self-reported stress.
Daily (A) and phase (B) means for outcome daily self-reported depression.
Daily (A) and phase (B) means for outcome daily self-reported mindfulness.
The aim of this study was to investigate the efficacy of an adjunctive treatment component that uses task-shifting (ie, nonspecialist peer counselors) to enhance engagement in a self-directed, web-based mindfulness intervention for stress and depression among Chinese undergraduate and graduate students.
The results indicated that participants assigned to the MIND+ (vs those assigned to the MIND) condition showed significantly less attrition and more adherence, as indicated by a greater likelihood of completing posttreatment assessments and a higher percentage of course completion, respectively. In addition, individuals in the MIND+ condition reported significant improvements in daily ratings of stress and depression levels across the trial compared with individuals in the MIND condition. These findings suggest that volunteer peer counselors receiving brief training and weekly supervision may significantly improve participants’ indices of treatment engagement and mental health outcomes in an internet-based mindfulness intervention among college and graduate students in China.
This study makes several unique contributions to the literature. First, an internet-based platform was used to deliver a mindfulness intervention in a sample of individuals from a non-Western LMIC. There have been no publications of results from randomized controlled trials investigating the efficacy of a self-guided, web-based, mindfulness intervention in China.
Second, this study uses a task-shifting informed approach aimed at increasing retention and adherence to an existing evidence-based intervention. There have been no publications of results from randomized controlled trials investigating the efficacy of an adjunctive, web-based, peer support intervention component intended to enhance treatment engagement in a self-guided, web-based, mental health intervention in an LMIC. Furthermore, only 3 studies have been published on task shifting in mental health services of any type in China [
Third, this study explored the effects of a very low-intensity, low-cost task-shifting intervention. Nonspecialist peer counselors received only 1 day of in-person training with ongoing web-based, group supervision once per week. Furthermore, each participant in the MIND+ group only received a mean of 4.69 peer counseling
Fourth, this study contributes new insights into the selection, supervision, and evaluation practices for task-shifting initiatives. According to a recent systematic review of 137 studies from 48 countries employing task shifting to deliver evidence-based mental health services in LMICs, fewer than 1 in 5 studies reported providing supervision on a weekly or biweekly basis [
Completion rates in this study (7/27, 26% for MIND and 16/27, 59% for MIND+) appear to be lower than those in previous studies. In comparison, Querstret et al [
One explanation for the lower completion rates in this study is that participants completed the course in their second language. Of the 43 participants who completed the posttreatment assessment, when asked the degree to which language was a barrier in completing the course, 16 (37%) indicated
Another explanation for this difference is that participants in the studies by Krusche et al [
Participants assigned to the MIND+ (vs those assigned to the MIND) condition showed significantly less attrition, as indicated by a greater likelihood of completing the posttreatment assessments in the internet-based course. MIND+ participants also demonstrated a nonsignificant trend toward lower rates of nonuse attrition (
Participants assigned to the MIND+ (vs those assigned to MIND) condition showed greater program adherence, as indicated by a higher percentage of the course completed. However, there were no between-group differences in attrition, as indicated by (1) more frequent log-ins to the course, (2) a less robust decrease in daily self-reports of mindfulness practice, or (3) a less robust decrease in daily self-reports of minutes of mindfulness practiced over the course of the treatment. Overall, these data suggest that the MIND+ task-shifting component increased participants’ likelihood of completing the program but not necessarily their likelihood to be more actively engaged in the program (ie, more frequent log-ins) or to report higher frequency or duration of mindfulness practice.
It is worth noting that participants in this study presented with mean baseline PSS (stress), GAD-7 (anxiety), and PHQ-9 (depression) scores of 23.27 (SD 4.28), 9.90 (SD 3.98), and 11.31 (SD 5.06), respectively. These means are higher than the scores provided in published population norms for the PSS (between 11.9 and 14.7) [
Although participants were randomized to study conditions, the MIND+ group participants reported significantly higher mean baseline PSS scores than those of the MIND group participants. PSS was the only baseline measure with significant between-group differences in this study. However, it is possible that this difference in stress helps in explaining why MIND+ participants completed more modules but did not report more frequent and longer-lasting mindfulness practice than MIND participants. On the other hand, it is possible that MIND+ participants reported more stress because they were assigned to the condition with a peer counselor, and they felt more pressure to complete the course. Existing research suggests that positive, high-quality social support can enhance resilience to stress and reduce depressive symptomology and medical morbidity and mortality [
Enrollment in this study was associated with a significant increase in reported trait mindfulness, as indicated by the FFMQ scores. This was true across both groups, with no significant between-group differences. Further analyses should explore whether changes in mindfulness mediate the effects of interventions on depression, anxiety, and stress. The results of Querstret et al [
This study improves upon previous studies of daily practice in relation to the
The results of this study indicate that participation in the internet-based intervention was associated with significant improvements in pre to posttreatment stress outcomes. The pre-post effect size (Cohen
These findings are significant because stress has been shown to be associated with a wide range of physical and mental health problems [
The pre-post effect sizes (Cohen
In addition, individuals in the MIND+ condition reported significant improvements in daily ratings of stress and depression across the trial compared with individuals in the MIND condition. These findings suggest that volunteer peer counselors receiving brief training and weekly supervision may significantly improve participants’ indices of treatment engagement and mental health outcomes in an internet-based mindfulness intervention among college and graduate students in China. It is worth noting that these differences between groups were not linear across the course of the study. The benefits of assignment to the MIND+ group appear late during the treatment, that is, between phases 2 and 3. In the middle of the study, MIND+ participants did not report less anxiety or depression, and they did not report practicing more than the MIND-only participants. Therefore, one explanation for the benefit of the program was weekly contact with peer counselors. Another explanation is that they received more content during the intervention. The effect size of the internet-based course on stress, depression, and anxiety scores suggests that this treatment is effective for Chinese students, regardless of whether they have contact with peers or a therapist.
MIND+ participants did not report significant improvements in daily ratings of state mindfulness across the trial compared with participants in the MIND-only condition. Instead, there was a main effect of treatment on improvements on daily mindfulness ratings. Similarly, there were no between-group differences in pre-post FFMQ scores, although there was a moderate main effect of mindfulness (FFMQ) among completers (Cohen
This study has several limitations. First, the sample was small, achieving 80% power to detect only moderately-sized group differences (ie, Cohen
This study provides preliminary support for the effectiveness of a 4-week, internet-based mindfulness course for the reduction of self-reported symptoms of stress, depression, and anxiety among English-speaking university students in China. The effects were compared with those reported in other mindfulness courses delivered on the web and in-person. Furthermore, these results highlight the potential of leveraging task shifting to enhance treatment engagement in self-guided evidence-based treatments. The combination of these approaches may represent a financially feasible, easily transportable, and quickly scalable way to provide mental health services in low-resource settings.
CONSORT-EHEALTH checklist (V 1.6.1).
College English Test
Five-Factor Mindfulness Questionnaire
7-item Generalized Anxiety Disorder
low- and middle-income country
Patient Health Questionnaire-9
Perceived Stress Scale
MZR is a Scientific Advisor for the Misophonia Research Fund, The Real Odin, and BehaVR.