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

Abstract

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.

Interventions in Chinese Undergraduate Students’ Mental Health: Systematic Review

“…The interventions proposed in the included studies can be divided into two broad categories: social support and coping strategies. Social support was provided by government authorities [ 49 , 52 - 54 , 61 , 62 , 68 , 72 , 84 , 86 - 88 ]; university authorities [ 12 , 48 , 50 , 51 , 53 - 55 , 57 - 59 , 62 , 64 , 65 , 67 , 69 , 91 , 93 ]; students’ affairs counselors and teachers [ 54 , 75 , 83 - 85 , 87 , 93 ]; family members [ 52 , 54 , 57 , 83 , 94 ]; health care authorities and professionals [ 52 , 63 , 66 , 75 , 77 - 79 , 87 ]; researchers [ 70 , 85 ]; and media-, internet-, and smartphone-based interventions [ 26 , 53 , 55 , 56 , 60 , 71 , 73 , 75 , 77 , 80 , 81 ]. Positive coping strategies were adopted by undergraduate students themselves [ 52 , 82 , 83 , 85 , 86 ,…”

“…Evidence-based digital mental health interventions were found to be useful in improving mental health concerns [ 56 , 60 ], because depressed undergraduate students became less hostile when logging onto the internet, suggesting the internet as a useful medium to provide treatment for people with depression [ 71 ]. In the context of face-to-face intervention delivery hindered by the COVID-19 pandemic, internet-delivered interventions such as internet-delivered cognitive behavioral therapy can be considered to address effects of social networking service addiction on the mental health status of Chinese university students [ 55 ].…”

“…Eleven of the 49 included studies described evidence-based internet-delivered digital mental health interventions such as internet-based cognitive behavioral and mindfulness training programs, online brief interventions, online sacramental ceremonies, internet-delivered cognitive behavioral therapy, and others [ 26 , 53 , 55 , 56 , 60 , 71 , 73 , 75 , 77 , 80 , 81 ]. These reported internet- or technology-based interventions can easily be incorporated into existing mental health service provision portfolios.…”

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

“…Step-by-Step was developed by the World Health Organization, the Ministry of Health in Lebanon, the University of Zurich, and Freie Universität Berlin ( Burchert et al, 2019 ; Carswell et al, 2018 ). The Chinese version of Step-by-Step was culturally adapted and pilot tested in Macao with support from the WHO ( Sit et al, 2020 , Sit et al, 2022 ). The intervention is brief (5-sessions), delivered via mobile app, designed to address depression, but is also expected to be transdiagnostic (i.e., also addresses anxiety, PTSD, other stress reactions and client-defined psychosocial problems), and covers general wellbeing.…”

“…The core therapeutic component of Step-by-Step is behavioral activation ( Carswell et al, 2018 ; Dawson et al, 2015 ). It has undergone technical adaptation for Syrian refugees in Germany, Sweden, and Egypt ( Burchert et al, 2019 ), culturally adapted for Overseas Filipino workers (OFWs) ( Garabiles et al, 2019 ), Syrian refugees, Lebanese, and Palestinians in Lebanon ( Abi Ramia et al, 2018 ), and Chinese young adults ( Sit et al, 2020 ) and showed promising preliminary results in these populations ( Harper Shehadeh et al, 2019 ; Heim et al, 2021 ; Sit et al, 2022 ).…”