Exploring the Perceptions of mHealth Interventions for the Prevention of Common Mental Disorders in University Students in Singapore: Qualitative Study

Measuring Mental Health in 2 Brazilian University Centers: Protocol for a Cohort Survey

BACKGROUND

Global concern for the mental well-being of university students is on the rise. Recent studies estimate that around 30% of students experience mental health disorders, and nearly 80% of these individuals do not receive adequate treatment. Brazil, home to around eight million university students, lacks sufficient research addressing their mental health. To address this gap, we aim to conduct a longitudinal mental health survey at 2 Brazilian universities.

OBJECTIVE

This paper outlines the research protocol for a web-based mental health survey designed to assess the well-being of Brazilian university students.

METHODS

The survey targets undergraduate students (N=8028) from 2 institutions: UniFAJ (Centro Universitário de Jaguariúna) and UniMAX (Centro Universitário Max Planck). Students will be invited to respond to self-reported questionnaires, including theSMILE-U (lifestyle and quality of life), the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]) self-rated level 1 cross-cutting symptom measure, and a brief version of the Adult Self-Report Scale for attention-deficit/hyperactivity disorder. Students who exceed thresholds for conditions such as depression, anxiety, and attention-deficit/hyperactivity disorder will receive additional diagnostic instruments. The survey will be conducted annually, tracking individual and group trajectories and enrolling new cohorts each year. Data will be analyzed using cross-sectional and longitudinal methods, focusing on descriptive, associative, and trajectory analyses.

RESULTS

The first wave of data collection began in February 2024 and is expected to conclude in December 2024. As of October 2024, a total of 2034 of 7455 (27.2 in 100) eligible students had completed the questionnaire. Cross-sectional statistical analysis is planned to commence immediately after data collection and is expected to be completed by June 2025.

CONCLUSIONS

This survey uses a scalable, cost-effective design to evaluate mental health conditions among Brazilian university students. The longitudinal framework facilitates the monitoring of mental health trends, supports the development of targeted interventions, and informs policy initiatives in higher education.

TRIAL REGISTRATION

OSF Registries OSF.IO/AM5WS; https://doi.org/10.17605/OSF.IO/AM5WS.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/63636.

The LvL UP trial: Protocol for a sequential, multiple assignment, randomised controlled trial to assess the effectiveness of a blended mobile lifestyle intervention

BACKGROUND

Blended mobile health (mHealth) interventions - combining self-guided and human support components - could play a major role in preventing non-communicable diseases (NCDs) and common mental disorders (CMDs). This protocol describes a sequential, multiple assignment, randomised trial aimed at (i) evaluating the effectiveness and cost-effectiveness of LvL UP, an mHealth lifestyle intervention for the prevention of NCDs and CMDs, and (ii) establishing the optimal blended approach in LvL UP that balances effective personalised lifestyle support with scalability.

METHODS

LvL UP is a 6-month mHealth holistic intervention targeting physical activity, diet, and emotional regulation. In this trial, young and middle-aged Singaporean adults at risk of developing NCDs or CMDs will be randomly allocated to one of two initial conditions ('LvL UP' or 'comparison'). After 4 weeks, participants categorised as non-responders from the LvL UP group will be re-randomised into second-stage conditions: (i) continuing with the initial intervention (LvL UP) or (ii) additional motivational interviewing (MI) support sessions by trained health coaches (LvL UP + adaptive MI). The primary outcome is mental well-being. Secondary outcomes include anthropometric measurements, resting blood pressure, blood metabolic profile, health status, and health behaviours (physical activity, diet). Outcomes will be measured at baseline, 6 months (post-intervention), and 12 months (follow-up).

DISCUSSION

In addition to evaluating the effectiveness of LvL UP, the proposed study design will contribute to increasing evidence on how to introduce human support in mHealth interventions to maximise their effectiveness while remaining scalable.

TRIAL REGISTRATION

The LvL UP Pilot trial was prospectively registered with ClinicalTrials.gov (NCT06360029).

Understanding and overcoming barriers to digital health adoption: a patient and public involvement study

BACKGROUND

Digital health (DH) technologies provide scalable and cost-effective solutions to improve population health but face challenges of uneven adoption and high attrition, particularly among vulnerable and minority groups.

PURPOSE

This study explores factors influencing DH adoption in a multicultural population and identifies strategies to improve equitable access.

METHODS

Using a Patient and Public Involvement approach, lay facilitators engaged adults at public eateries in Singapore to discuss motivations and barriers to DH adoption. A semi-structured guide facilitated discussions, followed by an optional socio-demographic survey. Data were analyzed through inductive thematic analysis and mapped to behavior change theory to identify mechanisms of action (MoA) and behavior change techniques (BCTs) to support adoption.

RESULTS

Facilitators engaged 118 participants between November 2022 and February 2023. Five key themes were identified from the discussions: (a) awareness of DH solutions, (b) weighing benefits against burdens, (c) accessibility, (d) trust in DH developers and technology, and (e) the impact of user experience. These themes were mapped to 13 MoA and 26 BCTs, informing five key strategies to enhance DH adoption: community-based promotion of credible DH solutions and digital literacy training, brief counselling at opportune moments in healthcare settings, variable rewards tied to personal values, policies ensuring accessibility and regulation, and gamified, user-friendly designs emphasizing feedback and behavioral cues.

CONCLUSION

Designing and implementing DH solutions that are accessible, trustworthy, and motivating-integrated within healthcare services and promoted through community efforts-can address barriers to adoption by diverse communities and may help to narrow the digital divide.

Delving into the world of webCHAT - an e-mental health support service for distressed youths in Singapore

Background

Young people face high rates of mental health issues, yet many do not seek professional help. In 2017, CHAT launched webCHAT - a free, anonymous, one-on-one synchronous web-based text service managed by case managers (CMs) to support young people aged 16 to 30 who may be hesitant about engaging in face-to-face mental health services.

Objective

This study aimed to explore the perspectives and experiences of users who accessed webCHAT for mental health support in Singapore.

Methods

A qualitative thematic analysis was conducted using transcripts of webCHAT sessions to identify main themes.

Results

Many users accessed webCHAT to seek support with emotional and behavioural concerns, valuing its immediacy and anonymity over traditional appointment-based services. A desire to 'get better' and self-realisation emerged as important motivators for seeking help, with webCHAT offering a supportive space for reflection. Key barriers to seeking additional support included fear of stigma, concerns about leaving a 'medical record', potential hospitalisation, and treatment costs.

Conclusions

webCHAT appears to be a viable early intervention and preventive approach, providing young people with a pathway towards in-person support services. Professional guidance from CMs is essential in encouraging users to pursue further support, emphasising the importance of human expertise in digital mental health platforms. By fostering early help-seeking and self-realisation, webCHAT has the potential to reduce the long-term impact of mental health challenges. Future research could explore webCHAT's long-term effects and identify improvements to facilitate users' transitions to in-person support.

Efficacy of the mHealth App Intellect in Improving Subclinical Obsessive-Compulsive Disorder in University Students: Randomized Controlled Trial With a 4-Week Follow-Up

BACKGROUND

Obsessive-compulsive disorder (OCD) is the third most prevalent mental health disorder in Singapore, with a high degree of burden and large treatment gaps. Self-guided programs on mobile apps are accessible and affordable interventions, with the potential to address subclinical OCD before symptoms escalate.

OBJECTIVE

This randomized controlled trial aimed to examine the efficacy of a self-guided OCD program on the mobile health (mHealth) app Intellect in improving subclinical OCD and maladaptive perfectionism (MP) as a potential moderator of this predicted relationship.

METHODS

University students (N=225) were randomly assigned to an 8-day, self-guided app program on OCD (intervention group) or cooperation (active control). Self-reported measures were obtained at baseline, after the program, and at a 4-week follow-up. The primary outcome measure was OCD symptom severity (Obsessive Compulsive Inventory-Revised [OCI-R]). Baseline MP was assessed as a potential moderator. Depression, anxiety, and stress (Depression Anxiety and Stress Scales-21) were controlled for during statistical analyses.

RESULTS

The final sample included 192 participants. The intervention group reported significantly lower OCI-R scores compared with the active control group after the intervention (partial eta-squared [ηp2]=0.031; P=.02) and at 4-week follow-up (ηp2=0.021; P=.044). A significant, weak positive correlation was found between MP and OCI-R levels at baseline (r=0.28; P<.001). MP was not found to moderate the relationship between condition and OCI-R scores at postintervention (P=.70) and at 4-week follow-up (P=.88).

CONCLUSIONS

This study provides evidence that the self-guided OCD program on the Intellect app is effective in reducing subclinical OCD among university students in Singapore. Future studies should include longer follow-up durations and study MP as a moderator in a broader spectrum of OCD symptom severity.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06202677; https://clinicaltrials.gov/study/NCT06202677.

Understanding university students' attitudes and preferences for internet-based mental health interventions

Internet-based interventions are recognised as a practical approach to address mental health issues. The acceptance and utilisation of such interventions are closely linked to user attitudes and preferences. This study aims to examine the predictors of university students' attitudes towards internet-based interventions. Additionally, it seeks to elucidate students' preferences regarding crucial features of these interventions, such as the format, delivery mode, content type, and structural components, to understand better what makes these interventions appealing and practical for university students. A total of 273 university students (comprising 68 % females and 32 % males) participated in the study. The data collection instruments employed were the Personal Information Form, Internet-Based Intervention Preference Survey, E-therapy Attitude Measure (ETAM), Digital Literacy Scale, Patient Health Questionnaire-9, and the Generalized Anxiety Disorder-7 (GAD-7). The data were analysed utilising descriptive statistics, Pearson correlation analysis, and multiple linear regression analysis. The multiple regression analysis revealed digital literacy as a predictive factor for attitudes towards internet-based interventions. Demographic variables, such as age and gender, and psychological variables, such as depression and anxiety levels, were found not to be associated with attitudes towards these interventions. While students are actively seeking mental health information online, a significant majority remain unaware of internet-based interventions. They show a preference for interventions offering greater human interaction, including face-to-face guidance and video content featuring people. Participants favour completing one or two sessions of the intervention weekly. Desired features of internet-based interventions include self-assessment scales, relatable characters, voice relaxation exercises, practical daily life activity tasks, and weekly reminders throughout the process. In conclusion, initiatives aimed at enhancing digital literacy levels could foster more positive attitudes towards internet-based interventions among students. Developers creating Internet-Based Interventions (IBI) for university students should consider these preferences.

Attrition in Conversational Agent-Delivered Mental Health Interventions: Systematic Review and Meta-Analysis

BACKGROUND

Conversational agents (CAs) or chatbots are computer programs that mimic human conversation. They have the potential to improve access to mental health interventions through automated, scalable, and personalized delivery of psychotherapeutic content. However, digital health interventions, including those delivered by CAs, often have high attrition rates. Identifying the factors associated with attrition is critical to improving future clinical trials.

OBJECTIVE

This review aims to estimate the overall and differential rates of attrition in CA-delivered mental health interventions (CA interventions), evaluate the impact of study design and intervention-related aspects on attrition, and describe study design features aimed at reducing or mitigating study attrition.

METHODS

We searched PubMed, Embase (Ovid), PsycINFO (Ovid), Cochrane Central Register of Controlled Trials, and Web of Science, and conducted a gray literature search on Google Scholar in June 2022. We included randomized controlled trials that compared CA interventions against control groups and excluded studies that lasted for 1 session only and used Wizard of Oz interventions. We also assessed the risk of bias in the included studies using the Cochrane Risk of Bias Tool 2.0. Random-effects proportional meta-analysis was applied to calculate the pooled dropout rates in the intervention groups. Random-effects meta-analysis was used to compare the attrition rate in the intervention groups with that in the control groups. We used a narrative review to summarize the findings.

RESULTS

The systematic search retrieved 4566 records from peer-reviewed databases and citation searches, of which 41 (0.90%) randomized controlled trials met the inclusion criteria. The meta-analytic overall attrition rate in the intervention group was 21.84% (95% CI 16.74%-27.36%; I2=94%). Short-term studies that lasted ≤8 weeks showed a lower attrition rate (18.05%, 95% CI 9.91%- 27.76%; I2=94.6%) than long-term studies that lasted >8 weeks (26.59%, 95% CI 20.09%-33.63%; I2=93.89%). Intervention group participants were more likely to attrit than control group participants for short-term (log odds ratio 1.22, 95% CI 0.99-1.50; I2=21.89%) and long-term studies (log odds ratio 1.33, 95% CI 1.08-1.65; I2=49.43%). Intervention-related characteristics associated with higher attrition include stand-alone CA interventions without human support, not having a symptom tracker feature, no visual representation of the CA, and comparing CA interventions with waitlist controls. No participant-level factor reliably predicted attrition.

CONCLUSIONS

Our results indicated that approximately one-fifth of the participants will drop out from CA interventions in short-term studies. High heterogeneities made it difficult to generalize the findings. Our results suggested that future CA interventions should adopt a blended design with human support, use symptom tracking, compare CA intervention groups against active controls rather than waitlist controls, and include a visual representation of the CA to reduce the attrition rate.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022341415; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022341415.

Exploring student preferences for implementing a digital mental health intervention in a university setting: Qualitative study within a randomised controlled trial

Objective

Digital interventions can be effective in preventing and treating common mental health conditions among university students. Incorporating student experiences and perspectives in the design and implementation of these programmes may improve uptake and engagement. This qualitative study explored university students' perspectives of a low-intensity video-based mental health intervention, their recommendations for implementing the programme in university settings, and their views and recommendations to address barriers to engagement.

Methods

Participants (N = 115) were students (mean = 20.63 years, SD = 2.10) with elevated distress from 31 Australian universities drawn from a randomised controlled trial of the Uni Virtual Clinic-Lite (UVC-Lite). Data from students randomised to the intervention condition were collected via semi-structured interviews (n = 12) and open-ended questions during post-intervention surveys (n = 103). Data were analysed using content analysis.

Results

Participants generally reported positive views of the intervention, and most felt it should be offered to students as a universal intervention. Multiple methods of disseminating the intervention were suggested, including through university counselling, official platforms (e.g. student support services) and informal channels (e.g. word-of-mouth promotion). Difficulty integrating the programme into everyday life, pre-existing beliefs about mental health and technology-related factors were highlighted as barriers to engagement.

Conclusion

A low-intensity video-based mental health intervention was generally considered to be acceptable and appropriate for students with mild to moderate distress. Participants provided several suggestions to encourage uptake of the intervention and possible pathways to disseminate the intervention to students. The effectiveness of these should be examined in future trials.

Development of "LvL UP 1.0": a smartphone-based, conversational agent-delivered holistic lifestyle intervention for the prevention of non-communicable diseases and common mental disorders

Background

Non-communicable diseases (NCDs) and common mental disorders (CMDs) are the leading causes of death and disability worldwide. Lifestyle interventions via mobile apps and conversational agents present themselves as low-cost, scalable solutions to prevent these conditions. This paper describes the rationale for, and development of, "LvL UP 1.0″, a smartphone-based lifestyle intervention aimed at preventing NCDs and CMDs.

Materials and Methods

A multidisciplinary team led the intervention design process of LvL UP 1.0, involving four phases: (i) preliminary research (stakeholder consultations, systematic market reviews), (ii) selecting intervention components and developing the conceptual model, (iii) whiteboarding and prototype design, and (iv) testing and refinement. The Multiphase Optimization Strategy and the UK Medical Research Council framework for developing and evaluating complex interventions were used to guide the intervention development.

Results

Preliminary research highlighted the importance of targeting holistic wellbeing (i.e., both physical and mental health). Accordingly, the first version of LvL UP features a scalable, smartphone-based, and conversational agent-delivered holistic lifestyle intervention built around three pillars: Move More (physical activity), Eat Well (nutrition and healthy eating), and Stress Less (emotional regulation and wellbeing). Intervention components include health literacy and psychoeducational coaching sessions, daily "Life Hacks" (healthy activity suggestions), breathing exercises, and journaling. In addition to the intervention components, formative research also stressed the need to introduce engagement-specific components to maximise uptake and long-term use. LvL UP includes a motivational interviewing and storytelling approach to deliver the coaching sessions, as well as progress feedback and gamification. Offline materials are also offered to allow users access to essential intervention content without needing a mobile device.

Conclusions

The development process of LvL UP 1.0 led to an evidence-based and user-informed smartphone-based intervention aimed at preventing NCDs and CMDs. LvL UP is designed to be a scalable, engaging, prevention-oriented, holistic intervention for adults at risk of NCDs and CMDs. A feasibility study, and subsequent optimisation and randomised-controlled trials are planned to further refine the intervention and establish effectiveness. The development process described here may prove helpful to other intervention developers.