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College students and working adults are particularly vulnerable to stress and other mental health problems, and mental health promotion and prevention are needed to promote their mental health. In recent decades, mindfulness-based training has demonstrated to be efficacious in treating physical and psychological conditions.
The aim of our study was to examine the efficacy of an Internet-based mindfulness training program (iMIND) in comparison with the well-established Internet-based cognitive-behavioral training program (iCBT) in promoting mental health among college students and young working adults.
This study was a 2-arm, unblinded, randomized controlled trial comparing iMIND with iCBT. Participants were recruited online and offline via mass emails, advertisements in newspapers and magazines, announcement and leaflets in primary care clinics, and social networking sites. Eligible participants were randomized into either the iMIND (n=604) or the iCBT (n=651) condition. Participants received 8 Web-based sessions with information and exercises related to mindfulness or cognitive-behavioral principles. Telephone or email support was provided by trained first tier supporters who were supervised by the study’s research team. Primary outcomes included mental and physical health-related measures, which were self-assessed online at preprogram, postprogram, and 3-month follow-up.
Among the 1255 study participants, 213 and 127 completed the post- and 3-month follow-up assessment, respectively. Missing data were treated using restricted maximum likelihood estimation. Both iMIND (n=604) and iCBT (n=651) were efficacious in improving mental health, psychological distress, life satisfaction, sleep disturbance, and energy level.
Both Internet-based mental health programs showed potential in improving the mental health from pre- to postassessment, and such improvement was sustained at the 3-month follow-up. The high attrition rate in this study suggests the need for refinement in future technology-based psychological programs. Mental health professionals need to team up with experts in information technology to increase personalization of Web-based interventions to enhance adherence.
Chinese Clinical Trial Registry (ChiCTR): ChiCTR-TRC-12002623; https://www2.ccrb.cuhk.edu.hk/ registry/public/191 (Archived by WebCite at http://www.webcitation.org/6kxt8DjM4).
According to the World Health Organization (WHO) [
In addition to working adults, emerging adults such as college students also experience high levels of stress. They are in the midst of identity exploration [
Besides mental health, according to the WHO, physical health is also one of the components that is intimately related to mental health [
Although effective treatments are available, it is noted that two-thirds of people who suffered from mental disorder did not seek help due to the stigma in seeking mental health services [
Increasing evidence has shown the efficacy of Internet-based interventions in the treatment of anxiety and depression, as well as the promotion of mental health in the general public. Meta-analysis found the efficacy of Internet-based cognitive behavioral intervention in the treatment of anxiety and depression [
Although the face-to-face mindfulness-based interventions are efficacious, few have tested the efficacy when delivered through the Web. Two previous feasibility and pilot studies showed preliminary evidence of Internet-based mindfulness programs in improving stress in nonclinical population [
Although much work has been done on mindfulness training and Internet-based cognitive behavioral training, few have tested these Internet-based interventions in Asia. Also, the efficacy of Internet-based mindfulness training in promoting mental health is at its early stage. With the risks and prevalence of depression and anxiety observed among the college students and working adults, this study aimed to test the efficacy of an Internet-based mindfulness training for the prevention and promotion of their physical and mental health, compared with the well-established Internet-based cognitive behavioral training in a randomized controlled trial. We hypothesized that both training could enhance the physical and mental health at postprogram and 3-month follow-up.
This study was a 2-arm, randomized, open-label, parallel positive-control trial involving two Internet-based interventions: a mindfulness training program named iMIND versus a cognitive-behavioral training program named iCBT. Clinical ethics approval was obtained from the principal investigator’s institution (Joint Chinese University of Hong Kong–New Territories East Cluster Clinical Research Ethics Committee) as well as from the Hospital Authority Kowloon Central or East Cluster and the Department of Health of Hong Kong.
The study targeted college students and young working adults and recruitment was done through (1) sending mass emails to students, teachers, and staff at different universities in Hong Kong; (2) distributing announcements to the staff of the Hospital Authority; (3) placing leaflets and posters in civil servant primary care clinics under Hong Kong Department of Health; and (4) posting advertisements in local libraries, newspapers, magazines, and social networking site Facebook.
Individuals who were interested in participating in the study visited our website where they were screened by completing Web-based questionnaires on mental health and demographics. Inclusion criteria included (1) age 18 years or above, (2) ability to read and understand Chinese, (3) computer literacy, and (4) consistent access to the Internet. Exclusion criteria included (1) an indication of suicidality by a score of 1-4 (out of 6) in item 16, 21, or 28 of the Mental Health Inventory (MHI) [
Eligible individuals were given detailed information about the study aims, length of the program, participant involvement, and the assignment of intervention through randomization. They were also informed that the study was conducted by the Department of Psychology at the Chinese University of Hong Kong. Participants provided informed consent by clicking the “I agree” button at the bottom of the study description page. From there, participants received an activation link via email and were then randomly assigned to 1 of the 2 conditions by computer-generated numbers. The pre-, post-, and follow-up assessments were completed by the eligible participants on the Web, instead of through supporters, so that the assessment could be free from assessors’ biases from knowing the participants’ assigned conditions. Individuals who did not meet the eligibility criteria received an on-screen message and email with a thank you note and a list of resources on mental health services in the community.
iMIND and iCBT were administered via the Internet on 2 separate Web pages that were in the Chinese language. Functional tests were conducted before the release of the website. Each program consisted of 8 30- to 45-minute sessions. Both programs lasted for 8 weeks. The delivery format of iMIND involved didactic readings (eg, nature of human suffering according to the Buddhist perspective), experiential learning (eg, guided meditation), and daily life applications (eg, developing awareness on how letting go of one’s attachment could lead to inner peace). To enhance the user experiences, we made improvement on iMIND based on its predecessor [
The content of iCBT was organized based on MacDonald and O’Hara’s 10 elements of mental health [
Overview of session content.
Session | Content (iMINDa) | Content (iCBTb) |
1 | Introduction on mindfulness | Introduction on mental health |
2 | Observing thoughts, feelings, and sensations as they are | Stress, body reactions, and emotion regulations |
3 | Mindful attitudes and nature of suffering | Cognitive distortions and strategies to cope with stress |
4 | Being in the present moment | Emotion regulation |
5 | Letting go in times of difficulties | Resilience in times of adversities |
6 | Ways to stay mindful | Ways to increase self-esteem |
7 | Mindful communications | Effective communication skills |
8 | Review and applications | Review and applications |
aiMIND: Internet-based mindfulness training program.
biCBT: Internet-based cognitive-behavioral training program.
Previous research has shown that (1) guided self-help has higher completion rates than unguided self-help [
At baseline, participants provided demographic and background information including age, gender, education level, income, marital status, religion, and previous experience with systematic mindfulness training (ie, mindfulness-based stress reduction therapy, MBSR, or mindfulness-based cognitive therapy, MBCT), regular meditation practices, cognitive-behavioral training, and yoga. To assess the route of participation, participants also indicated how they learned about this study.
The WHO 5-item WBI [
The 18-item MHI was used to assess psychological distress [
Life satisfaction was assessed by the 5-item Satisfaction with Life Scale (SWLS) [
Average level of energy was measured by the visual analogue scale (VAS) [
The 4-item sleep disturbance subscale of the Medical Outcomes Study (MOS) Sleep Scale [
Average level of pain was measured by VAS [
Usage is defined as the time (in minutes) spent in the previous week on browsing the website and practicing the assigned homework. Participants reported these figures at the beginning of every session. At the end of the 8-week program, attitude toward and satisfaction with the Internet-based interventions were assessed using the Chinese version of the 8-item Client Satisfaction Questionnaire (CSQ) [
At baseline, participants completed the 6-item Credibility or Expectancy Questionnaire (CEQ) that aimed to examine if expectancies or perception of treatment credibility were related to outcomes. Five items were rated on a 9-point Likert scale from 1 (not at all) to 9 (very much) and 1 item was rated on an 11-point Likert scale ranging from 0 (0%) to 11 (100%). The CEQ comprises 2 factors: cognitively based credibility and affectively based expectancy. It was shown to have a total item correlation of .78 [
All analyses were conducted using SPSS version 20.0 (IBM Corp) . Linear mixed models were conducted to test if both conditions showed improvements in all outcomes over time. Compound symmetry covariance was used and missing data were treated using restricted maximum likelihood estimation. Model for each outcome variable consisted of the time effect, condition effect, and the interaction effect of time by condition. When the main effect of time was significant, follow-up analyses were conducted to compare the outcomes in postprogram and follow-up program with the preprogram, and results were adjusted with Bonferroni correction.
Participants were recruited between July 2013 and March 2015. A total of 4215 registrants were screened for eligibility. Among those who registered, 932 (22.11%, 932/4215) registrants were deemed ineligible, 1202 (28.52%, 1202/4215) eligible registrants did not activate their accounts, whereas 2081 (49.37%, 2081/4215) eligible registrants proceeded with account activation followed by randomization. Our sample consisted of those who, after randomization, completed the presurvey and received course materials (N=1255). About one-fifth of the participants (n=253) completed the entire 8-session program, 16.97% (213/1255) completed the postprogram survey, and 10.12% (127/1255) completed the 3-month follow-up (see
Participants learned about the study from a variety of avenues: work institutions or universities (36.65%, 460/1255), Facebook (28.21%, 354/1255), family or relatives or friends (21.27%, 267/1255), other means such as posters and leaflets (10.92%, 137/1255), and primary care clinics (2.95%, 37/1255).
To investigate the potential causes of attrition, we compared the baseline attributes between the attrition group (did not complete postprogram assessment; n=1042) and the retention group (n=213). No significant differences in their demographic characteristics were found, except for yoga experience. A slightly higher percentage of participants reported having had yoga experience in the retention group (28.6%) than in the attrition group (21.8%), χ21 =4.5,
Baseline characteristics across conditions.
Characteristics | iCBTa (n=651) | iMINDb (n=604) | |
Age in years, mean (SD) | 32.52 (12.41) | 32.73 (12.68) | |
Male | 173 (26.6) | 149 (24.7) | |
Female | 478 (73.4) | 455 (75.3) | |
Primary or below | 2 (0.3) | 1 (0.2) | |
Secondary | 125 (19.2) | 118 (19.5) | |
Bachelor or diploma | 346 (53.1) | 313 (51.8) | |
Master or above | 178 (27.3) | 172 (28.5) | |
Student | 226 (34.7) | 208 (34.4) | |
Full-time | 331 (50.8) | 310 (51.3) | |
Part-time or freelance | 29 (4.5) | 28 (4.7) | |
Others | 65 (10) | 58 (9.6) | |
No religion | 392 (60.2) | 382 (63.1) | |
Christianity | 178 (27.3) | 153(25.3) | |
Catholicism | 28 (4.3) | 26 (4.3) | |
Buddhism | 41 (6.3) | 34 (5.6) | |
Others | 12(1.9) | 10 (1.7) | |
Yes | 36 (5.5) | 40 (6.6) | |
No | 615 (94.5) | 564 (93.4) | |
Yes | 60 (9.2) | 57 (9.4) | |
No | 591 (90.8) | 547 (90.6) | |
Yes | 149 (22.9) | 139 (23.0) | |
No | 502 (77.1) | 465 (77.0) | |
Yes | 16 (2.5) | 18 (3.0) | |
No | 635 (97.5) | 586 (97.0) |
aiCBT: Internet-based cognitive behavioral training program.
biMIND: Internet-based mindfulness training program.
Baseline characteristics across conditions.
Measures | iCBTa (n=651), Mean (SD) |
iMINDb (n=604), Mean (SD) |
||
Well-being index | 2.02 (1.05) | 2.14 (1.06) | ||
Mental health inventory | 3.90 (0.83) | 3.93 (0.83) | ||
Life satisfaction scale | 3.90 (1.36) | 3.94 (1.43) | ||
Sleep disturbance | 26.92 (20.24) | 26.03 (20.69) | ||
Pain | 26.14 (25.75) | 26.31 (25.62) | ||
Energy | 52.01 (26.41) | 55.67 (25.64) | ||
Credibility | −0.02 (.86) | 0.03 (0.86) | ||
Expectancy | 0.01 (0.86) | −0.01 (0.88) | ||
aiCBT: Internet-based cognitive behavioral training program.
biMIND: Internet-based mindfulness training program.
Flow diagram of this study.
Results from the linear mixed model indicated a significant time effect (
The results indicated that there was a significant time effect (
The results indicated a significant time effect (
Results showed that energy improved over time (
Improvement was shown over time (
Results showed that pain significantly improved over time (
Means and standard errors across conditions.
Measuresa | iCBTb (n=651) | iMINDc (n=604) | |||||
Mean (SEd) | Mean (SE) | ||||||
Pre | Post | Follow-up | Pre | Post | Follow-up | ||
WBIe | 2.02 (0.04) | 2.90 (0.10) | 2.84 (0.12) | 2.14 (0.04) | 2.92 (0.10) | 2.78 (0.12) | |
MHIf | 3.90 (0.03) | 4.43 (0.07) | 4.25 (0.09) | 3.93 (0.03) | 4.31 (0.08) | 4.08 (0.09) | |
SWLSg | 3.90 (0.05) | 4.69 (0.11) | 4.71 (0.14) | 3.94 (0.06) | 4.69 (0.11) | 4.82 (0.14) | |
Energy | 52.01 (0.99) | 66.00 (2.26) | 66.52 (2.87) | 55.67 (1.03) | 66.89 (2.29) | 68.00 (2.89) | |
Sleep disturbance | 26.92 (0.77) | 19.13 (1.51) | 18.03 (1.85) | 26.03 (0.81) | 17.58 (1.53) | 19.99 (1.88) | |
Pain | 26.14 (0.99) | 21.04 (2.15) | 23.12 (2.71) | 26.31 (1.03) | 23.50 (2.19) | 21.43 (2.73) |
aSignificant time effects were shown for all measures (
biCBT: Internet-based cognitive behavioral training program.
ciMIND: Internet-based mindfulness training program.
dSE: standard error.
eWBI: well-being index.
fMHI:Mental Health Inventory.
gSWLS: Satisfaction with Life Scale.
Overall time effects and effect sizes across conditions.
Measures | Scales | iCBTa |
iMINDb |
Overall time effect | |||||
Cohen's dc | Cohen's d | Post versus pre mean |
Follow-up versus pre mean |
||||||
Post versus pre | Follow-up versus pre | Post versus pre | Follow-up versus pre | ||||||
WBId | 0.86 | 0.81 | 0.79 | 0.65 | −0.83 (−0.996 to −0.66) | <.001 | −0.73 (−0.94 to 0.51) | <.001 | |
MHIe | 0.70 | 0.46 | 0.51 | 0.20 | −0.46 (−0.59 to −0.33) | <.001 | −0.25 (−0.41 to −0.09) | .001 | |
SWLSf | 0.55 | 0.64 | 0.52 | 0.61 | −0.77 (−0.96 to −0.59) | <.001 | −0.85 (−1.08 to −0.62) | <.001 | |
Energy | 0.56 | 0.58 | 0.45 | 0.49 | −12.60 (16.54-8.67) | <.001 | −13.42 (−18.37 to −8.47) | <.001 | |
Sleep |
0.41 | 0.46 | 0.44 | 0.31 | 8.12 (5.66-10.58) | <.001 | 7.46 (4.39-10.53) | <.001 | |
Pain | 0.21 | 0.12 | 0.11 | 0.20 | 3.95 (0.27-7.63) | .03 | 3.95 (−0.67 to 8.57) | .12 |
aiCBT: Internet-based cognitive behavioral training program.
biMIND: Internet-based mindfulness training program.
cCohen's d was computed from postprogram or 3-month follow-up score minus preprogram score divided by the pooled standard deviation.dWBI: Well-Being Index.eMHI: Mental Health Inventory.fSWLS: Satisfaction with Life Scale.
This study developed and evaluated the efficacy of the Internet-based mindfulness training in comparison with an Internet-based cognitive-behavioral training on college students and young working adults in Hong Kong. Results showed that the Internet-based mindfulness training was as efficacious as the widely supported Internet cognitive-behavioral training in improving mental well-being, psychological distress, life satisfaction, energy level, sleep disturbance, and pain at the end of the 8-week program. Furthermore, users’ perceived credibility, expectancy, and satisfaction of both programs were similar. The results are encouraging as both Internet-based programs received support for their utility, satisfaction, and efficacy in mental health promotion. Given the weight of mental illness disease burden in our communities, this study shows that Internet-based mindfulness and cognitive-behavioral training programs with minimal guided support can be a highly scalable and convenient way for prevention and promotion of mental and physical health among college students and young working adults
In Hong Kong, the majority of individuals who seek help for mental health issues do not receive psychiatric and clinical psychological services in primary and secondary care settings until their problems have become severe. In comparison with face-to-face interventions, Internet-based interventions are more easily accessible and affordable and have the potential to fulfill the need for mental health promotion and prevention in community settings. This study provided empirical support for the efficacy of Internet-based cognitive-behavioral and mindfulness training programs, which can be easily incorporated into existing service provision portfolios that promote mental health and reduce psychological distress among the college students and young working adult population in Hong Kong.
In terms of service management, these developed Internet-based interventions are highly sustainable. In Hong Kong, the number of mobile phone customers reached over 8 million in June 2016, and the amount of mobile data usage has been 10-folded from 2006 to 2016, demonstrating the rapid increase of mobile phone and mobile Internet usage [
Future research should explore methods for enhancing adherence of Internet-based health solutions in order to harness the expanding proliferation of technology among the public. For instance, recent studies have begun to incorporate ecological momentary intervention components into Internet-based programs so that interventions can be directed to real-time events and be more personalized [
Although improvements in outcomes were observed at postprogram, the improvements for pain were not maintained at 3-month follow-up. This could be the result of reduced practice or application of skills learned on the websites. In addition, this might also due to the low level of pain observed within this group of population. The floor effect might have limited the possibility in detecting improvement in pain at postprogram and 3-month follow-up.
The two Internet-based interventions in this study yielded similar results. Future studies can explore how individual differences may affect intervention benefits. It may be possible that cognitive styles can play a role in the receptivity of iMIND and iCBT and matching their styles with the treatment approach may maximize the outcome.
This study has several limitations. First, our target population was college students and young working adults. By nature, our sample is skewed toward those who were educated or were employed. As our programs were Internet-based, it is possible that they appealed to a selective group in the population who were more comfortable in accessing interventions over the Internet with their personal computers. They might have higher mental health literacy and be more willing to participate in Internet-based mental health programs. These biases in our sample limit the generalizability of our findings to all segments of the population (eg, less educated individuals, older adults). It is possible that the delivery of mental health materials over the Internet may only be appropriate for specific segments of the populations, rather than the entire population. Future studies should focus on how Internet-based interventions can cater to different segments of the populations through various adaptations.
Second, the attrition rate of our study is high. High attrition rate has been a perennial problem for Internet-based interventions. Similarly high attrition rates have been reported in other Internet-based mental health programs. For example, Christensen and colleagues [
Third, we did not include a waitlist control group in this study. As this study aimed to compare Internet-based mindfulness training with a well-established Internet-based cognitive behavioral training, and previous study has found Internet-based mindfulness training to have significant improvements in mental health than waitlist control [
In sum, this study showed that both Internet-based mindfulness training and Internet-based cognitive-behavioral training were efficacious in improving mental and physical health indicators among college students and young working adults in a convenient fashion. To leverage the power of technology in reducing mental illness burden, it is paramount for mental health professionals to work in tandem with professionals in other disciplines (eg, designers, computer scientists) in creating user-friendly programs that enable seamless integration into users’ daily lives.
Screenshots of the iMIND and iCBT.
CONSORT EHEALTH checklist.
cognitive behavioral therapy
Credibility or Expectancy Questionnaire
Client Satisfaction Questionnaire
Hong Kong Mental Morbidity Survey
mindfulness-based stress reduction
mindfulness-based cognitive therapy
Mental Health Inventory
Satisfaction with Life Scale
visual analogue scale
Well-Being Index
World Health Organization
We would like to acknowledge the Health and Health Services Research Fund (Ref. No. 09100711) for funding this project.
The study was supported by the Health and Health Services Research Fund (Ref. No. 09100711). The first author of the study, Winnie Mak, is one of the developers of the content of the trials but does not own the source code of the website.