Xianhong Li

Background: Chinese men who have sex with men living with HIV (MSMLWH) experience substantial psychological distress driven by minority stress and HIV-related challenges. However, culturally tailored digital mental health interventions that address HIV-specific maladaptive cognitive schemas and culturally specific psychosocial stressors remain scarce in China. Objective: This study aimed to systematically adapt an evidence-based cognitive behavioral therapy (CBT) intervention Effective Skills to Empower Effective Men (ESTEEM) into a WeChat (Tencent) Mini-Program–based intervention (iESTEEM) specifically for Chinese MSMLWH and to evaluate its preliminary feasibility and usability. Methods: We used a three-phase user-centered design approach guided by the Assessment, Decision, Adaptation, Production, Topical Experts, Integration, Training, and Testing (ADAPT-ITT) framework. The study proceeded in three phases: (1) a qualitative needs assessment using semistructured interviews with 20 MSMLWH (mean age 23.25, SD 3.08 years); (2) systematic intervention adaptation and platform development, including theater testing (n=5); and (3) a 2-week pilot study involving 10 MSMLWH and five counselors to evaluate feasibility, usability, and acceptability through focus groups and objective platform analytics. Results: Phase 1 identified 3 major themes of psychological distress: persistent health anxiety fueled by catastrophizing, intersectional stigma internalization, the disclosure dilemma, and intimacy barriers rooted in defectiveness and shame schemas. Participants also prioritized anonymity and bite-sized learning. Guided by these findings, iESTEEM was developed as a counselor-assisted, privacy-preserving WeChat Mini-Program incorporating HIV-specific scenarios, multimodal learning modules, and a back-end risk-alert system. During the 2-week pilot, participants logged into the platform 14.1 (SD 6.7) times per person and completed 134.3 (SD 103.1) minutes of learning activities; all participants accessed module 1, and 90% (9/10) accessed modules 2‐5. Anxiety scores decreased from 8.9 (SD 2.3) to 7.2 (SD 3.0), whereas depression scores remained stable. All participants expressed a willingness to continue using the program and to recommend it to peers. Participants and counselors endorsed its contextual relevance, privacy protections, and clinical utility. Conclusions: This study provides a theory- and evidence-informed model for culturally adapting digital mental health interventions for highly stigmatized populations. By integrating lesbian, gay, bisexual, transgender, and queer (LGBTQ)-affirmative CBT principles, HIV-specific adaptations, and a privacy-preserving, counselor-assisted WeChat Mini-Program, iESTEEM demonstrated promising preliminary feasibility, acceptability, and engagement among Chinese MSMLWH. These findings support the potential of culturally tailored digital interventions to expand access to psychological support for this stigmatized population in resource-constrained settings. Ongoing randomized controlled trials will further evaluate its efficacy, implementation outcomes, and mechanism of action.

Interventions aimed at improving the psychological well-being of Deaf and Hard-of-Hearing children have been overlooked. This study aimed to develop a targeted picture-book-focused, multi-component psycho-emotional support intervention for Deaf and Hard-of-Hearing children and to evaluate its feasibility and acceptability. A mixed-methods design based on the Successive Approximation Model (SAM) was used. A user-centered picture book was developed and evaluated through a multi-component intervention involving 76 Deaf and Hard-of-Hearing children. Quantitative data were collected at baseline (T0) and one-month follow-up (T1) using the Children’s Loneliness Scale, the General Self-Efficacy Scale, and the Adolescent Mental Resilience Scale. Focus group interviews explored acceptability and appropriateness. Five empowering components were identified, which guided the development of the picture book. The recruitment rate of the study was 92.7% (76/82). A total of 68.4% (52/76) of participants completed the intervention and follow-up. The adherence rate was 92.3% (48/52). Most participants (88.5%, 46/52) reported satisfaction with the intervention. Exploratory changes were observed for loneliness (IQR 41.5 vs. 39.0; 95%CI: 0.275, 0.723) and self-efficacy (IQR 24.0 vs. 25.0; 95%CI: −0.577, −0.027), while resilience showed no significance (IQR 85.0 vs. 87.0; 95%CI: −0.176, 0.435). Most participants rated the picture book as acceptable and were willing to share it. The intervention appears acceptable, feasible, and appropriate, supporting the need for a randomized or implementation study.

Oral health-related quality of life (OHRQoL) is a client-centered outcome, yet it is often overlooked in routine HIV care. This study aimed to describe the status of the OHRQoL among people living with HIV (PLWH) in China, examine factors independently associated with OHRQoL, and identify oral-psychological burden profiles. A cross-sectional study was conducted with a convenience sample of 449 participants recruited from two designated HIV hospitals in Hunan Province, China, between May and August 2025. Data on sociodemographic and clinical characteristics, oral and psychosocial factors, and OHRQoL were collected. OHRQoL was assessed using the 14-item Oral Health Impact Profile (OHIP-14), which comprises four dimensions-functional limitation, pain and discomfort, disability, and psychosocial impact-with higher scores indicating poorer OHRQoL. OHRQoL and covariates were summarized descriptively, and potential correlates were examined using multivariable regression analysis. Latent profile analysis was then performed using oral health status, depressive symptoms, anxiety symptoms, and HIV-related stigma to identify oral-psychological burden profiles. External comparisons across the retained profiles were conducted using OHRQoL and other sociodemographic and clinical variables. The mean OHIP total score was 12.27±9.12 (range 0-56). Domain scores were: pain and discomfort (3.74±2.25, range 0-12), functional limitation (2.87±2.45, range 0-12), psychosocial impact (2.62±2.45, range 0-12), and disability (3.03±3.43, range 0-20). Poorer oral health status (β=1.117, 95% CI 0.815-1.419; P<.001) and greater depressive symptoms (β=0.958, 95% CI 0.115-1.801; P=.026) were independently associated with worse OHRQoL. Three oral-psychological burden profiles were identified: low (n=154, 34.3%), moderate (n=191, 42.5%), and high (n=104, 23.2%). External comparisons showed a graded pattern, with the high-burden profile characterized by older age, a higher proportion of women, lower socioeconomic status, poorer antiretroviral therapy adherence, lower social support, and worse OHRQoL. These findings indicate that PLWH in this study reported measurable oral health impacts on daily life, particularly in pain and discomfort, with oral health status and depressive symptoms as key correlates. Oral and psychological burdens clustered into distinct profiles, highlighting the potential value of considering within-population heterogeneity when addressing oral health and related quality of life.

Qualitative evaluation is crucial for leadership feasibility RCTs, as it deepens the interpretation of findings and informs definitive trial design. Yet, such evaluations are lacking. This study describes nurse leaders' perspectives on a feasibility RCT evaluating an online training program to improve evidence-based leadership. This qualitative descriptive study followed a feasibility RCT. Using purposive sampling, we recruited nurse leaders from the intervention group. From August 15 to August 24, 2023, we conducted five focus group interviews with 25 participants. Data were analyzed using content analysis, focusing on four feasibility categories: (1) intervention content and delivery, (2) trial design, conduct, and processes, (3) outcomes, and (4) measures. The reporting of the study was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Participants valued the training but found its complex content challenging to understand and apply in daily practice; this led to specific suggestions for refinement (Category 1). They emphasized the need for leadership training to be accessible to all nurses, recommending either entry requirements or multi-level training tailored to different competency levels (Category 2). For outcome evaluation, they proposed replacing "self-efficacy" with "evidence-based leadership efficacy" (Category 3), developing targeted assessment tools for evidence-based leadership, and incorporating qualitative methods to assess the intention to leave their professional role or workplace (Category 4). This study pioneers the qualitative evaluation of a feasibility RCT focused on leadership training, providing participant-informed insights across key feasibility domains. The findings yield valuable insights for enhancing the feasibility and effectiveness of future evidence-based leadership training programs utilizing RCT designs. Furthermore, they offer practical guidance for developing leadership interventions in comparable contexts. This trial was prospectively registered at ClinicalTrials.gov (NCT05244499) on February 7, 2022. The protocol and feasibility RCT are published in peerreviewed journals.

Autism spectrum disorder poses a growing global health challenge due to rising prevalence and significant disability burdens. Early intervention during the 0- to 6-year developmental window is critical to reduce individual, familial, and societal impacts. However, implementation gaps persist in China, particularly in resource-limited settings, where context-specific barriers and facilitators remain understudied. This multicenter qualitative study (July 12 to October 28, 2024.) across 11 cities in Hainan Province involved 47 stakeholders (4 policymakers, 13 managers, 13 practitioners, and 17 family caregivers of children with autism spectrum disorder aged 0–6 years). Semi-structured interviews guided by the Consolidated Framework for Implementation Research were complemented by document review and field observations, with data analyzed via template analysis. Key facilitators included government funding, stratified training, caregivers’ positive attitudes, and clear implementation standards. Barriers mainly included low social acceptance, regional resource disparities, workforce shortages, caregiver challenges, and limited evidence-based practice adoption. Four key strategies were identified: strengthening external support, optimizing internal resources, empowering stakeholders, and refining implementation through technology and evidence-based practices. This first China-based study uses a stakeholder-driven approach to co-design contextualized strategies, offering a model for improving autism spectrum disorder care delivery in similar resource settings globally. Lay This study explored how to improve early support services for young children aged 0 to 6 years with autism spectrum disorder in resource-limited areas. We interviewed 47 stakeholders, including policymakers, service managers, healthcare professionals, and parents of autistic children across 11 cities to identify factors that support or limit effective early support services. Key helpful factors were government funding, practical staff training, and parents’ proactive attitudes. Major challenges included low public understanding of autism, unequal resources between regions, too few trained professionals, and difficulties families face accessing care. To address these, we suggest four solutions: increasing funding and community awareness, sharing resources more fairly, training more staff and supporting parents, and using technology and proven therapies. As the first study in China to design solutions with families and professionals, these strategies could help similar communities globally deliver better early autism care.

Background and objectives Timely progression through the early detection-diagnosis-intervention pathway is critical for optimizing outcomes in autistic children but is often impeded by barriers. This multi-center study aimed to describe this care pathway through the experiences of parents to identify key factors influencing its efficiency across diverse settings. Methods This multi-center mixed-methods study (July–Oct 2024) integrated survey data collected from 397 primary caregivers and interviews with 17 family caregivers of autistic children across 11 Hainan cities. Survey data on child/family characteristics and clinical timelines were analyzed using regression/comparative tests. Interview data on care-pathway determinants were analyzed thematically. Findings were integrated via triangulation. Results Findings demonstrated significant delays across all stages of the pathway. Descriptive analysis of survey data indicated that family members initiated detection in 70.3% of cases, with language delay the most common initial concern (88.9%), and that 76.6% of children received 15 or fewer intervention hours weekly. Integrated mixed-methods analysis identified key multilevel determinants: individual (e.g., developmental regression, parental awareness), inner setting (e.g., uneven resource distribution, workforce shortages), and outer setting (e.g., policy, cultural beliefs). Conclusions Substantial delays and systemic barriers in the autistic care pathway necessitate coordinated strategies. Recommendations include enhancing parent education, developing integrated regional care networks, expanding telehealth, and implementing targeted public awareness campaigns. This framework offers transferable solutions for under-resourced settings, particularly in low- and middle-income countries facing similar autistic care challenges. Impact This study identifies delays throughout the early detection, diagnosis, and intervention pathway for autistic children, influenced by individual, inner, and outer factors. It presents a comprehensive mixed-methods assessment of the care pathway in resource-limited settings, underscoring the key role of caregivers, cultural belief and structural barriers such as workforce shortages and geographic disparities in resource availability. The findings support the implementation of coordinated evidence-based strategies, including parent education, integrated regional care systems, telehealth services and targeted public awareness campaigns to strengthen early autistic care in comparable settings worldwide.

The therapeutic alliance is a well-established predictor of psychotherapy outcomes. With the advancement of digitization, guided internet-based cognitive behavioral therapy (ICBT) has demonstrated effectiveness. However, the conceptual framework of the digital therapeutic alliance (DTA) within ICBT remains conceptually underdeveloped. Data were collected from a guided ICBT program in China. We conducted virtual individual semi-structured in-depth interviews among a purposive sample of intervention recipients (young sexual minority men, n = 20), and all implementers (counselors and supervisors, n = 6). Data were analyzed using qualitative template analysis. A DTA framework was developed with 4 key components: roles, interactions, characteristics, and influencing factors. Clients typically initiate the counseling process through online materials and assignments, treating the digital platform as a “safe space,” “invisible friend,” “warm harbor,” or “repository of knowledge and tools.” Counselors serve as guides and provide professional support asynchronously. High frequency of interaction and emotional connection via phone calls strengthened DTA. “Being client-driven,” “fostering an equal relationship,” and “being difficult to establish but easy to terminate” were identified as characteristics. Influencing factors included client-related aspects (eg, motivation), counselor-related elements (eg, response timeliness), and platform-related considerations (eg, trust, confidentiality). This study develops a DTA conceptual framework, elaborating on the roles, interactions, characteristics, and influencing factors among clients, counselors, and digital platforms in guided ICBT. Findings inform strategies to enhance engagement, counselor training, and platform design in digital psychosocial interventions.

Professional resilience, rather than career resilience, is an important attribute for nurses’ retention in the profession. The concept of nursing pro

Background: Youth aged 15‐24 years carry a disproportionate HIV/sexually transmitted infections (STIs) burden. In recent years, different modalities of digital health interventions (DHIs) have been explored to promote safer sex behaviors among youth, but their comparative effectiveness across modalities and relative to nondigital interventions (NDIs) remains unclear. Objective: This study aimed to compare DHI modalities on safer sex behaviors and HIV/STI incidence, rank modalities using Bayesian network meta-analysis (NMA), and position their effectiveness relative to NDIs. Methods: A systematic review and Bayesian NMA of randomized controlled trials were conducted by comprehensively searching PubMed, EMBASE, Web of Science, and Cochrane Library (inception to November 2025). Eligible studies were those that enrolled youth aged 15‐24 years and evaluated mobile app-based intervention, telecommunication-based intervention (TCI), static web-based intervention (SWI), or interactive online-based intervention (IOI)—with an NDI or another DHI. Primary outcomes were condom use at last sexual contact, consistent condom use, and proportion of condom use. Secondary outcomes included condom use self-efficacy, number of sexual partners, and STI incidence (including HIV). Risk of bias was assessed with the Cochrane Risk of Bias 2 tool, and certainty of evidence with GRADE/CINeMA (Confidence in NMA). Bayesian random-effects NMAs estimated odds ratios (ORs) with 95% credible intervals (CrIs), and complementary frequentist NMAs provided 95% CIs and 95% prediction intervals. Results: Twenty-four randomized controlled trials (20,134 participants) were included, forming treatment networks across 5 intervention types. TCI was the only intervention that significantly improved condom use at last sex compared with NDI (OR 1.13, 95% CrI 1.02‐1.26). For consistent condom use, SWI and IOI outperformed TCI (SWI vs TCI: OR 1.77, 95% CrI 1.03‐3.06; IOI vs TCI: OR 1.68, 95% CrI 1.02‐2.76). For the proportion of condom use, IOI outperformed SWI (OR 1.34, 95% CrI 1.01‐1.80), and mobile app-based intervention ranked highest in probability rankings, though estimates lacked precision. For STI incidence, NDI was associated with fewer STIs than SWI (OR 0.61, 95% CrI 0.46‐0.82). Conclusions: This is the first NMA to compare the effectiveness of DHIs on condom use and HIV/STI outcomes among youth populations. It demonstrates that the impact of DHIs on HIV prevention varies substantially by intervention modality and outcome type. While TCI demonstrates the most consistent improvement in condom use at last sex, SWI and IOI may be more effective for promoting consistent condom use, though estimates remain imprecise. However, wide prediction intervals and low-certainty evidence suggest that self-reported behavioral changes may not translate into reductions in HIV/STI incidents without integration with offline services and broader structural support. Future trials might consider including standardized outcome indicators and longer follow-up to generate more precise estimates of the effectiveness of DHIs and guide generalization of youth-centered digital HIV/STIs prevention.