Social Worker-led Mindfulness-based Intervention for Managing Depressive Symptoms in Community-dwelling Older Adults in Hong Kong: A Randomised Controlled Trial
Phase: NA
Conditions: Depressive Symptoms
Sponsor: The University of Hong Kong

Social worker-led mindfulness-based intervention for managing depressive symptoms in 
community-dwelling older adults in Hong Kong: A randomised controlled trial  
 
NCT ID not yet assigned 
Unique Protocol ID: EA220105- Amendment 3 
Date of the document: 29 July, 2024 
 
INVESTIGATORS  
Terry YS Lum (Principal Investigator)  
Department of Social Work and Social Administration, HKU  
Gloria HY Wong (Co-Principal Investigator) 
School of Psychology and Clinical Language Sciences, University of Reading  
Wai Chi Chan (Co-Principal Investigator) 
Department of Psychiatry, HKU 
Raymond CL Chan  
Department of Social Work and Social Administration, HKU  
Dara KY Leung  
Department of Social Work and Social Administration, HKU  
Stephanie MY Wong 
Department of Social Work and Social Administration, HKU  
Yun-Lin Wang 
Department of Social Work and Social Administration, HKU  
Yun-Han Wang 
Department of Social Work and Social Administration, HKU  
Oscar LH Chan 
Department of Social Work and Social Administration, HKU  
Zuna LY Ng 
Department of Social Work and Social Administration, HKU  
 
PARTNERING ORGANIZATIONS 
The Hong Kong Jockey Club Charities Trust 
Christian Family Service Centre 
The Mental Health Association of Hong Kong 
The Salvation Army, Hong Kong and Macau Command 
Haven of Hope Christian Service 
Hong Kong Sheng Kung Hui 
Tung Wah Group of Hospitals 
Aberdeen Kai-fong Welfare Association 
Hong Kong Society for the Aged 
The Neighbourhood Advice-Action Council 
 
 

Background 
Mindfulness-based cognitive therapy (MBCT) is a promising approach to managing a series of 
health and psychological conditions among older adults (Hazlett-Stevens et al., 2019). To 
increase its acceptability, feasibility, and scalability, MBCT has been adapted and delivered in 
a variety of formats. Apart from delivering the intervention in-person by a certified mindfulness 
teacher, MBCT has been adapted to be self-taught (e.g., Crane et al., 2020; Montero-Marin et 
al., 2021), delivered online (e.g., Dragomanovich et al., 2021), or partially led by social workers 
(Wang et al., under review).    
Preliminary findings from Wang et al. (2024; under review) suggest that a task-shared 
approach with modified MBCT supported by social workers is effective in producing change 
in older adults’ mental health and mindfulness. Based on this finding, more research is needed 
to evaluate whether social workers are competent to lead a mindfulness-based intervention 
(MBI) informed by MBCT on their own and produce effective changes in outcome measures 
pertaining to mental health.  
Furthermore, based on recent focus groups conducted by the investigators, qualitative 
data provide supporting evidence that incorporating peer supporters into the program is a 
promising way to improve engagement in MBI. However, whether the inclusion of peer 
supporters has the potential to enhance intervention outcomes remains unknown.   
Peer supporters in mental health, also called “experts by experience” (World Health 
Organization, 2021, p. 2), are those who have direct lived experience and can exchange 
practical or emotional support with peers who are going through similar challenges (Mead et 
al., 2001) in a non-judgmental way (World Health Organisation, 2021). The literature suggests 
that the effects of incorporating peer support in mental health interventions are mixed. 
In an online intervention based on CBT principles designed for older adults with 
elevated depressive symptoms, peer support has been found to improve engagement and 
adherence to the intervention (Tomasino et al., 2017). However, in a systematic review and 
meta-analysis, Smit et al. (2022) found that peer support intervention, as a standalone 
intervention, has a modest effect in improving clinical (i.e., psychiatric symptoms) and 
personal recovery (e.g., empowerment, hope) across different patient groups when being 
compared to a comparison group. Thus, more research is needed to understand the effectiveness 
of incorporating peer supporters into mental health interventions. 
As a follow-up study to Wang et al. (2024, under review), the objectives of the current 
proposed study are below:  
 
 

Objectives 
• To evaluate the effectiveness of social worker-led MBI in improving depression in 
older people with mild to moderate depressive symptoms as compared to care as usual 
(cognitive behavioural therapy and behavioural activation)   
• To examine the effectiveness of incorporating peer supporters in social worker-led MBI 
compared to those without peer supporters   
• To identify potential mechanisms of change in MBI for depressive symptoms  
 
Methods 
Design 
The study will utilise a combination of randomised controlled trial (RCT) and propensity score 
matching technique to incorporate pragmatic considerations, following consultations with 
researchers and social workers. Participants will be randomly allocated to either a peer 
supporter-enhanced social worker-led MBI or a social worker-led MBI. The control group will 
consist of participants receiving usual care and will be identified from the larger JoyAge project, 
using propensity score matching that takes into account demographic information, depressive 
symptoms, and anxiety levels. 
 
Participants 
Participants will be recruited from District Elderly Community Centres (DECC) and Integrated 
Community Centre for Mental Wellness (ICCMW). Based on sample size power calculation, 
the investigators aim to recruit 69 participants for each arm, totalling 207 participants in the 
study. Participants will be included if they are aged (1) 60 years or older, (2) have depressive 
symptoms of mild level or above, as indicated by scoring 5 to 14 in PHQ-9, and (3) can give 
informed consent to participate. The exclusion criteria are (1) known history of autism, 
intellectual disability, schizophrenia-spectrum disorder, bipolar disorder, Parkinson’s disease, 
or dementia, (2) current abuse of drugs or alcohol, and (3) difficulty in communication. After 
participants are allocated to the intervention group, a screening interview will be scheduled. 
Participants will be further excluded if they have (4) imminent suicidal risk, or (5) if the timing 
or the training is unsuitable for the participant.     
 
Intervention 

The intervention in the current program is in parallel with Wang et al. (2024, under review).  
However, participants in one of the intervention groups will receive support from peer 
supporters throughout the study. In addition, to reduce the intensity of the intervention, the 
current MBI has reduced the number of sessions from eight 2-hour weekly sessions in the 
modified MBCT to six 2-hour weekly sessions. Each session contains guided mindfulness 
exercises, feedback and discussion, homework review, and psychoeducation. The programme 
is conducted in Cantonese and led by social workers who received training from a certified 
mindfulness teacher. The care as usual group received usual service provided in DECC and 
ICCMW. 
 
Measures 
Demographic information will be collected at baseline. All outcome measures will be collected 
at baseline (T0), 6 weeks (T1: immediately after the intervention), and 18 weeks (T2; 3 months 
following intervention) after baseline. The questionnaires are self-administered but trained 
social workers or research assistants will provide support in completing the questionnaire when 
needed. The questionnaire is expected to last for roughly 60 minutes. 
 
Depressive symptoms will be assessed using the validated Chinese version of the Patient Health 
Questionnaire (PHQ-9; Wang et al., 2014). The 9-item instrument incorporates depression 
diagnostic criteria and other leading major depressive symptoms. Participants rate the 
frequency of the symptoms on a four-point Likert scale ranging from 0 (not at all) to 3 (nearly 
every day). PHQ-9 scores of 5-9, 10-14, 15-19, 20 and above represent mild, moderate, 
moderately severe, and severe depression. 
 
Anxiety symptoms will be assessed using the validated Chinese version of the Generalized 
Anxiety Disorder 7-item scale (GAD-7; Tong et al., 2016). The instrument assesses prominent 
diagnostic features for GAD. Participants rate the frequency of symptoms on a four-point 
Likert scale, ranging from 0 (not at all) to 3 (nearly every day). GAD scores of 5, 10, and 15 
are taken as the cut-off points for mild, moderate, and severe anxiety, respectively. 
 
Mindfulness will be assessed using the Chinese validated Five Facet Mindfulness 
Questionnaire (FFMQ-SF; Hou et al., 2013). The 20-item instrument measures mindfulness by 
five domains: ‘observe’, ‘describe’, ‘acting with awareness’, ‘non‐judging’ and ‘non‐
reactivity’. Participants rate how much each statement reflects their lives on a 5-point Likert 

scale ranging from 1 (never) to 5 (always). Higher scores indicate higher mindfulness. 
 
Stress will be using a single-item measure (SLS-1; Wong et al., 2021). This item measures 
participants’ subjective levels of stress over the past month. Participants rate the level of stress 
on a Likert scale ranging from 0 (not at all) to 4 (extremely). A higher score indicates a higher 
subjective level of stress. 
 
Health-related quality of life will be assessed using the Chinese version of the EuroQol-5 
dimension 5-level version (EQ-5D-5L; Herdman et al., 2011). The measure assesses five 
dimensions of health, including mobility, self-care, usual activities, pain/discomfort, and 
anxiety/depression. Each dimension is rated on five levels ranging from “no problem” to 
“extreme problems”, which will be transformed into a 5-digit code, with an index score 
computed. A score closer to 1 indicates better health state. Participants will also indicate their 
current health condition on a visual analogue scale ranging from 0 (the worst health you can 
imagine) to 100 (the best health you can imagine). Higher values on the scale indicate better 
current health. 
 
General health status will be assessed using one non-comparative and two comparative 
questions pertaining to health (DeSalvo et al., 2006; Li et al., 2006). The non-comparative 
question assesses participants’ perception of their overall health condition. Participants rate 
their perceived health status on a Likert scale ranging from 0 (very good) to 4 (very bad). A 
higher score indicates poorer health status. The two comparative questions assess participants’ 
perceptions of their health status compared to one year ago and compared to peers with the 
same age. Participants rate their health status on a Likert scale ranging from 0 (much better 
than one year ago/much better than others) to 4 (much worse than one year ago/much worse 
than others). Higher values on the scale indicate poorer health status. 
 
Self-compassion will be assessed using the Chinese version of the Self-Compassion Scale-
Short Form (SCS-SF; Meng et al., 2019). The 12-item scale measures different components of 
self-compassion including self-kindness, common humanity, mindfulness, self-judgement, 
isolation, and over-identification. Participants rate the items on a scale ranging from 1 (almost 
never) to 5 (almost always). Higher scores indicate higher levels of self-compassion. 
 
Rumination will be assessed using the Chinese version of the Brooding Subscale of the 

Ruminative Response Scale (RRS-10 Chinese version; Lei et al., 2017). This 5-item subscale 
assesses the tendency to make negative evaluations or comparisons. Participants will rate the 
items on a scale ranging from 1 (never) to 4 (always). Higher scores indicate greater levels of 
rumination.  
 
Self-efficacy will be assessed using the 10-item Chinese version of the General Self-Efficacy 
Scale (C-GSE; Zhang & Schwarzer, 1995). This measure assesses participant’s perceived 
ability to cope with different situations. Participants will rate the items on a scale ranging from 
1 (not at all true) to 4 (exactly true), with higher scores indicating greater self-efficacy.  
 
Resilience will be measured using the 2-item Chinese version of the Connor-Davidson 
Resilience Scale (CD-RISC2; Ni et al., 2016). This scale measures participants’ stress coping 
ability. Participants will rate items on a scale from 0 (not true at all) to 4 (true nearly all the 
time). Higher scores indicate higher resilience.  
 
Expectancy and acceptability ratings of the current MBCT program will be assessed by 
adapting questions by Hirsch et al. (2021) and Williams et al. (2013). The expectancy question 
will measure participants’ expected usefulness of the program. Participants will rate “how 
useful do you think this program will be in improving your mental health?” on a five-point 
scale from 0 (not at all useful) to 4 (very useful) at baseline (T0). A higher score indicates 
higher levels of expected usefulness. Acceptability of the program will be measured after 
program completion (T1). Participants will rate “how useful was this program in improving 
your mental health?”, “how satisfied are you with the program?”, and “with what degree of 
confidence would you recommend this program to other older adults?” on a five-point scale 
from 0 (not at all useful/satisfied/confident) to 4 (very useful/satisfied/confident). Greater 
scores indicate greater acceptability (i.e., usefulness, satisfaction, and confidence) about the 
program. 
 
Data analysis 
To explore group differences, baseline demographic information and outcome measures among 
the three groups will be compared using ANOVAs. Using an intention-to-treat approach 
(Fisher et al., 1990), follow-up data will be collected from participants who withdraw from the 
study. Therefore, all collected data will be included in data analysis. Linear mixed models will 
be used to compare outcome changes from T0 to T2 among the groups. 
 

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