title: Evaluation of a Creative Crowdsourcing Intervention on Mental and Sexual Health Outcomes among First-Year College Students in Suzhou, China
Creators: name: Jaime Hinojosa, Etienne
Publisher: name: University of Liverpool Repository
Year: 2023

description: Background
The transition between secondary school and college can be a crucial period for young adults. During this period students undergo many lifestyle and developmental changes as they transition from adolescence to adulthood. Particularly, first-year university students are vulnerable to developing severe mental health problems from stressors and changes. Additionally, they might engage in high-risk sexual behaviours such as condomless or unprotected sex and having multiple concurrent sex partners which can lead to a high risk of contracting Sexually Transmitted Infections (STIs). In China, research has found about one fifth of college students to struggle with different levels of mental health issues. Similarly, a high number of young adults engage in condomless sex leading to increasing rates of sexually transmitted infections. We first conducted a qualitative study to identify and understand perceptions and factors among college students in eastern China regarding sexual and mental health. The aims of the study were to understand reasons and factors influencing mental health, engagement in high-risk sexual behaviours, identify potential barriers and challenges to STI/HIV prevention and mental health services, and explore their associations with religion, social capital, and collectivism. Secondly, we conducted a Randomized Controlled Trial evaluating a crowdsourced health promotion intervention and a text-messaging intervention among college students in eastern China with the purpose to analyse whether engaging in active creative crowdsourcing results in improved mental health outcomes and sexual behaviours. Lastly, we conducted an effect modification analysis to evaluate the effects of the intervention by collectivism level among college students in eastern China.

Methods
For the qualitative study, we designed a semi-structured interview with questions regarding mental health, dealing with mental health issues, sexual behaviours, and attitudes towards sexual health. Interviews lasted 45-60 minutes approximately and were conducted on a one-to-one basis via online communication (e.g., Zoom). Qualitative data analysis was conducted using a framework method, a type of thematic analysis, in which a matrix is developed to systematically index qualitative data.
For the RCT, first-year college students were randomly assigned to one of four groups: ACCE group, engaged in creating messages promoting sexual and mental health (n = 129), TMI group, receiving health promotion messages bi-weekly (n = 111), ACCE &amp; TMI group, engaged in both activities of creating and receiving messages (n = 105), or to the control group (n = 135). The intervention lasted 8 months with follow-ups at four, eight, and twelve months. Psychological distress (PD) levels, self-reported sexual activity, and condomless sex in the past three months was analysed at baseline and post-intervention.

Results
Major themes found from the qualitative study include factors from mental and sexual health, religion, social capital, and how they relate to each other. When participants were asked to talk about their mental health, most participants reported academic performance being the main source of psychological distress (described as stress, pressure, anxiety, or insomnia). Most participants reported dealing with their mental health issues alone at first, and later by talking to friends or by distracting their attention in other activities. No participant reported seeking professional health or considering seeking professional health. Regarding sexual health, about half reported currently being or having a romantic partner but only two having sexual experience. The knowledge regarding how STI/HIV are acquired varied between participants with some believing physical contact can be a source of transmission or lack of hygiene being a reason of acquiring an STI. Only two participants reported having a conversation with their parents regarding sexual health and STI prevention with the majority not feeling comfortable discussing sensitive topics with their families. For the results of the RCT, at baseline, 57% identified as male, 42% had above normal PD scores, 8% of participants had sex three months prior of which 4% had condomless sex. While interventions had significant changes from baseline to post-intervention in certain outcomes such as in PD (p &lt; .001), depressive symptoms (p &lt; .001), anxiety symptoms (p &lt; .001), and sexual activity (p = .02); the post-intervention analysis showed no statistically significant differences between intervention groups. Additionally, the results from the effect modification analysis showed collectivism not being an effect modifier.

Conclusion
College students deal with unique health issues, their transition into adulthood can be challenging and produce stressors leading to mental health issues. College students also are susceptible to engage in high-risk sexual behaviours due to the social norms in this new environment, as well as romantic and sexual exploration. From the qualitative interviews, several factors were found to influence the attitudes and behaviour of college students regarding mental and sexual health. The findings of the RCT suggest that participation in creative crowdsourcing health promotion interventions has minimal effects on mental health or promoting condom use during sex among college students. Limitations included high-dropout rates, potential underreporting of sexual activity, and unwillingness to seek services due to the topics’ sensitivity in China. Given the hyper connectedness and widespread use of mobile technologies, crowdsourced mHealth interventions are a practical method to reach young adults in China. Nonetheless, for public health professionals, it is important to understand the needs of college students to develop tailored and successful interventions. This study contributes to their feasibility and provides guidance for future public health interventions and research in a Chinese context. With the increasing utilization of crowdsourcing methods and mobile technologies in public health interventions, further research on the effects of crowdsourcing on mental and sexual health is essential to develop evidence-based interventions.