Efficacy of a single-session online ACT-based mindfulness intervention among undergraduates in lockdown during the COVID-19 pandemic

Abstract Introduction COVID-19 has trickle-down psychological effects on multiple strata of society, particularly university students. Apart from the worry of contracting or spreading COVID-19, Malaysian university students were also locked down on their campuses, suffering significant psychological distress. Hence, an online mindfulness intervention was proposed to alleviate psychological distress and improve psychological flexibility and mindfulness. Methods This was a quasi-experimental study with university students as participants. Intervention group participants were instructed to complete online questionnaires which covered basic demographics and instruments assessing depression, anxiety, stress, mindfulness, psychological flexibility, and fear of COVID-19 before and after the one-hour intervention. The control group also completed before and after questionnaires and were subsequently crossed over to the intervention group. Repeated measures ANOVA was conducted to assess time*group effects. Results 118 participants were involved in this study. There were significant differences in anxiety (F(1,116) = 34.361, p < 0.001, partial eta-squared = 0.229) and psychological flexibility between the two groups (F(1,116) = 11.010, p = 0.001, partial eta-squared = 0.087), while there were no differences in depression, stress, mindfulness, or fear of COVID-19. Conclusion The results of this study corroborate the efficacy of online single-session mindfulness therapy as a viable short-term psychological intervention under financial and time constraints. Since university students are in the age group with the highest incidence of depressive and anxiety disorders, it is crucial to utilize resources to address as many students as possible to ensure maximum benefit.


Introduction
The novel SARS-CoV-2 virus, currently known as COVID-19, was first reported in Wuhan, China in December 2019. 1  In view of rampant transmission, the Malaysian government enforced strict social and movement restrictions and mandatory quarantine or isolation for persons under investigation and positive cases respectively. 4,5 Although retrospectively swift actions were essential to blunt the progression of spread, nevertheless, such lockdowns have crippled the economy, causing untold social and psychological impairment. 6 This corroborates with existing literature that psychological illnesses are on the rise during the COVID-19 pandemic. 7,8 Early Chinese data from the initial phase of the outbreak showed that more than half of respondents had suffered moderate to severe psychological impact. 9 This can be due to direct causes such as stress, fear of contamination, depression, and grief evoked by exposure to the virus as well as indirect consequences of the socioeconomic impact. 10 Undergraduate students in Malaysia in particular are in unusual circumstances. Due to a sudden explosion in cases related to two less fortuitous coincidences, namely a prison outbreak of Covid-19 and a concurrent general election in the same state, 11  There are however descriptive studies of ultrabrief psychological intervention modules that adapt mindfulness techniques, allowing them to be delivered in shorter-format single interventions outside of formalized psychotherapeutic protocols. 41

Study design and setting
This was a quasi-experimental study conducted with university students during the Malaysian Conditional Movement Control Order (CMCO) period, when social gatherings were not permitted. During the CMCO period, participants attended a one-hour single-session online mindfulness intervention. Questionnaires were answered before and after the online session. Since this was a psychological intervention, it was impossible to blind participants, therefore both intervention and control groups received the same intervention at different times. The intervention group attended the session prior to the posttest, while the control group attended it afterwards.

Participants and sample size
By applying the nonequivalent groups design approach, and to ensure both groups were as similar as possible, equal numbers of participants from batches of undergraduate medical students were divided into intervention and control groups based on each year's student roll. The sample size calculation was based on a formula described by Lehr, 42 using a significance criterion of 0.05, statistical power of 0.8, and effect size of 0.63. 43 The required sample size was 41 in each group, hence 82 participants cumulatively. The inclusion criteria were university students over the age of 18 who were locked down on campus, were willing to participate in the study, and were able to read and converse fluently in Malay. The exclusion criteria were non-consent and acute medical or psychiatric illness, which was obtained from the electronic medical records of the university hospital and corroborated with self-reported symptoms as a second-level safety net.

Fear of Covid-19 Scale (FCV-19S)
The Fear of Covid-19 Scale 44 consists of seven items (e.g. "It makes me uncomfortable to think about coronavirus-19"). It is scored on a five-item Likert response scale ranging from 1 (strongly disagree) to 5 (strongly agree), with possible scores ranging from 7 to 35. Higher scores indicate more severe fears of COVID-19. 44,45 In this study, a validated Malay version 46

Acceptance and Action Questionnaire (AAQ-II)
The AAQ-II 49 is a widely-used measure of experiential avoidance and psychological inflexibility.
It was developed and revised from the original AAQ. 50 It is a unidimensional scale with 7 items rated on a 7-point Likert scale ranging from 1 (Never true) to 7 (Always true). Possible scores range from 7 to 49.
Higher scores on the AAQ-II indicate higher levels of psychological inflexibility. The Malay version of AAQ-II used in this study has a Cronbach alpha of 0.910, excellent parallel reliability, and adequate concurrent validity. 51

Results
A total of 118 participants volunteered for the mindfulness intervention. They were divided into intervention and control groups, containing 61 and 57 participants respectively. The demographics of the students are as described in Table 1. Table 2 illustrated that all continuous data for depression, anxiety, stress, FCV-19S, MAAS, and AAQ-II scores were normally distributed with skewness and kurtosis within appropriate ranges (+/-2 and +/-10 respectively) as per normality requirements. 53 As shown in Table 3, normality checks were   carried out on the residuals for FCV-19 scores       This study certainly has certain limitations. Firstly, all of the participants are medical students, who might have higher awareness and knowledge regarding updates about COVID-19, compared to other students on different courses or to the general public. [62][63][64] This could therefore represent a selection bias. Secondly, the sample size of 118, including both the intervention and the control group, was relatively small, partly due to internet access limitations and time constraints and also because three batches of medical students had already undergone mindfulness intervention training preresearch, thus raising the possibility that their inclusion would unduly distort the final results. As it stood, only 183 students had not undergone mindfulness training before. One more limitation includes the lack of an active control group. The significant effects on reduction of anxiety and increasing psychological flexibility may have simply been caused by the fact that there was interaction with a caring and supportive professional, rather than being related to any specific effect of the mindfulness technique used.
On the other hand, the absence of effects on the other scales may also simply represent the need for sustained practice to modify the aspects measured. This can be tested with one or more follow-up assessments.
Lastly, since the participants were locked down on campus and staying in proximity to each other in the hostel, it was difficult to blind participants and there was a possibility of the intervention group participants sharing the techniques taught during the mindfulness intervention with the control group, hence affecting the results.
In conclusion, the results of this single-session intervention study are crucial because there is a need for evidence-based short interventions that can be provided to the largest number of people to yield the greatest good, rather than for multiple-session interventions which no doubt have unquestionably higher efficacy due to the additive effect of multiple sessions, but are exhaustive to run and have high attrition rates, and may result in fewer individuals getting the benefits of mindfulness training and thus have less public health impact. 65 ACT techniques have been successfully delivered in single-session modalities with good evidence for multiple indications [66][67][68][69][70] and it is especially crucial we offer them to undergraduate populations, because they are in the age group with the highest incidence of depressive and anxiety disorders. 71 Therefore, it is our greatest hope that this single session intervention will be adopted in other universities as this intervention has shown limited efficacy, albeit in a single center, and larger sample sizes would be ideal to explore the efficacy of this intervention further.

Disclosure
No conflicts of interest declared concerning the publication of this article.