Voluntary medical male circumcision (VMMC) is a safe and effective HIV prevention strategy. However, adherence to recommended in-person, postoperative follow-up is inefficient for procedures with few adverse events. Two-way texting (2wT)–based follow-up appears to be a safe and an efficient alternative to scheduled clinic visits for low-risk patients who underwent VMMC. To ensure that 2wT responds to the needs of health care workers (HCWs) and patients, HCWs were closely involved in app design using a human-centered design (HCD) approach.Embedded within an ongoing randomized controlled trial of 2wT in South Africa and complementary HCD processes of 2wT app optimization, this qualitative study aimed to use key informant interviews (KIIs) to explore the thoughts, suggestions, and opinions on and perceptions of 2wT’s usability and acceptability among HCWs involved in 2wT implementation in both urban and rural South Africa.A total of 7 HCWs using 2wT in Gauteng and the North West province participated in KIIs regarding the usability and acceptability of 2wT. HCWs were asked for their opinions on 2wT as a viable, useful, appropriate, and accessible method of postoperative VMMC care. They were also asked about 2wT-related working, exploring areas where 2wT could add to or reduce their daily tasks. The KII data were explored, coded, and analyzed by 3 qualitative researchers using thematic content analysis and the ATLAS.ti (ATLAS.ti Scientific Software Development GmbH) software.Most HCWs felt confident, comfortable, satisfied, and well supported using a 2wT-based follow-up as an alternative to in-person clinical reviews. They felt that 2wT was easy to use and required little technical support after initial mentoring on how to use the 2wT system. Few noted safety concerns, as men can receive clinical guidance, reassurance, and referral via 2wT. Although fewer in-person visits reduced the in-person review workload and eased clinical flow, HCWs noted the added burden of having to interact with clients via SMS text messages on evenings or weekends. HCWs reinforced the need for enhanced postoperative counseling to ensure that 2wT patients could recognize and understood how to respond to early signs of complications. HCWs suggested a rotation to spread the evening and weekend workload and ensure swift patient responses.In this formative qualitative study focused on HCWs, 2wT was a highly usable alternative to in-person postoperative reviews for patients who underwent VMMC in South Africa. The HCD processes likely improved the usability and acceptability of 2wT for HCWs. HCWs supported the scale-up of 2wT given the distance from the clinic to the men’s homes and the potential for reducing workload. To ensure success, providers urged sensitizing patients to the fact that 2wT augments, but does not replace, the existing after-hours and emergency care services. Health care worker (HCW) shortages are common in many low- and middle-income countries (LMICs), including those in sub-Saharan Africa (SSA), and contribute to the compromised quality of health care systems and reduced access to quality patient care ,2. SolutThere is also broad recognition that diverse users must be engaged in the design, development, delivery, and optimization of digital health innovations. User- or human-centered design (HCD) should better amplify the perspectives of HCWs . Giving In South Africa, there are chronic HCW shortages across all service delivery contexts , includiTherefore, the Aurum Institute, in partnership with the International Training and Education Center for Health at the University of Washington, the CHAPS, and its technology partner Medic, is undertaking an RCT to test whether 2wT can provide the same safety and efficiency advantages in both urban and rural VMMC settings in South Africa. The core aim of the RCT is to apply HCD principles to 2wT design, including the assessment of 2wT’s usability and acceptability from the HCW perspective, to provide guidance to inform the adoption and expansion of 2wT in the local context. A solid evidence base of the high usability and acceptability of 2wT is imperative for VMMC programs in South Africa and other contexts that consider implementing 2wT interventions to support follow-up. The RCT and cost results are not included in this paper but will be published separately.Usability is commonly defined as the extent to that a product can be used to complete a task efficiently, effectively, and with satisfaction  because they know that doesn’t matter what time. They can always ask a question if something comes up. So yeah, it’s been a great help.” (P3). Another HCW framed 2wT’s advantage for men who are highly mobile, as 2wT is accessible at home, at work, or while traveling:The 2wT system provided clients with direct access to VMMC clinicians and allowed HCWs to respond to client questions and provide individualized care without requiring the clients to return to the clinic for the same support. In a good way...they actually have to like, they can stay at home, do their check-ups at home, they don’t actually have to come here. Maybe, let’s say, for example, they had places to be. And then that’s how they can like, go to wherever where they wanted to go.P6“have to come in and stand in the long queues...especially now, because 2wT really fits in this COVID thing. It just parts with all the stress of coming here to the clinic and waiting in the long queues with of a lot of people” (P6).The 2wT system also offered benefits to client care in terms of infection prevention during the COVID-19 pandemic because patients did not Time and cost savings was reported by the HCWs as a primary benefit for 2wT clients. Several respondents noted similarly that 2wT “reduces...the patient’s cost for them to come here [clinic]” (P2) and “saved them a lot of time and money” (P3). The 2wT system was also perceived as convenient for clients who are employed, as it does not require them to take time off work to attend their clinic appointments:...they are welcoming it and they took it positively. More especially the ones that are employed full time that are always at work like those who did not have money to travel or to come for check-ups on outside they find it very convenient.P7HCWs reported that the 2wT system allowed patients to reach out to clinicians quickly and efficiently. The 2wT system provided HCWs with alerts and visual cues to focus effort on men who needed support, suggesting that 2wT provides better follow-up than routine physical follow-ups. One of the benefits of 2wT is daily interaction, which helps alert clinicians to patients who may have concerns and would otherwise be seen only on days 2 and 7:The nice thing about texting, you are in contact with your clients, you know what’s happening with them, you know what’s happening with [name]. Not everyone is not like that. Seven days, two days, they [routine men] come in there. Now you have an element of surprise. It [2wT] helps you to prevent the problem before it comes across.P5A 2wT clinician reinforced the advantage of consistent interaction with clients for swift AE identification and management:I think about last year, we had that particular patient that was bleeding after he had removed the bandage, and we were able to bring him in the very next day, and he had to be reopened and cauterized. You know I think if we hadn’t caught it on 2wT, I don’t know if he would have found emergency number...And I mean, he didn’t want to come in, but he did. We were able to sort him out quite quickly before he became something more severe.P3The 2wT approach was reported to be beneficial not only to clients but also to HCWs in terms of their workload associated with daily client reviews. In both rural and urban settings, HCWs reported that “...[2wT] reduces their work in terms of seeing the clients every day when [clients] comes to follow up check-up” (P1). In the rural context, the benefit may be greater, as it is common “to drive 100 plus KM just to see one patient” (P2). Reducing unnecessary checkups using 2wT may result in an increased number of MCs done per day, as clinicians “can focus on maybe getting new (VMMC) clients for that day to cut them instead of going to fetch those ones for follow up” (P2). This advantage may also be more acute during the peak season, when clinicians may perform >100 circumcisions per day. This benefit further translates into clients being attended to more rapidly for circumcision, thus leading to a reduction in the number of clients absconding from the queue owing to lengthy waiting times for the procedure:Then we’ve got clients with complications that need our attention. And we also have new cases. Clients that need to be circumcised on that day. 2wT reduced the number of in-person reviews, so it makes life easy on our side as well...On that day, you find that we still having 100+ clients with those who were cut 48 hours ago who came for check-up. And then that itself puts us in a spotlight whereby we find ourselves fighting with the parents, fighting with the clients themselves and fighting with the next-of-kin, because they all need to be attended to, all of them, at the same time, which is highly impossible.P7.HCWs identified that reduced workload would translate to reduced travel and fuel costs for the program, “which is great, because our fuel bill can be hugely expensive” (P3). Respondents also noted that reduction in unnecessary travel would reduce the pressure on the VMMC driver, typically 1 per siteHCWs reported that the 2wT system is simple to use for HCWs. “The system is not complicated. It’s just it needs one to be on the system daily to get used to the things that needs to be done. It’s not complicated at all” (P1). Another HCW reported the following:This system, I enjoyed it so much...This has been with me I didn’t have a problem with the system. It was straightforward. First basically self-explanatory. As long as they came and taught me a code it’s quite immediate. So, for me, it was not something that was like a mountain on my shoulders.P5The need for 2wT training appeared to be reasonable, with mentoring or on-site training using the suggested method of learning. An HCW noted how once they were trained and began using 2wT for daily follow-up, they trained others in 2wT use at the facility, providing subsequent mentoring to ensure that the trainee was proficient:Some are meant to teach someone else or train someone else with what you’re doing daily. For me, it’s easier to teach another clinician...because I’m usually doing 2wT. I will show them step by step. The following day, maybe show them again the next time then they can do it. I don’t think it’s a very difficult thing to show them. But yeah, it does need time for them to understand.P2“There’s only three clinicians and it’s a busy day. We’ve got so many clients to cut. In those particular days. It’s really hard to sit down and answer [2wT] when there are clients waiting” (P2). Several HCWs noted that 2wT only works with an effective clinical team approach where HCWs work together to balance and rotate responsibilities for performing MCs, conducting follow-up for men who want or need in-person review, and interacting with men via 2wT. One of the participants said the following:Although 2wT is reported to be user friendly, some HCWs, particularly those in understaffed VMMC facilities, reported that they were short staffed, so the additional work of responding to clients while performing other duties was overburdening them. On the texting side is that if there is no teamwork, if we can’t work together as a team, you will find yourself working alone, even on weekends, because now you’d be on the 2wT responding, doing things, and then there is no rest for you.P4“it’s really this recording of the same thing over and over and over in different places, you know, it’s that intake form, then it’s medic mobile [2wT system], then it’s the Google Doc, it can be quite time consuming, especially if you’re having a busy day at the clinic” (P3). Combined 2wT intervention and RCT tasks created an undue burden for routine HCWs who were supposed to perform VMMC and conduct follow-ups in addition to daily RCT monitoring:HCWs expressed some confusion as to what tasks were part of the 2wT intervention and regarding the requirements for RCT-specific monitoring, leading to a lack of initial buy-in and confusion about 2wT follow-up workload. Research-specific tasks, including the duplication of patient reports in both routine paper (NDoH) and electronic research reporting , added considerably to the staff’s workload. Remarking on the increased documentation, one of the HCWs lamented, When there are clients waiting...we had like 17 clients, we cut all those 17 clients in one day, it was a very busy day that we even finished around half past six. So, if we had to answer the phone, and enroll clients, update the Google Doc, it was it was impossible to happen. So, the challenge is the shortage of staff members, and maybe increase work for the staff member.P2“once people understand that it’s going to be part of routine care,...they will definitely buy into it” (P3).Due to staff turnovers, HCWs received refresher training that enhanced their understanding of RCT versus routine activities. This added orientation was implemented to “make sure that and reassure people that two-way texting is part of your normal VMMC routine” (P4), hoping that “Usually, we do not work on weekends. So then, now...our clinician has to make sure that they check the system” (P1). Some clinicians “won’t take the phone over weekends or after hours because [they] see it as work and its overtime, and [they] want to be paid for it” (P3). However, another nurse noted that she feels personally responsible for the men, making herself available to interact with men who work nightshifts:Men also responded via 2wT over weekends, after hours, and on public holidays, creating work for the clinician outside routine clinic hours. Although there is an automated 2wT response that indicates the clinic is closed and provides emergency numbers, one of the clinicians noted, I always check are there any messages that might have come in late, because some guys work the night shift. So, they only respond when they go to work and they’ve got some time in between. Because during the day, they’re sleeping. So, you know, you won’t get a response from them. But only after hours, you get a response. So, I find that if I just check before I go to bed, whether it be 9 o’clock or whether it be 11 o’clock or midnight...just to make sure that there’s nothing.P3The 2wT system can potentially exclude clients based on their access to cell phones, literacy, disability, and other health dimensions. One of the HCWs stated, “[2wT] would be a problem for the ones that do not have access to cell phones” (P1). Another HCW suggested that illiteracy was also a limitation for clients by stating, “it would also become an issue for the ones who cannot read or write. So as much as it will help our VMMC clients, there will be a portion that might be left behind” (P1). Age could also be a limiting factor owing to potential unfamiliarity with technology and unwillingness to access health care via a phone, as one nurse stated, “...our generation, we are technologically aware. All those who are in their 40s and upwards? It was a little bit of a strange phenomenon, I would say. They don’t believe in such a way that I can just communicate with someone via phone, they still [prefer visits] physically” (P5). Finally, some clients require closer postoperative monitoring because of underlying comorbidities; in such cases, nurse-led clinical monitoring would be expedient:For example, you have a diabetic. You can’t have them not coming in...and also immunocompromised people, you know, unless they are properly stable on the medication. You want to see them because obviously, things can go wrong quite quickly, if you don’t monitor them in person.P3. The lack of access to Wi-Fi at home was another limitation reported by a participant who worked after hours at home and reported challenges with “the data connection because sometimes when you are home, it’s not easy” (P2).Technological issues such as tablets with low memory or slow network connections affected enrollment, as VMMC clients required confirmation of an enrollment text or the response rate of HCWs to clients’ messages if the network was slow. In rural areas, this issue was felt more often because with 2wT, “you should be always making sure that you check the clients on the 2wT app. At times as we travel, there’s a network problem” (P4). Network issues could result in clients not being enrolled into 2wT “because we have to actually see the [2wT enrolment message] when we are doing enrolment before the client leaves the facility” (P1), or the client resorts to in-person visitsThe 2wT system was considered usable, acceptable, and advantageous by all the HCWs in this formative, qualitative study in South Africa, providing benefits such as cost and time savings, ensuring quality patient care, and improving access to postoperative clinical support. These findings confirm previous results regarding the usability of 2wT for VMMC in Zimbabwe, where 2wT was also found to be usable, acceptable, and advantageous for HCWs to provide quality postoperative VMMC care -19,37. IFirst, using an HCD approach helped match the app adaptation to the local context. Familiarity with the use of mobile phone technologies such as WhatsApp  and SMS text message exchange improved HCWs’ ease of using and confidence with the system from study inception. Using this solid foundation, the HCD process ensured that the app features (reporting content and provider decision support), flows (clerk vs nurse 2wT activities), and alerts  reflected the local VMMC program and service delivery in both rural and urban contexts. Consistent feedback sessions with HCWs as part of the HCD process resulted in a 2wT app that was user-friendly, intuitive, and supportive of clinical decision-making. Because of HCD, HCWs expressed that 2wT was easy to use, reducing anxiety and increasing the motivation to adopt 2wT for postoperative care. Moving forward, additional adaptations should also follow this cocreation process with HCWs, giving them a clear voice and opportunity to contribute to apps designed for their benefit.Second, the TAM behavioral theory aided in the understanding of how and why 2wT’s usability and acceptability grew over time ,32, infoThird, although the 2wT reduced workload in terms of in-person visits, 2wT does require HCWs to spend time on interacting with, and providing telehealth for, patients. Instead of routine postoperative reviews, providers regularly monitored the 2wT system, interacting with patients via SMS text messages and reporting any potential AEs within the 2wT system forms, which is a trade-off in terms of work activities but not a true reduction in work hours. Patients who responded after hours, or requested help during evenings and weekends, also conflicted with subjective institutional norms, where overtime work is compensated through overtime pay. In addition, service delivery patterns or seasonal scheduling, such as high face-to-face patient loads on certain days, limited HCWs time to respond to postoperative clients on the 2wT platform, delaying their and, in turn, their clients’ responses. These realities negatively impacted HCWs’ attitudes toward and use of 2wT, as evidenced by some HCWs’ refusal of or delay in replying to clients outside of clinic operating hours or during busy work hours. HCWs suggested that having additional personnel tasked specifically with 2wT duties or a rotation of nurses to handle off-hour or weekend calls would increase buy-in and reduce potential care delays.Fourth, conducting an RCT in a routine public health care setting and relying predominantly on routine HCWs has clear advantages in terms of understanding real-world opportunities, working within existing constraints, and gaining insights into successful sustainability and scale-up. A research coordinator was deployed at each site for study-related activities , whereas routine VMMC teams were expected to complete all other routine VMMC-related tasks and NDoH forms for study participants as part of their normal duties without additional compensation. However, post hoc HCD sessions with routine HCWs and the RCT research team illuminated core confusion in research (RCT specific) versus routine  activities, muddling workload perceptions. For example, on top of routine work, existing VMMC staff members were tasked with completing time-consuming daily study logs of enrolled patients’ clinical processes and completing both paper- (NDoH) and 2wT-based visit documentation, activities that took time but did not continue beyond the study. Additional sensitization would help clarify routine versus research tasks and potentially help HCWs distinguish temporary study-related documentation from the intervention itself. This could aid HCW buy-in and better set expectations for workload benefits. Continued conversations with relevant stakeholders, such as the NDoH and other MC implementation partners, on integrating 2wT into the current documentation systems would further lessen HCW workload and centralize important patient health information.Finally, continued emphasis on the rigorous evaluation of digital innovations, especially in routine health service delivery settings, will strengthen the evidence base for mHealth optimization and expansion . A comprFirst, although 2wT’s usability among HCWs was high, the HCD process could not ensure that 2wT optimization addresses all the challenges of real-world implementation or incorporate all suggestions. The 2wT system is not a one-size-fits-all solution for weaknesses in VMMC programs but a focused digital health innovation aimed at addressing the dual concerns of quality and workload. If 2wT optimization supports most men who underwent VMMC in most locations to use 2wT successfully, HCWs and resources can be focused on attending to men with concerns through 2wT, conducting reviews for those who cannot be enrolled into 2wT, or addressing other gaps in VMMC service delivery. Second, patients’ experiences of 2wT were not included in this study but were explored in a parallel study. As with most qualitative studies, the small sample size reduces the diversity of perspective; additional KIIs in subsequent 2wT study phases will expand insights into 2wT scale-up. Furthermore, HCW participants’ experiences with the 2wT system were confounded with the experience of undertaking an RCT with its associated paperwork. Moreover, likely because of severe HCW scarcity and low resources, KIIs noted challenges with teamwork and workload distribution at the site level. Although beyond the scope of this paper, additional understanding of and amelioration of these work site constraints could improve the success of this or other innovations. Finally, although community health toolkit–based apps are optimized for low-connectivity and low-power settings, sporadic network issues that slowed or stymied client or provider communication lessened confidence in the system. As infrastructure improves, it is hoped that these challenges will reduce over time.HCWs involved in the 2wT post-VMMC follow-up approach found the system to be both usable and acceptable but also noted several improvements to bring 2wT to scale. Several suggestions were implemented immediately: (1) 2wT patient counseling was enhanced to better illustrate expected patient responses, reinforce AE warning signs, and remind patients that 2wT is not for emergencies; (2) educational messages were integrated with daily response messages to remind men about normal wound healing progress; and (3) cheat sheets were provided to 2wT nurses to guide daily task completion. Other suggested changes are more complex and require a more systematic or system-wide approach. HCWs noted that a rotation system, shift in work hours, or compensation for overtime was needed to interact with men using 2wT during nights, weekends, or holidays. Although these challenges are not easily addressed, additional HCW sensitization to promote the workload trade-off of 2wT interaction versus time-consuming, largely unnecessary physical postoperative visits could help facilitate HCW buy-in for the 2wT approach. Additional 2wT app modifications could also improve the intervention in the future. First, as HCWs principally use 2wT on smartphones or tablets to communicate with patients, a system-generated audible 2wT message notification, as is common with SMS text messaging or WhatsApp, could help provide an audible nudge to improve timely responses. Second, additional logic flows or machine learning could automate initial responses to common wound care concerns , relieving the workload of responding to expected, low-risk questions or requests for reassurance. Overall, HCWs enjoyed the process of providing feedback and insights. Attention to both HCW cocreation and the incorporation of HCWs’ suggestions would ensure continued HCW buy-in and support for 2wT scale-up.


Subgroup analyses for Narrative Enhancement and Cognitive Therapy (NECT) produced a statistically significant and highly homogenous effect ; I2 = 0%). In conclusion, the majority of the psychological interventions are successful in lowering levels of internalized stigma, especially NECT, and interventions that integrate multiple therapies may be more beneficial.In recent years, psychological interventions have been used to alleviate internalized stigma in people with schizophrenia spectrum disorders, but outcomes have been inconsistent. The aim of this review was to examine the existing evidence regarding this matter. Four electronic databases  were searched from inception until 8 September 2022, using appropriate strategies. The eligibility, quality, and strength of evidence of each study were all evaluated against the predetermined standards. Further quantitative analyses were performed using the RevMan software. A total of 27 studies were included in the systematic review. Eighteen studies with extractable data for meta-analysis yielded a statistically significant overall effect (Z = 3.00;  Internalized stigma occurs when an individual with a mental health condition adopts stigmatizing attitudes about their condition as their own. This acceptance can have a negative impact on the person’s sense of self-worth and ability to recover from their illness ,2,3. IncSchizophrenia is a renowned, serious mental illness that affects a large number of people in society. According to the WHO in early 2022, schizophrenia affected approximately 24 million people, or 1 in 300 people (0.32%) worldwide . Males aThe World Health Organization has identified three main points regarding stigma and mental illness: (1) stigma is the primary reason for discrimination against and rejection of people with mental illness; (2) stigma has negative effects on both the prevention of mental health problems and the treatment and care of those who suffer from them; and (3) stigma violates human rights . AccordiPsychological interventions aiming to reduce the detrimental effects of internalized stigma on individuals with schizophrenia spectrum disorders have garnered considerable attention in recent years. The results of several systematic reviews and meta-analyses published in the last few years on interventions to diminish internalized stigma are still inconsistent ,26,27,28The aim of this study is to perform an updated systematic review and meta-analysis of the evidence for the effectiveness of interventions for internalized stigma among adults with schizophrenia spectrum disorders and to determine the efficacy of interventions on internalized stigma reduction among adults with schizophrenia spectrum disorders.The systematic review and meta-analysis have been carried out in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline ,36. It wThe search was conducted across four electronic databases: EMBASE, MEDLINE, PsycINFO, and the Cochrane Central Register of Controlled Trials. Materials that existed from inception until 8 September 2022 were obtained from the selected electronic databases by using their own designed search strategy made from phrases with acceptable truncation (indicated with asterisks) and Boolean operators of AND and OR. The related search terms were “adults”, “Not adolescents, elderly”, “schizophrenia”, “psychosis”, “delusional”, “schizoaffective”, “mental illness”, “mental disorder”, “perceive stigma*”, “perceived stigma*”, “selfstigma”, “self stigma”, “internalized stigma”, “internalised stigma”, “shame”, “stigma intervention*”, “stigma reduction”, “antistigma”, “anti-stigma”, “destigmatisation”, “destigmatization”, “educat*”, “attitude change”, “NECT”, “CBT”, “photovoice”, “coming out proud”, “self disclosure”, “psychoeducat*”, “depression literacy”, “pamphlet*”, “brochure*”, “booklet”, “contact-base*”, “video-base contact”, “video-based contact”. The search method was restricted to English-language publications and research involving human participants. No geographical limitations were imposed. A bibliographic search from relevant systematic reviews and acceptable studies was carried out at the start of the research to maximize the likelihood of finding relevant studies.Studies included in the review met the following criteria: (1) used a randomized controlled trial or similar type study design ; (2) includes individuals ranging in age from 18 to 65 years old; (3) evaluated interventions for reducing internalized stigma; (4) quantitatively assessed the reduction in internalized stigma; and (5) published full papers in the English language. The exclusion criteria were (1) non-English language papers, (2) case reports, reviews, unpublished research, conference abstracts, trial protocols, and proceedings, and (3) studies that did not include people from the diagnoses of schizophrenia spectrum and other psychotic disorders.www.covidence.org (accessed on 8 August 2022)]. This program will automatically sort out any duplicate studies upon import, making it much simpler for two independent reviewers to examine the titles and abstracts of the research. Thereafter, the eligibility of the entire texts was meticulously examined based on the inclusion and exclusion criteria that had been established previously. When there were discrepancies between the two reviewers (SJ and other members of the team), a third reviewer or the group’s consensus was used to reach a decision.All of the collected search results were subsequently transferred to reference management software ; n = 1633), although there was considerable heterogeneity . This indicates that on the whole, the interventions that were utilized were effective in lowering internalized stigma in comparison to Treatment as Usual or the Waiting List; nevertheless, there was a significant amount of variation across these studies ; n = 297), as well as there was considerable heterogeneity ; I2 = 85%). Even after further segmentation according to age, gender, duration of illness, and level of education, there was still high levels of heterogeneity.Four studies compared the effectiveness of Group Psychoeducation to that of Treatment as Usual (TAU) or the Waiting List (WL) ,31,32,41There was no indication of publication bias in any of the papers that we chose to include in the meta-analysis, as can be seen in the funnel plot that is shown in This review found that certain interventions may be effective methods for reducing internalized stigma; however, variations in these interventions needed to be considered as well. The overall rating of B for the NHRMC Evidence Statement Matrix was given. This indicates that there is some evidence in support of the recommendations, but caution should be exercised while implementing them. This study explores a number of various psychological interventions that have the potential to reduce internalized stigma in individuals who have been diagnosed with schizophrenia spectrum disorders. To the best of our knowledge, this is the largest review to date on psychological therapies for internalized stigma in schizophrenia spectrum disorders, encompassing a total of 27 studies with a combined sample size of 2975 individuals from 15 different countries. Overall, the findings suggest that a variety of psychological therapies may be effective in reducing internalized stigma in people with schizophrenia spectrum disorders. A systematic review of studies revealed that 15 out of 27 trials yielded statistically significant results in favor of psychological therapies for decreasing internalized stigma. This is further supported by the meta-analysis of 18 trials, which demonstrated a significant effect of the therapies in reducing internalized stigma compared to Treatment as Usual or the Waiting List.According to the findings, not only was Narrative Enhancement and Cognitive Therapy (NECT) somewhat effective from the standpoint of the systematic review, but it was also efficacious from the perspective of the meta-analysis that we conducted. These results are consistent with those of previous research that came to the conclusion that NECT is beneficial in reducing self-stigma as well as other subjective components of recovery such as hope and self-esteem in people who have suffered from psychotic-related illnesses ,48,54. NBased on the findings of previous studies, Group Psychoeducation was the most commonly used psychological intervention for reducing internalized stigma ,26,28. TIt was discovered that among the most effective interventions were those that included a few different therapies. Combinations across therapies such as psychoeducation, cognitive behavioral therapy, social skills training, mindfulness, problem-solving skills, communication skills, and support groups were common. Among the interventions that had such multi-faceted elements were Self-stigma Reduction Program , AntistiAnother notable matter is that the majority of the available interventions are carried out in groups rather than individually or in a combination of the two. This trend may have arisen for a variety of reasons, including the fact that group therapy is commonly viewed as more efficient financially and time-wise; patients gain comfort in knowing they are not alone in their struggles ; individFurthermore, internalized stigma is a multifaceted phenomenon that is comprised of a variety of components. One of the most effective strategies for overcoming it is to first identify the relevant principal targets that are involved, followed by prescribing interventions that are designed to explicitly address those targets while also taking into account many other aspects of the patient’s capabilities and requirements. For instance, we may use the Internalized Stigma of Mental Illness (ISMI) Scale to determine which parts of internalized stigma are primarily impacted in a patient. This can be carried out by analyzing the patient’s responses to the various questions on the scale. If Stereotype Endorsement and Alienation are a problem, then interventions such as NECT , SolutioAmong the strengths of this study is that, to the best of our knowledge, this is the largest review to date on psychological interventions for internalized stigma in schizophrenia spectrum disorders. In addition, this is also the first meta-analysis to examine the effectiveness of Narrative Enhancement and Cognitive Therapy (NECT) in lowering internalized stigma in people with schizophrenia spectrum disorders. However, there were some limitations to our study. Firstly, we limited our search to only include studies that had been published in English. As a result, we are unable to include the findings of other research that was published in a variety of languages, which leaves open the potential for publication bias. Secondly, the studies that were included in our research at times employed varying definitions of internalized stigma to some extent and also assessed it using different questionnaires that each had their unique method of ascertaining it.Recommendations for future research include conducting more clinical trials testing the efficacy of each psychological intervention. This would allow for the measurement of pooled effects for each intervention, so providing a clearer picture of each’s effectiveness. After that, head-to-head comparisons of successful interventions might be conducted, yielding the most effective intervention. In addition, we also recommend that future research focus on the patient-tailored strategy of prescribing therapies based on the detected elements of internalized stigma.According to this systematic review and meta-analysis, the majority of the psychological interventions evaluated are successful in lowering levels of internalized stigma, the use of NECT shows promise, and interventions that mix several therapies may be more beneficial. The strength of our research is that it is the largest review to date on psychological interventions for internalized stigma in people with schizophrenia spectrum disorders, as well as the first meta-analysis to evaluate the effectiveness of Narrative Enhancement and Cognitive Therapy (NECT) in lowering internalized stigma in people with schizophrenia spectrum disorders.Insights from this study have the potential to give mental health practitioners more effective alternatives for implementing psychological therapies to reduce internalized stigma. Moreover, we recommend that future research focus on the patient-tailored strategy of prescribing therapies based on the detected elements of internalized stigma. In addition, we urge that future studies concentrate on the patient-tailored method of prescribing therapies based on the detected elements of internalized stigma.


Human response times conform to several regularities including the Hick-Hyman law, the power law of practice, speed-accuracy trade-offs, and the Stroop effect. Each of these has been thoroughly modeled in isolation, but no account describes these phenomena as predictions of a unified framework. We provide such a framework and show that the phenomena arise as decoding times in a simple neural rate code with an entropy stopping threshold. Whereas traditional information-theoretic encoding systems exploit task statistics to optimize encoding strategies, we move this optimization to the decoder, treating it as a Bayesian ideal observer that can track transmission statistics as prior information during decoding. Our approach allays prominent concerns that applying information-theoretic perspectives to modeling brain and behavior requires complex encoding schemes that are incommensurate with neural encoding. Human response time during task performance is one of the most widely studied phenomena in behavioral psychology. The time it takes to respond to a stimulus provides a measurable behavioral window into otherwise hidden cognitive processes, facilitating insight into diverse aspects of cognition such as priming effects , which we will denote p(s). Let N be an array of n Poisson processes, or simulated neurons, with a baseline firing rate ρbn-length vector ρb, ρb, …]. This vector represents the channel’s noise. An encoder g encodes a message s by increasing the firing rate of each neuron in N by some value, written as an vector ρs,1, ρs,2, …, ρs,n]. The total firing rate of the vector of neurons encoding message s is then ρb + ρs,1, ρb + ρs,2, …, ρb + ρs,n]. This vector represents the channel’s signal.In the model we propose, an encoder encodes discrete symbols into an array of Poisson process rates with noise added. A decoder observes events produced by the Poisson processes and decides which symbol is being encoded. This scenario is illustrated in n = 3 and a signal s1 had a corresponding signal vector ρb = 6. Then the overall firing rate, in spikes per second, would be For example, suppose the population of neurons was size C  = p(s|et) of the number of observed spikes given each message, as shown in Let the set of symbols and corresponding “signal vectors” be stored in a codebook C . The jobs is being encoded? The decoding cannot be instantaneous: in zero time, zero spikes will have been observed. The random nature of the observations, generated as they are by Poisson processes, means that the decoder should never be 100% confident in any decoding judgment, no matter how much time has passed. Taken together, these imply that the decoder should observe spikes emitted from the encoder until it is sufficiently confident in the encoded symbol, or said another way, until its uncertainty about the symbol value is sufficiently reduced. As is common in models of information transmission, we use the self-entropy 𝓗 to compute uncertainty.How long will this ideal decoder take to infer which signal Pr(S = s) = q(s). Note that the true transmission frequency p(s) and the decoder’s belief about transmission frequency q(s) may be different distributions. The decoder uses Bayes’ rule to compute a posterior belief over possible messages, Pr(S = s|et) ∝ p(et|s)q(s) = q(s|et), using q to indicate that the value includes the decoder’s (possibly incorrect) prior beliefs. Let the vector of posterior probabilities at time t be referred to as Qt, with an initial entropyQt|et) in an example transmission is shown in The decoder’s uncertainty depends on the likelihood of the observations, but it also depends on the decoder’s prior belief about how likely each symbol is to be transmitted, call this https://github.com/tom-christie/transmit.Our goal in this section is to demonstrate via simulations the relationships between patterns of decoding times the model described above and patterns of response times described in the literature. In particular, we show that a very simple model can parsimoniously account for a range of phenomena. We instantiated the model in both R and Python. Code used to reproduce the results in this section is available at ρb > 0 and where the signal rate for a single neuron ρs,i > 0 and ρs,j = 0 for all other neurons j ≠ i. Despite our use of Poisson processes, the model presented here is not a model of neural activity; rather, it is a toy model designed to show that a wide range of phenomena can, in principle, arise from basic principles.Our interest in the current paper is in investigating qualitative similarity rather than quantitative model fitting. To that end, we keep the model and encoding scheme as simple as possible. With the exception of our analysis of sparse coding, the codebook consists of 1-hot sparse codes, with a pre-specified noise rate ρb = 10, a codebook with 10 possible messages (encoded as a 1-hot vector where each neuron corresponds to a symbol), with three different signal powers, Low (8 spikes/second), Medium (10 spikes/second), and High (15 spikes/second). The entropy threshold was set at 0.5 bits, and the decoder utilized a uniform prior over possible symbols, with a corresponding initial entropy of log2 10 bits. The plot shows the distribution of decoding times for 2000 transmissions for each level of signal power.Human response times are characteristically noisy, varying substantially even with repeated presentations of the same stimuli. This variability is well-modeled by both Wald and shifted log-normal distributions  is bounded from below by the entropy of the source producing symbols to be transmitted. The entropy of the source, of course, is linearly related to the logarithm of the number of equally likely possible symbols. To our reading, Laming is criticizing Hick’s inference that the logarithmic relationship between response time and the number of options is an outcome of this relationship because the relationship can only hold if the encoding were transmitted while maximally compressed. Compression, in turn, requires knowledge of symbol statistics and a complex encoding scheme. Or does it?S, the set of symbols. As before, the decoder used a uniform prior over possible symbols. The results shown in without sophisticated encoding schemes or the transmission of many messages together in a long block. It is worth considering how this is possible.To investigate the relationship between decoding time and the number of possible symbols, we transmitted symbols while varying the cardinality of does appear to be linear with the entropy of the decoder’s prior belief about message symbols across tasks, or said another way, across codebooks. For each task, this relationship is dependent on the decoder’s prior belief over symbols, because the prior (rather than the source statistics) defines the effective entropy of the symbols. As it is a function of the decoder’s belief, entropy is a subjective value. If the decoder’s belief about the relative likelihood of symbols changes, we should expect decoding times to change accordingly. Indeed, our results in Hick interpreted his data as suggesting that information is transmitted from stimulus to response at a constant rate, which manifests as a logarithmic relationship between the number of possible stimuli and response time. Our model reveals the same relationship. At first glance, this result seems to contradict our claim above that information transmission is not linear with time, but has diminishing returns. This confusion is an opportunity to make a subtle but important point. In our model, indeed, information transmission (as captured by uncertainty reduction) is not constant over time while decoding a single symbol. However, decoding time must be learned through practice rather than explicit instruction. Despite being aware that there are e.g., 10 bulbs to choose from, the subject behaves as if there are many more possibilities, as reflected by their response time, until practice is achieved and the probability mass on the decoder prior rests heavily on 10, and only 10, options. Viewed a certain way, practice can be seen as a mechanism for compressing stimulus features until only those most relevant to the task at hand are considered as plausible “symbols” to be decoded. Once this has taken place, the number of possible stimuli does appear to vary logarithmically with response time.We cannot know the prior belief of the subjects in Hick’s experiment, but we do know they practiced the task extensively. Hick asked subjects to practice each condition many times; the reported number is at least 8,000 on his first experiment. He also reported practice effects in Figure 3 of his Hick,  paper, arate do response times achieve this apparently efficient value as a function of practice? We will address each of these in turn.Several questions arise naturally at this point: What if stimuli have unequal probability? What if the decoder’s prior belief is incorrect? And finally, at what belief about the relative probabilities of the stimuli, specifically the stimulus surprisal.While Hick’s findings describe a relationship between the number of stimuli and response time, Ray Hyman varied the statistics of stimuli within the task, both by modifying the relative frequency of stimulus options and the conditional probabilities of sequences of stimuli Hyman, . Hyman’set at the time the decoding decision is made, averaged over many transmissions:q(s), is the same for each transmission, but the posterior has its probability mass re-weighted over symbols, with the most mass on the most likely symbol given the observation. When a rare symbol — or a symbol believed to be rare — is being decoded, the divergence between the prior belief and the belief at decoding time is large. It takes longer for this symbol to be decoded than a likely symbol, as it takes longer to collect sufficient evidence to overwhelm a skeptical prior. This is reflected in the decoding time, which once again appears to be linear with information gain. To reiterate, this relationship holds across messages, but not within individual transmissions.We simulated Hyman’s manipulation by transmitting four symbols with a non-uniform distribution and recording decoding times. In each case, the decoder had accurate prior knowledge of the relative message frequencies. As suggested above, this is our model’s equivalent to a subject having had extensive practice at a task—and indeed, Hyman reports over 15,000 reaction times recorded over a course of 3 months for each subject. Decoding time is a function of the decoder’s prior belief about message frequency rather than the probability of messages defined by the symbol generating process. Accordingly, a uniform prior over messages with very different source frequencies will result in uniform decoding times. As the decoder’s prior changes, so does the decoding time for messages: messages believed to be more likely will be decoded more quickly, because less evidence is needed to “convince” the decoder of the signal’s content. This relationship is illustrated in If the decoder’s prior belief about message frequency influences decoding time, we should be able to minimize decoding time by optimizing the prior to match the true frequency of symbol transmissions. Efficient coding systems, such as Huffman coding, achieve optimal codes by perfectly matching an encoding scheme to the statistics of the messages to be encoded. In practice, however, perfect knowledge of the message statistics is often unavailable and must be estimated and continually updated from observations.Suppose a person began practicing an unfamiliar task with many trials. In the beginning, they would have very uninformative, mild beliefs about task statistics: they could not know which stimuli occur at what rate, or even which features of the environment are task-relevant. During the course of practice, two things happen: the person would narrow their focus to only task-relevant stimuli . We would expect each decoder to start with a distinct value for q(s) and maintain a distinct learning profile that is characteristic of the specific sequences of messages the decoder has received.The power law of practice  has been criticized as describing aggregate behavior over subjects rather than the expected learning rate of any individual , incongruent (‘green’ written in red ink), or neutral (‘green’ written in black ink). When compared to the neutral condition, response times are characteristically faster when stimulus properties are congruent, and slower when incongruent Stroop, .We modeled the simultaneous transmission of two symbols  creating an encoding consisting of a linear combination of the constituent rate vectors. Resulting response distributions are shown in n-length vectors of firing rates). This mapping was available to the decoder during decoding, consistent with our model assumptions above.While the above results prioritized simplicity by mapping discrete signals to 1-hot vectors of firing rates, we additionally investigated the characteristics of learned codebooks. To do this, we used a reinforcement learning algorithm to learn a codebook that minimized a combination of decoding accuracy, decoding time, and the number of spikes during transmission. In this paradigm, the agent acts as both transmitter and decoder and is tasked with learning a policy (encoding) that maps states (symbols) to actions , which models the accumulation of evidence via a log-likelihood ratio as a Wiener process . We accordingly consider it a model of ‘information accumulation’ by the decoder rather than ‘evidence accumulation.’The DDM can be understood as a continuous-time version of Wald’s Sequential Probability Ratio Test, introduced in Wald . Wald asimplementation of information theoretic concepts to human behavior, but that the wholesale disregard of information theoretic ideas is not warranted.The application of information theoretic concepts to inference in a non-standard way is a key contribution of our model. The model explicitly treats a collection of Poisson processes as a noisy channel over which a message can be transmitted by modulating the processes' rates. The decoder maintains a codebook and updates its uncertainty in real-time as spikes are observed. Entropy is the appropriate quantification of message uncertainty in this context, as it captures subjective uncertainty and is scalable to any number of possible symbols. Entropy computed over the decoder’s posterior belief additionally provides a natural place for leveraging learned task statistics to optimize decoding times, which is critical for reproducing both the Hick-Hyman results and the power law of practice. As applied in engineered systems, information-theoretic models of signal transmission typically maximize efficiency and minimize error by grouping adjacent sequences of symbols and encoding them in batches (Cover & Thomas, The results described in this paper were produced by simulations with brute-force sweeps to find parameter values that fit human data. Unfortunately, we do not yet have a closed-form relationship between model parameters and expected decoding times. Such a relationship would facilitate easier model fitting to experimental data and Bayesian model comparisons with competing approaches. We intend to perform such a comparison in subsequent work.In addition, the model has several simplifying assumptions that could be relaxed. For example, we assume that the decoder knows when the transmission of each symbol begins, with decoding time computed as the difference between the transmission start and the time the entropy threshold is reached. It would be worthwhile to investigate an alternative model in which the decoder continually observes a series of spikes, waiting for a message. We also assume that the decoder maintains a full list of possible messages in the codebook, but we could consider a mechanism for learning the codebook via observations. Finally, while we have provided an analogy between our model and the channel model of transmission, the relationship should be formalized, with the nature of concepts such as transmission rate articulated in the new model.in principle via simulation. We hope this model, and the conceptual shift from evidence accumulation to information accumulation that it requires, stimulates renewed interest in information-theoretic analyses of human behavior.The goal of this work is to show that several characteristic patterns of response time can be generated by a simple model of continuous-time inference using information-theoretic framing. We have used information theory to provide a parsimonious explanation for a range of behavioral phenomena that were widely assumed to be unrelated. The spirit of this work is aligned with the recent proposal by Zénon et al.  that cog1 The baseline firing rate reflects neural “noise” present in recurrent dynamics. It also forces decoding times to take the form of a positively skewed distribution rather than an exponential distribution. Without noise, the first spike in a 1-hot encoding would unambiguously reveal the encoded message.2 dt = .1 seconds. The only effect of a smaller dt is increased precision of decoding times.To instantiate the model computationally, the entropy of the decoder is continually updated at a set time interval 3 Marr’s second level of analysis Marr, .The authors thank the organizers of the “Information Theoretic Principles in Cognitive Systems” workshop at NeurIPS 2022 for creating a venue for rich discussion about early versions of this work and related topics. We thank the anonymous reviewers for thoughtful and thorough feedback. Finally, we thank John Moore for continued encouragement and editing help on short notice.S. Thomas Christie: Conceptualization, Data curation, Investigation, Methodology, Software, Visualization, Writing—original draft, Writing—review & editing. Hayden Johnson: Data curation, Software, Visualization, Writing—original draft, Writing—review & editing. Paul Schrater: Conceptualization, Methodology, Supervision.This project did not receive grant funding.https://github.com/tom-christie/transmit/vignettes.The code used to run simulations and generate plots can be found at


Mental wellness can be related to healthier living, the learning process and working environments for people in the university community. A wide range of mental wellness programmes have been explored to provide students with pleasant and satisfying experiences. The purpose of this study is to explore the effects of integrating Zen meditation and music listening on the mindfulness and happiness levels of university music therapy students. A qualitative methodology was used, and data were collected through surveys and semi-structured interviews. To investigate various aspects of data regarding the role of the meditation and music (MM) programme for mindfulness and happiness, this study used thematic analysis within a qualitative research design. The findings of this study suggest that the 8-week Mindfulness Meditation (MM) programme is a potential approach for enhancing mindfulness, happiness and stress management. These results carry broader implications, particularly in terms of supporting mental health resources in higher education. Furthermore, the study contributes to the ongoing discussion regarding the positive impact of combining meditation and music to promote mental well-being. This integrated approach has the potential to strengthen coping strategies and further promote the integration of music and meditation practices in various contexts, including higher education. Meditation and music are each widely used in health, education and social community settings to promote general health and emotional and social well-being ,2,3. In The feeling of happiness plays a vital role in the quality of life. Happiness is a subjective experience that encompasses positive emotions, life satisfaction, and overall well-being. When individuals experience a sense of happiness, it can have a profound impact on their physical health, mental well-being, and overall satisfaction with life . TherefoThis study aims to investigate how 8-week meditation and music (MM) programmes can contribute to cultivating a mindful state of mind and happiness, and examine the impact of these processes on students’ lives. There is a close relationship between mindfulness and happiness, as the practice of mindfulness has been shown to promote greater levels of happiness and well-being . MindfulIn this study, the feeling of happiness and mindfulness was explored using a combination of music and traditional Buddhist meditation based on Zen principles. The meditation practices incorporated elements such as present moment awareness, letting go, non-self, non-attachment and non-judgmental awareness, drawing inspiration from works like Nanamoli (1991)  and HanhIndeed, numerous studies have demonstrated the benefits of meditation and music in managing various sources of stress and pressure in university life, as well as improving academic achievements and emotional stability ,32,33. MIn this study, an 8-week MM programme was designed, integrating with meditation and music. In the past two decades, the benefits of combining meditation and music have been discussed, and mindfulness utilising music has been introduced in music therapy (MT) ,43,44. CMindfulness-based music therapy programmes have been increasingly adapted with various groups, including musicians, university students and those with Huntington’s disease, drug and alcohol dependency and autism ,50. LesiIntegrating meditation and music into mental health is not a new concept, and various aspects of meditation and music related to emotional wellness have been investigated ,51,52. AHow does the supportive and structured 8-week meditation music (MM) programme contribute to increases in the participants’ feelings of happiness and mindfulness?How does the MM programme have a positive impact on participants’ ability to cope with emotional difficulties and ultimately improve their daily lives?Therefore, the purpose of the current study was twofold: First, to explore the state of mindfulness and the feeling of happiness cultivated through an 8-week structured programme. Second, to investigate how an 8-week programme (combining meditation and music) would affect psychological well-being, distress, self-control, positive states of mind, calmness, distraction and the overall experience of daily life for postgraduate music therapy students. Hence, the following research questions were explored:The participants were invited to take part in this study to explore the effect of music and mindfulness on their ability to achieve mental wellness during the 8-week programme. The participants had to be 18 years of age and older and with no history of neurological or psychiatric illness, and people who were interested in meditation and music were recruited See . The memThis study employed a qualitative research methodology utilising thematic analysis. Data were collected through semi-structured interviews, aiming to obtain an in-depth understanding of the role of music and meditation in promoting mental wellness. The study also sought to explore the relationship between the 8-week MM programme and the participants’ levels of mindfulness and happiness.The 8-week MM programme See  took plaThe participants were informed that a session would consist of approximately 1–1.5 h. Each week, the programme consisted of: (a) a brief explanation about the session plan and setting intentions; (b) mini meditation; (c) music listening; (d) Zen meditation; (e) lying down meditation with music; and (f) sharing experience and closing See . For selInterviews: Data were collected through audio-taped semi-structured interviews with each of the participants who attended the MM programme. The interviews consisted of both direct and indirect questions and ranged from 50 to 60 min in length. Semi-structured interviews were chosen because they would allow the participants a certain degree of freedom to explain their views and remain open to ideas . The preThe main interventions of this study were mindfulness meditation, music listening and meditation with music See the  above.Music: The music was carefully selected depending on the session themes and types of activities. This is because different music brings different responses and results. Therefore, special attention is required to select music; for example, how the musical qualities  and duration of music can be matched with each meditation practice and activity. The majority of the music was relaxing music to provide a calming influence. However, other types of music were also used for some activities such as walking meditation. Every piece of music was short (between 4 and 9 min) in order for participants to not go too deep into a meditative state. Music genres included European classical music, new age music, binaural beat music, temple music and traditional Korean music. For the group listening, two wireless speakers were used. According to the theme of each week, participants experienced mindful music listening during each session and listened to background music before and after the session with selected music. Prior to the start of each session, participants were given handouts to read about all the resources of music in order to better understand the music resources.Mindfulness Meditation: In this study, various postures of meditation were conducted, such as sitting, walking and lying down, and instructions were given before each session. Second, several key practices from the traditional Zen meditation subjects (Kammaṭṭhāna) were applied such as breathing meditation (Ānāpānasati), loving-kindness meditation (Mettā), compassion meditation (Karuṇā) and light meditation (Āloka kasiṇa) . Third, For the qualitative data analysis, thematic analysis (TA) was used as it is an effective and systematic approach to identifying important themes from a large collection of interview data. TA can provide a theoretical framework for the qualitative analysis of in-depth interview data . In thisThrough the semi-structured interviews, six main themes, along with their respective subthemes and example quotes, were identified See .Many of the participants reported experiencing a shift in mindset, such as moving from a restless and wandering mind to being more present in the moment, and from a judgmental mindset to one characterised by non-judgmental awareness.“When I was listening, it’s kind of… I’m in the moment” (P2).Mindfulness is inherently a practice of present moment awareness, and the ability to be fully present is one of the main benefits of mindfulness practice . Partici“I don’t know what the word is…but I felt a bit more in touch with what was going on around me… like noticing small things, noticing sounds…you are on your own…you notice them and then you let them go” (P4).Participants frequently cited the advantages of cultivating a ‘positive mindset’, ‘practising non-attachment’ and embracing the concept of ‘letting go’. These practices provided a sense of peace and helped to calm overwhelming emotions and thoughts.“When I drive back home, I feel more awake and more present and sort of revived a little bit… I feel refreshed when I drive back…I felt a lot more positive about the journey” (P2).They discussed the positive impact of their shifting mindset on various aspects of their lives, such as their mindset, attitude and lifestyle. Many participants shared how the 8-week MM programme had become an integral part of their daily lives, and engaging in meditation and music practices played a role in cultivating a more positive mindset and attitude towards life.“I noticed a positive change in my attitude after our session…” (P3).Previous research has explored the relationship between mindfulness and attitude transformation. This encompasses the link between mindfulness and concepts such as letting go, fostering an accepting mindset, balancing active ‘doing’ with present ‘being’ modes, transforming negative thoughts and emotions into positive ones and shifting from restlessness to a state of calm awareness ,64. In tParticipants shared their experiences of feeling a sense of calmness and transitioning from restlessness to a more relaxed state while attending the MM programme.“This was my first time trying mindfulness meditation through music, and it felt very relaxing” (P6).“It made me feel calmer and more relaxed” (P2).The connection between music and its psychological and physical stimulation of positive emotions and relaxation responses has been a frequent topic of discussion ,65. Part“I know that it [music and meditation] is something that I should do on a daily basis and to be honest with this whole coronavirus thing going on what better time to start than now” (P4).Interestingly, the link between ‘feeling relaxed’ and ‘preferring meditation’ was often mentioned. Individual preferences for meditation were varied. The most favoured and relaxed practices were lying with breathing practice, mini meditation and informal mindfulness meditation.“I liked the compassion meditation and lying down meditation, they were really relaxing. I’ve never experienced anything like that before” (P3).“They [raisins meditation and chocolate meditation] were really interesting…I’ve never ever done anything like that before…that was a nice surprise” (P5).Several participants preferred the short version of meditation as they can quickly fall into meditation states and was not difficult to practise. However, some participants preferred longer meditation. P3 engaged in mindful observation of the back and spine areas, finding relaxation in the process. Both P1 and P4 expressed that ‘walking meditation’ held particular significance for them, and they expressed a desire to continue practising it, even on their way home.“Lying down meditation, even if it was a longer one, I could really get the full benefit of it” (P3).“I’ve never thought about really meditating when I’m walking and that’s really nice” (P1).P3 had never practised meditation before but found the breathing exercises particularly helpful in coping with university life. The benefits of meditation, which can be easily integrated into daily activities, have been extensively explored . BreathiThe words ‘centredness’, ‘attention’ and ‘concentration’ were frequently mentioned by the participants. They found that music could help clarify and focus their thoughts, enhancing their ability to concentrate for longer periods.“The music really helped me focus and concentrate better” (P1).Some mentioned focusing on the music with mindful breathing techniques helped reduce ruminative thinking. Indeed, attention to the present moment is the main practice of mindfulness and by doing this, it can stop overthinking which causes tension or stress ,30. P1 f“I think a lot and I can’t focus…but music helps me focus more on the here and now” (P5).Participants expressed that the aesthetic experience of concentration played a primary role in their ability to experience mindfulness and cultivate a sense of calm in their lives. By immersing themselves in activities that required focused attention and concentration, such as engaging with aesthetic experiences like music or nature, they found themselves entering a state of mindfulness. This state of focused concentration allowed them to let go of distractions, connect deeply with the present moment and experience a heightened sense of calmness and tranquillity.“When I listened to music during breathing practice, I felt like something was going [happening] deep inside of me…much more deeply” (P4).This finding highlights the significance of aesthetic concentration in facilitating the experience of mindfulness and its associated benefits. A participant said, “It [meditation] made me listen to the music in a more attentive way” (P7). During the 8-week programme, concentration practice and meditation were integrated into each session, as well as assigned for home practice. This integration was based on the understanding that concentration and mindfulness are closely interconnected .The literature extensively explores the state of mindfulness during meditation, further highlighting the relationship between concentration and the experience of mindfulness. Evans et al. (2017) discuss how meditation can strengthen the feeling of mindfulness and how mindfulness can be a useful tool for improving concentration levels . In Zen Many interviewees expressed a desire to incorporate music and meditation into their lives because of the benefits these practices provide. The integrated method of meditation and music had identified effects, such as ‘empowering’ and ‘supported experiences.’ For instance, P3 expressed, “I feel strong”. Participants use music and mindfulness in various ways, depending on their situations and needs.“It is really helpful and powerful” (P3).“This experience is very healing energetically and emotionally and can really connect you to other people” (P1).Some participants initially found meditation challenging, but with regular sessions, they became more comfortable with the practice. For example, P5 mentioned, “I feel I can access it and have a bit more direction in where I want to go with it”, while P4 said, “I’m starting to use mindfulness meditation, especially when I feel low in energy and distracted”. Consequently, it appears that participants perceived benefits from meditation and music, and they contemplated adapting these practices to enhance self-care and improve their quality of life.Throughout the 8-week programme, participants received materials and information from the session leaders each week to facilitate their home practice. The intention was to motivate participants to continue their exploration of music and meditation, not only during the programme but also in their daily lives. These materials were delivered via email every week and distributed in person by the session leaders after each session. This approach created an opportunity for participants to practice more frequently, with some even incorporating meditation into their nightly routines before bedtime, when possible. While some participants turned to meditation to address insomnia, others found that frequent practice helped them to achieve a psychologically stable state and improved sleep. Several participants actively applied the principles from the 8-week programme to their everyday lives. During the interviews, it became evident that they were actively seeking various self-care methods.The interviewees discussed personal challenges and how the MM programme assisted in coping with them. P3 said he encountered some challenging personal life experiences during the music and meditation sessions, but attending the sessions provided relief. P4 found that practicing mindful breathing and staying present with awareness can be very helpful in managing anxiety.“I suffer from anxiety anyway. That’s why I wanted to try this [combination of music and meditation] … and having that weekly … it just gave me like a sense of calm for the rest of the week” (P6).Five participants spoke of their sleeping problems and stated that these problems were the most stressful and difficult for them. P3 started practising meditation, both at university and at home, which included guided meditation for sleep to address night-time sleep issues, which were the most stressful times of the day for them. They commonly mentioned breathing meditation because they perceived that it improved their sleep quality. In fact, breathing-focused meditation has been frequently applied for insomnia . A numbe“I wake up like three/four in the morning with so many ideas and I keep waking up” (P1).“I meditated quietly while listening to music while lying down at night. This was the most relaxing time of the day for me” (P4).P7 mentioned music performance anxiety and believed that using any form of mindfulness meditation during a performance might be worthwhile and meaningful. P3 said that mindfulness is a journey of self-discovery or self-awareness beyond stress management. Indeed, mindfulness practice increased self-awareness and through this, people often obtained a deeper sense of self-understanding and self-acceptance . In addi“I feel better able to cope with stresses in my life” (P6).“I would like to do a daily practice of at least 10 min of meditation” (P4).Music and mindfulness have long been recognised, both separately and combined, as beneficial interventions for stress relief ,77. DuriOne interesting finding in this study was that, for some participants, their favourite music proved to be a much quicker way to induce a meditative state compared to music they did not prefer. This suggests that the impact of music on meditation may be influenced by personal preferences. Participants had varying opinions on combining meditation with music, both with and without lyrics. Some participants  favoured music without lyrics, as lyrics can carry specific meanings that could potentially distract them from their meditative state. However, P6 expressed a different perspective, finding meditation songs with lyrics to be the best, as the lyrics, akin to poetry, enhanced their relaxation experience with the music. Additionally, participants mentioned the combination of meditation with oriental music. P1 expressed curiosity about temple meditation music and had a keen interest in exploring new cultural music. Similarly, P8 showed interest in Eastern temple music.“It’s like opening a window to different ways of existing and living is a bit different from the likes of stressful society” (P8).Some pieces of music were unfamiliar to the participants, yet they discovered that even unfamiliar music could enhance their meditation experience. As P4 put it, “All music I found fascinating, whether I liked it or not”. Classical music was generally favoured for its capacity to induce a state of calmness, with P1, in particular, feeling more attuned to Western classical music. However, one of the participants did not enjoy classical music due to their association with it during music exams, which reminded them of practising it for the exam. It is worth noting that music can evoke personal memories , and cer“I remember having a really good time. listening very deeply to the Chopin Nocturne” (P1).Most participants in this study recognised that the MM programme included various types of music and meditation, and music preferences were not considered a significant issue for practising meditation. However, some participants felt that there was a relationship between the depth of meditation and their preferences. This suggests that personal preferences may play a role in the effectiveness of meditation practices involving music for some individuals. The relationship between personal music preferences and a deeper meditative experience is likely to have implications for the effectiveness and adoption of mindfulness practices involving music. Developing personalised mindfulness interventions that take individual preferences into account could help to optimise the effectiveness of mindfulness practices involving music and enhance their adoption among diverse populations. Meditative experiences and responses may vary depending on music preferences. However, in general, participants commonly perceived that most of the music in this programme helped them to reach meditative states.“The music that you had was really helpful” (P1). “…more in-depth…thinking about the music” (P6).Lastly, participants particularly experienced the emotional aspect of music during meditation. Musical experiences evoke emotional responses, and music influences emotions profoundly ,79. PartThe study aimed to investigate the effects of an MM programme, which combined elements of music and meditation, on two main outcomes: mindfulness and students’ subjective mental happiness. The primary objectives were to understand how this programme impacted various aspects of participants’ well-being, including their ability to cope with emotional difficulties and daily life stress, as well as their overall mental wellness. The key findings of the study revealed that the MM programme had a notably positive impact on the psychological well-being of the participants. Specifically, the programme led to significant improvements in participants’ subjective happiness and mindfulness. Additionally, it was observed that the programme enhanced participants’ capacity to handle emotional challenges and effectively manage stress in their daily lives. Overall, these findings underscored the programme’s effectiveness in promoting well-being, mindfulness, and mental wellness among the students involved in the study.During the 8-week programme, participants had various experiences of ‘state’ and ‘trait’ changes, and they discussed their experiences with the intervention and how it affected their daily lives. Participants reported feeling more mindful and peaceful during and after the MM sessions. However, it is also noteworthy that individuals had different experiences with aesthetic music and varied feelings of calmness depending on their preferences for types of interventions and the duration of practice. During the 8-week programme, participants actively engaged in discussions regarding their preferences and individual experiences. They openly expressed their feelings of mindfulness and shared their musical preferences, contributing to a more personalised and tailored approach to the programme.This focus on individual experiences allowed participants to deepen their mindfulness practice and cultivate a greater sense of well-being. Additionally, they discussed feeling relaxed and expressed a preference for meditation as part of their practice. Interestingly, despite receiving positive external comments about their experiences, the participants demonstrated a thorough understanding and openness to the use of diverse types of music and meditation. They also expressed a willingness to explore culturally different music and engage in aesthetic meditation practices. This highlights their embrace of a wide range of experiences and their commitment to promoting cultural diversity and enrichment within the programme.In relation to the duration of practice, it has been observed that meditation can elicit various levels of mindfulness states based on the depth of practice. Several studies have demonstrated that the length of mindfulness practice is primarily associated with an increase in the level of mindfulness . IncreasTherefore, the outcomes may differ from previous studies that offered longer and deeper mindfulness practice , as the As reviewed in the literature, happiness is considered one of the positive aspects of psychological functioning, and it is influenced by personal attitudes and behaviours . In the What is notable in this study is that participants described various positive changes in their lives during the 8-week programme using terms such as ‘stress-free’, ‘positive’, ‘comfortable’, ‘letting go of painful feelings’, ‘moment-to-moment awareness’, ‘calm and clear-minded’, ‘relaxing’, ‘enhanced concentration’, ‘stability’, ‘grounding’ and ‘energetic’. These findings indicate that participants had a positive and stable mindset experience from the MM programme overall. Thus, the study objectives have been achieved by the findings: (1) The supportive and structured 8-week MM programme had a positive effect on increasing participants’ levels of mindfulness and happiness. (2) The combination of mindfulness and aesthetic music experiences had a positive impact on participants’ ability to cope with emotional difficulties and daily life stress, ultimately promoting their mental well-being and potentially leading to an improved academic performance.In addition, there were discussions about reflections on the MM programme. First, many participants perceived that combining techniques effectively worked together: “The integration of music with mindfulness is such a good idea” (P7); If we didn’t have the music, I wouldn’t be able to get into that meditative state very easily because my mind is so busy” (P1). Second, in terms of group sessions, some participants found meditating with others to be particularly meaningful and mentioned it felt like a special connecting experience. P1 mentioned that continuous group meditation sessions helped in many ways, such as calming down and stopping excessive thinking. Third, the experience of weekly practice was discussed: “I like the structure of it (MM programme) and I think that it was particularly good” (P6); “It exceeded my expectations because of the positive outcomes I experienced” (P1). Some participants expressed their desire to continue practising through websites and online courses even after the programme ended: “Having the weekly session in my diary started to show me a few things which were important to me” (P5). Fourth, there were discussions about other factors that facilitated mindful music listening: “I think the way that the room and session are set up helps as well” (P4); “The yoga mats and circle of chairs provided a space to be still and quiet” (P5). Careful session preparation was necessary for this programme to ensure that it did not distract from stillness and deep listening, as mindful music listening requires a more focused way of listening.Some topics and issues need to be reflected here which were emphasised by interviewees. First, participants described the mindful music listening experience as ‘focussing quite intently and deeply on the here and now’ and they said that this was similar to listening to music in music therapy. Particularly, they perceived deeper awareness along with focusing attention on features such as ‘aesthetic feeling’, ‘spiritual connections’, ‘stillness in my brain’, ‘aesthetic self’, ‘calming’, ‘become aware’, ‘feeling relaxed’ and ‘self-discovery’ while listening to music mindfully. Mindfulness and music therapy could share certain aspects, for example, ‘a sense of self-awareness in the moment during music listening’  and beinSecond, the notions of satisfaction and motivation were emphasised. Participants had a strong intention to learn self-help techniques in order to cope with daily life stress [“I think too much and I have to stop doing that…I need any technique to clear my mind” (P2)]. Some remembered their protective behaviours and uncomfortable feeling about new things in the first week of the MM session: “When anything is new, we are a little bit on edge…but gradually I found that it was more and more helpful” (P7). Participants felt personal benefits and they were self-motivated in their own way. Those senses of satisfaction or reward may increase people’s autonomous reasons for home practice. In addition, self-motivation may improve the ability to think creatively . “I am iIn terms of instruments, several participants mentioned gongs, Tibetan singing bowls and crystal bowls after following the links provided in the handout. These instruments have unique sound vibrations and, from ancient times, healing aspects of sound have been reported ,95. SounFourth, the advantage of group practice and group dynamics were discussed [“the group session is quite powerful” (P4)]. Several participants realised that there are differences between group and individual practice and group practice is more supportive to induce a deeper level of focus and relaxation. They spoke of feeling ‘more connected’, ‘collective energy in room’ and ‘group energy’. In fact, the value of the group format and a sense of group cohesion have been explored in other studies, such as “collective effort to make yourself feel better”, and “benefits of being on a shared journey” ,96,97. IBased on the findings presented, here are some suggestions for future directions and implications: First, further investigate the effectiveness of MM programmes in promoting happiness and emotional well-being in different populations, such as individuals with mental health disorders or those undergoing stress-inducing situations like academic or work-related stress. Second, explore the potential of incorporating different types of music and mindfulness practices into MM programmes, such as yoga or art therapy, to enhance the programme’s effectiveness in promoting mindfulness and well-being. Third, develop and implement MM programmes in educational institutions to help students cope with academic stress and promote their mental wellness. Fourth, consider the potential of MM programmes as a preventive measure for mental health disorders and incorporate them into public health policies aimed at promoting mental well-being. Fifth, evaluate the long-term effects of MM programmes on participants’ well-being and assess the sustainability of the programme’s positive impact.Finally, it is crucial to compare the distinctions between the programme that combines music with mindfulness-based programmes and meditation programmes in isolation. In this study, many participants reported unique experiences during meditation with music. For instance, they found it easier to focus, achieve a deeper state of calmness and delve into more profound contemplative experiences, depending on the themes of the 1–8-week programmes. Indeed, these findings suggest that the integration of music and meditation plays a distinct role within the context of mindfulness and music-based programmes. This observation holds the potential to provide more substantial implications for researchers and clinicians in both the fields of music and meditation.This study aimed to explore the effect of the MM programme on mindfulness and students’ subjective mental happiness. Overall, the study findings highlighted that the MM programme had a positive and meaningful impact on participants’ physical and psychological well-being. The programme also enhanced participants’ ability to cope with emotional difficulties and daily life stress. Support for student mental health and providing appropriate mental wellness services are increasingly recognised as new challenges facing higher education institutions ,107,108.Music and meditation interventions have each gained recognition for their benefits to health and wellness, and healthcare practitioners have carried out a great deal of work in this area ,113,114.