Lifestyle Medicine Interventions for Improving Common Mental Disorder Symptoms in The Hong Kong General Population: A Qualitative Study

CassyYing-TungChan1

VincentWing-Hei1

Wong1

Associate Professor

FionaYan-YeeHo1,2✉Phone(852)3943 3469Emailfionahoyy@cuhk.edu.hk

FionaYan-YeeHo1

1Department of PsychologyThe Chinese University of Hong KongShatinHong Kong

Department of PsychologyThe Public Mental Health Laboratory, The Chinese University of Hong KongShatinN.T., Hong Kong

Cassy Ying-Tung Chan^1,† Vincent Wing-Hei Wong^1,†, Fiona Yan-Yee Ho^1*

¹ Department of Psychology, The Chinese University of Hong Kong, Shatin, Hong Kong

Word count: 5,733 (excluding abstract and references)

Table: 1

Figure: 0

Corresponding author: Fiona Yan-Yee Ho

^* Correspondence. Fiona YY Ho, Associate Professor, The Public Mental Health Laboratory, Department of Psychology, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong. Telephone: (852) 3943 3469. Fax: (852) 2603 5019. Email: fionahoyy@cuhk.edu.hk

Cassy Ying-Tung Chan, Vincent Wing-Hei and Wong Co-first authors

Data Availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate:

This study was conducted in accordance with the Declaration of Helsinki.

All participants provided informed consent prior to participation.

Ethical approval was obtained from the Survey and Behavioral Research Ethics Committee (SBREC), The Chinese University of Hong Kong (CUHK) (SBRE-21-0515).

Consent for publication:

Not applicable.

Competing interests:

The authors have no competing interests to report.

Funding:

This study was funded by the Research Support Fund for Master of Social Sciences in Psychology students at the Department of Psychology, The Chinese University of Hong Kong.

Author Contribution

C.Y.C. and V.W.W. conceptualized the study, conducted the formal analysis, led the methodology development, managed the project administration, and wrote the original draft. F.Y.H. provided supervision and wrote the original draft of the manuscript. All authors reviewed the manuscript.

Acknowledgements:

We extend our heartfelt thanks to the study participants for their time and contribution to psychological science.

Abstract

Background

Lifestyle medicine (LM) is increasingly recognized as a promising approach for managing common mental disorders (CMDs). However, the perceived effectiveness, relevance, and challenges of implementing LM interventions for CMDs in Eastern societies remain underexplored. This study explored the perceptions and beliefs surrounding LM interventions for improving CMD symptoms among the Hong Kong Chinese population.

Methods

A qualitative approach was adopted. Semi-structured interviews were conducted on 21 participants experiencing minimal to severe depressive and/or generalized anxiety symptoms. Data were analyzed using thematic analysis.

Results

Participants generally perceived LM interventions as effective, practical, safe, and acceptable for improving CMD symptoms. However, many associated LM with traditional Chinese medicine, perceiving it as traditional and outdated. Participants with minimal to mild symptoms prioritized the physical health benefits of LM, whereas those with moderate to severe symptoms emphasized its impact on both physical and mental health. Preferences for intervention modalities varied widely, but there was a notable reluctance toward formal, top-down delivery approaches. Key barriers to engagement included perceptions of a slow clinical response, as well as the significant effort, motivation, and commitment required for sustained lifestyle modifications. Potential adaptations for enhancing future LM interventions are discussed.

Conclusion

These findings underscore the potential value of LM for managing CMD symptoms in the Hong Kong Chinese population and emphasize the importance of considering cultural interpretations and historical practices in the promotion and implementation of LM. Further research is recommended to validate these findings across more diverse age groups and clinically diagnosed populations.

Keywords:

Lifestyle

lifestyle medicine

depression

anxiety

common mental disorders

qualitative

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Introduction

Common mental disorders (CMDs), including depressive and anxiety disorders, represent a significant global public health concern. Epidemiological data indicate a global prevalence of approximately 3.8% for major depressive disorders and around 4% for anxiety disorders (1–3). These disorders are characterized by symptoms such as persistent low mood, excessive worry, irritability, and fatigue, which can significantly impair daily functioning, interpersonal relationships, and quality of life (4). Additionally, CMDs are associated with an elevated risk of comorbid physical health conditions, such as cardiovascular disease and diabetes, thereby amplifying their burden on both individuals and healthcare systems (5, 6).

In recent years, lifestyle medicine (LM) has gained increasing attention as a promising approach for managing CMDs. The LM approach utilizes multicomponent lifestyle-based interventions to prevent and manage diseases with a lifestyle etiology (7–9). These interventions typically integrate recommendations from two or more lifestyle domains, such as physical activity, diet and nutrition, sleep management, stress management, social connection, and substance use. Furthermore, a range of behavioral change strategies (e.g., goal setting, motivational interviewing) are frequently employed to facilitate and sustain the lifestyle modification process (7–9). A growing body of evidence from meta-analyses of randomized controlled trials supports the efficacy of LM interventions in improving CMD symptoms, with effect sizes ranging from d = 0.45 to 0.66 for clinical and subclinical populations and d = 0.14 to 0.49 for non-clinical populations (8–10). In terms of intervention perception, service users with CMDs generally perceive LM interventions as safe, natural, cost-effective, less stigmatizing, and easy to incorporate into daily routines with minimal side effects (11–16). Notably, a cross-sectional survey among Hong Kong Chinese adults found that up to 55% of potential service users preferred LM interventions over psychotherapy and pharmacotherapy for the management of CMD symptoms. This preference was particularly pronounced among older adults (16). Given the accumulating clinical evidence and the favorable attitudes of service users, recent clinical practice guidelines have recognized LM interventions as a foundational strategy in the management of mood disorders (17, 18).

Despite the increasing evidence supporting the efficacy and clinical utility of the LM approach for managing CMDs, critical research gaps remain. To date, most existing studies examining public perceptions of LM for CMDs have been predominantly conducted in Western contexts (11–15). In contrast, there is a lack of in-depth qualitative data exploring how individuals from Eastern societies perceive the relevance and challenges of implementing LM interventions for CMDs within their unique social and cultural contexts. This geographic imbalance limits the generalizability of existing findings and risks overlooking the unique social and cultural factors that shape public attitudes toward the uptake of LM interventions for CMDs in non-Western populations (19, 20). Furthermore, the barriers and facilitators that influence the adoption and maintenance of lifestyle modifications within Eastern cultures remain largely unexplored, creating a critical gap in the literature.

Given these research gaps, this qualitative study serves as a pioneering attempt to: (1) understand the general perceptions and orientations toward LM interventions for improving CMD symptoms in the Hong Kong Chinese population, and (2) examine potential service users’ intervention-specific beliefs and preferences, such as perceived effectiveness, preferred modes of intervention delivery, and perceived facilitators and barriers. By addressing these objectives, the study aims to generate culturally relevant insights to inform the adaptation and implementation of LM interventions in Hong Kong and similar contexts. Additionally, it seeks to provide actionable recommendations for researchers, practitioners, and policymakers to enhance mental health care delivery and outcomes.

Methods

Design

Ethical approval

was obtained from the Survey and Behavioral Research Ethics Committee (SBREC), The Chinese University of Hong Kong (CUHK) (SBRE-21-0515). All participants provided informed consent prior to participation. This qualitative study utilized a general inductive approach to ensure that the findings are directly rooted in participants’ experiences and perspectives (21).

Participant recruitment and sampling

Prospective participants were recruited via word-of-mouth, the CUHK mass mail system, and advertisements on social media platforms, including Facebook and Instagram, between July 2022 and May 2023. Participants were included if they met the following inclusion criteria: (1) Hong Kong residents aged 18 years or above, (2) Cantonese language fluency and readability, and (3) willing to provide informed consent. To enhance data richness and relevance, a purposive sampling strategy was employed to select participants based on their severity of depressive and generalized anxiety symptoms (22). Specifically, 11 of the included participants had a Patient Health Questionnaire-9 (PHQ-9) score of 0 to 9 and/or Generalized Anxiety Disorder-7 (GAD-7) score of 0 to 7, indicating the presence of minimal to mild depressive and/or generalized anxiety symptoms, while the remaining 10 participants had a PHQ-9 score of ≥ 10 and/or GAD-7 ≥ 8, indicating the presence of clinically significant depressive and/or generalized anxiety symptoms (23–25). We excluded individuals who presented a current serious suicidal risk (i.e., non-fleeting intent or plan) as indicated by a score > 2 on Item 9 of the PHQ-9. Individuals identified as having a current serious suicidal risk were provided with referral information for professional mental health services. The recruitment process was ceased when no new concepts, insights, or ideas emerged.

Procedure

Prospective participants were invited to complete a series of online screening questionnaires on Qualtrics, which included (1) initial assessment consent; (2) PHQ-9 assessing the level of depressive symptoms; (3) GAD-7 assessing the level of generalized anxiety symptoms; and (4) basic demographic information. Eligible participants were invited to participate in this study via an approximately 20-minute phone call conducted by the first author (C.Y.C.).

The call involved an explanation of the study objectives and the consent form.

Participants who provided informed consent were enrolled in this study. Subsequently, an online semi-structured interview was scheduled with each eligible participant. Upon completing all study procedures, participants were offered a total of HKD200 and access to a smartphone-delivered LM intervention (Lifestyle Hub) designed for improving mental health (26, 27).

The online semi-structured interviews were conducted by the first author (C.Y.C.), a Psychology Master’s student, between July 2022 and May 2023. The duration of each interview session ranged from 42 to 93 minutes, with an average duration of 65 minutes (SD = 15). An interview guide was developed by the authors based on the research objectives (see supplementary file for details). The interview guide was designed to be flexible, with prompts and open-ended questions to facilitate an in-depth exploration. Specifically, the interview guide was structured into four sequential sections to facilitate a natural flow of discussion and ensure alignment with the study objectives. The first section focused on introduction and rapport building. Participants were provided with an overview of the study aims, reassured about confidentiality, and a brief and neutral explanation of the LM approach to CMDs to ensure a shared understanding for subsequent discussion. The second section explored participants’ perceptions and attitudes toward LM as a strategy for managing CMD symptoms, with questions designed to elicit views on the relevance, acceptability, and perceived effectiveness of LM interventions. The third section addressed intervention preferences and design, gathering insights into participants’ preferred modalities, types of support, and content for LM interventions. Finally, the last section focused on identifying facilitators and barriers to participating in LM interventions and sustaining lifestyle modifications. Throughout the interview, flexibility was maintained to allow for follow-up questions and deeper probing of emergent themes, while clear transitions were used to signal shifts between topics.

The interview concluded with an invitation for participants to share additional thoughts, ensuring that all relevant insights were captured. The interview guide was pilot tested by three laypersons, and the questions were subsequently refined to improve clarity and relevance.

To ensure interview quality, C.Y.C. received a one hour of training on the semi-structured interview guide and guidance on LM for CMDs from two other authors (F.Y.H. and V.W.W.). F.Y.H. holds a doctoral degree in Clinical Psychology, while V.W.W. received a doctoral degree in Psychology, and both of them are board-certified LM professionals. Additionally, the research team held regular meetings to discuss emerging themes and address any challenges encountered during the interview process. All interviews were audio-recorded with the informed consent of participants, and were transcribed verbatim to maintain accuracy, and subsequently translated into English.

Data analysis

The first author (C.Y.C.) performed thematic analysis to identify, analyze, and report patterns (i.e., themes) in the data, following Braun and Clarke’s six-phase approach (2006) using NVivo 12. The research team first listened to all audio recordings and prepared verbatim transcriptions. Subsequently, C.Y.C. reviewed and revisited the transcripts to familiarize with the data and become immersed in its content. A line-by-line coding method was employed to systematically generate an initial set of core codes. These codes were iteratively refined and organized into overarching themes, which were further broken down into sub-themes to provide a nuanced understanding of the data. Themes were first identified within individual interviews and then examined across the entire dataset to identify broader patterns, following the principle of ‘following the thread’(28). To ensure the validity and reliability of the findings, a consensus meeting was held between the three authors (C.Y.C., V.W.W., and F.Y.H.) to review, refine, and finalize the identified themes.

Results

A total of 29 potential participants were invited to participate in this study, with eight (i.e., 27.5%) declining to participate or failing to respond.

The remaining 21 participants provided informed consent and were enrolled in this study. Table 1 shows the demographic characteristics of the included participants. The mean age of the participants was 33 years (SD = 8.52), with 12 of them being female (i.e., 57%).

Table 1
Demographic characteristics.
Participant ID	Gender	Age	Moderate to severe depressive and/or generalized anxiety symptoms	Self-reported clinical diagnosis of major depressive or anxiety disorder	Occupation
1	Female	30	Yes	Yes	Clerk
2	Female	27	No	No	Teacher
3	Female	36	No	No	Program officer
4	Male	30	No	No	Freelancer
5	Female	35	No	No	Banking analyst
6	Male	39	No	No	Professor
7	Male	23	Yes	Yes	Unemployed
8	Female	38	Yes	No	Associate medical technologist
9	Female	38	No	No	Marketing officer
10	Male	27	Yes	No	Research assistant
11	Female	41	Yes	No	Tutor
12	Male	34	No	No	Manager
13	Female	18	Yes	No	Waitress
14	Male	51	Yes	No	Clerk
15	Female	25	No	No	Social worker
16	Male	32	No	No	Student
17	Female	37	Yes	Yes	Clerk
18	Female	20	Yes	No	Freelancer
19	Male	39	Yes	Yes	Civil servant
20	Male	49	Yes	Yes	Professor
21	Female	30	No	No	Marketing manager

Perceived effectiveness and general perceptions

Participants’ responses regarding the general perceptions of the LM approach for managing CMDs revealed a mix of optimism and skepticism. A recurring theme among participants, regardless of symptom severity, was the association of the LM approach with the foundational principles of traditional Chinese medicine. While a few participants appreciated and valued this connection, the majority expressed that this connection shaped their perception of LM as being traditional, old-fashioned, and more appropriate for older individuals. For some participants, this perception emerged as a barrier to intervention access, as they often viewed the outdated and old-fashioned image of LM as conflicting with their personal values, such as modernity and autonomy.

| “I am a relatively traditional Chinese person, so perhaps Taoist ideas, or Confucian thoughts, are related in this regard (lifestyle medicine).” (HK15)

| “This name (lifestyle medicine) sounds a bit ‘Kai’ (stupid). Practicing Tai Chi, dietary therapy, and making soups. These are old-fashioned things meant for the elderly anyway. I don’t think it concerns me at all. I find it very outdated. Honestly, it does not sound like a serious matter… I think the term itself is really ‘Leung’ (outdated).” (HK11)

| “It’s definitely for the elderly, for old people. When you talk about this, it’s usually for those who are retiring or even those with a long-term illness, approaching the end of life. People in their sixties or seventies are into it. Like planting flowers and trimming plants! Maybe I have a misunderstanding.” (HK21)

| “I am concerned about how others might perceive me if I engage in LM. Will they say, you go to attend a lifestyle talk? My feeling is that when many people hear this term, they immediately associate it with retiring, retired, an alternative lifestyle, or even people who are not hardworking or ambitious. I don’t know if that person might stereotype me for being into health preservation.” (HK21)

| “When talking about health preservation, you might think of these people as lazy, sluggish, or indifferent. There is a stereotype. I might be misunderstanding this, but I have such an immediate reflection.” (HK21)

Albeit the common perception of an outdated image of the LM approach, a majority of participants acknowledged the significance of healthy lifestyle in maintaining mental health and considered LM interventions highly clinically valuable for managing CMDs. They found LM interventions easy to implement, practical, acceptable, and safe, while also appreciating their potential to improve both physical and mental health simultaneously. However, participants experiencing minimal to mild CMD symptoms tended to believe that LM interventions primarily benefitted physical health over mental health, which was considered as the main motivator for adopting the LM approach. In contrast, individuals experiencing elevated CMD symptoms viewed LM as not only beneficial for physical health but also crucial for improving mental health, reducing CMD symptoms, and fostering hope for recovery. Compared to those with minimal to mild CMD symptoms, this group approached LM with a greater sense of urgency and optimism, viewing it as a potential primary intervention strategy or an adjunctive approach to complement conventional treatments (e.g., psychotherapy, pharmacotherapy), with the potential to reduce reliance on psychiatric medications.

| “I have to take medicine every day to control my condition. I don’t know how long I need to take. And it turns out that apart from taking pills, there are other ways to try. Maybe there is hope. There are other ways to substitute (medicine).” (HK6)

Among the cohort of participants, three participants with minimal to mild CMD symptoms did not recognize LM as a specific intervention strategy for managing CMDs and exhibited reluctance towards adopting the LM approach. One participant noted that, despite acknowledging the potential clinical benefits of LM, she was hesitant to engage with it due to the perceived association with outdated practices. The legitimacy of LM was questioned by two participants; they expressed concerns about whether LM truly constituted as a valid intervention for CMDs or if it merely functioned as a marketing scheme for some health campaigns.

| “Lifestyle medicine…? Is it about having some flower tea, and improving your physical health?” (HK3)

| “Advertisement. Probably trying to sell Chinese herbal products.” (HK8)

Intervention modalities

While participants valued professional expertise, a notable barrier to engaging with LM interventions, whether delivered individually or in a group, was their unfavorable anticipation of a formal, top-down delivery style. Some participants indicated that this perception stemmed from their prior experience with lifestyle-based interventions for promoting physical health, while others attributed it to the inherent nature of lifestyle-based interventions. Regardless of its origin, both groups viewed this approach as ineffective for fostering meaningful and sustainable lifestyle modifications, as it failed to engage the service users and promote motivation.

|“... don’t just come out with a purely professional demeanor. I’ll think, I don’t want to know, it’s just more lecturing. Don’t be preachy, don’t lecture people.” (HK11)

|“...Don’t always be like, I am a professional and then make me feel that you are an expert, whatever you say is correct. Because I think there are already enough top-down things in the community.” (HK4)

Instead, some participants preferred a collaborative approach, with lay health workers or facilitators working alongside them to facilitate discussions, set lifestyle goals, and tackle challenges together. Additionally, participants emphasized the importance of these lay health workers or facilitators delivering content in an engaging, relatable, and supportive manner, which was seen as essential for creating a welcoming environment to foster active and sustained lifestyle modifications.

| “...a person who knows how to teach, rather than necessarily being very professional. Yes, that is, synchronize with you. Professionals may have a little airtime, or they are at a high level to do the program design, content design, but really, on the other hand, they need some teaching skills, some good interaction, communication—at least so participants are willing to listen.” (HK4)

| “...I always feel that it doesn’t necessarily has to be done by an education institution or researcher. Instead, I think that maybe people in the academy, you really focus on doing research, or validating results… The person who might be the agent to do the training really needs to have that kind of connection with the participants.” (HK7)

A few participants highlighted inconveniences such as traveling long distances to attend interventions, along the significant costs associated with these interventions, which served as major structural barriers to accessing individual or group-delivered LM interventions. To address these barriers, they proposed leveraging digital technologies, such as a website featuring pre-recorded videos and resources, to enhance accessibility.

| “...might have to travel long distances to faraway places, so location is a factor. If it can be done virtually, it would be more convenient.” (HK15)

| “...some articles or webpages that you read by yourself, or some recorded lectures or lecture talks, some sharing, would it be better? That is, you watch it when you are free.” (HK21)

| “I think time is the most important factor, and another one is that if the cost is too high, it is also a factor.” (HK15)

| “Very busy with my work. So basically, time is the biggest concern.” (HK9)

Regarding group-based LM interventions, several participants expressed reluctance towards the group format, perceiving it as less effective in fostering meaningful intervention engagement compared to individually delivered LM interventions. This view stemmed from discomfort in sharing sensitive information about their lifestyle habits and mental health within a group setting. However, for those who preferred group-based LM interventions, the share goal and peer learning opportunities were key motivating factors.

They felt that participating in a group with similar challenges and objectives could create a sense of community, mutual support, and accountability. This shared experience was seen as a valuable way to learn from others’ perspectives, strategies, and successes, ultimately boosting their own engagement and motivation for lifestyle modifications.

|“...Everyone who takes part (in LM intervention) is working toward the same goal. We all want to achieve it. I think this kind of power will be great.” (HK13)

|“I think this step is the most difficult. First, you need to be willing to face, accept, or open yourself up to others.” (HK4)

|“I wouldn’t open like that. This is quite personal, so I usually deal with issues on my own, like self-help therapy. So, joining any activities, I probably wouldn’t.” (HK11)

| “I think mental health is personal and I don’t want to open myself. I won’t want to join and discuss with people. (Interviewer: Why?) It is you won’t know what other people think of you. They will judge if you have a mental condition. People are like this.” (HK20)

|“Often, the difficulty with these workshops is that the participants’ backgrounds are too diverse, and many very individualistic people don’t really want others to know about their participation or problems.” (HK21)

Intervention content

Participants, regardless of symptom severity, perceived LM interventions that only provide general lifestyle recommendations, such as regular exercise, healthy eating, and better sleep practices, as information that is ‘already known’ and intuitive. Hence, much of this content was dismissed as generic or common knowledge, failing to spark interest or encourage active intervention engagement. This perception was particularly pronounced among participants with higher educational backgrounds, who viewed such recommendations as basic and readily accessible from various other sources. In general, participants indicated that LM limited to general lifestyle recommendations were deem lacking in practical value, hence failing to warrant their time, effort and commitment to participate.

| “If you are going to tell me to eat more apples and exercise more, even some auntie from the local market can tell me that…. I wouldn’t say no in principle, but I would carefully assess which workshops are most likely to benefit me. If your evidence (on LM) only supports what everyone already knows, so the impact? It’s actually very hard to create…” (HK6)

“Common sense, I don’t need to hear it from you. You just need to write a paper to tell me it’s actually correct. Conversely, if I were to do it myself, it would be to find something surprising.” (HK7)

“Actually, I’ve always known about these things. These things have always been there. For instance, I follow things on Instagram, and they post memes or motivational quotes like ‘Eat Well, Sleep Well,’ which I’ve always known, and I see them from time to time. So, it seems to overlap. Since I already see them, it feels like I don’t really need something extra.” (HK11)

Instead, participants suggested that LM interventions should be personalized to individual lifestyle and symptom profiles, focusing on delivering targeted and outcome-oriented lifestyle recommendations that could swiftly improve their mental health and daily functioning. They also stressed the importance of avoiding overly repetitive or vague, open-ended goals in interventions, as these were perceived as demotivating and difficult to commit to.

| “For example, if I can’t sleep well, what practical suggestions are there to improve? This kind of thing. The motivation will drive you to continue engaging.” (HK8)

Intervention engagement

Participants with minimal to mild symptoms often regarded LM as a conceptually beneficial approach but challenging to sustain over time. They voiced apprehensions regarding the substantial effort and extent of lifestyle modifications required. Concerns were raised about the time, energy, and commitment required to implement lifestyle modifications, particularly given their hectic schedules and various competing priorities. For these individuals, they perceived the required effort often outweighed the potential clinical benefits, especially since their symptoms were not severe enough to necessitate immediate actions.

| “We all know that a healthy lifestyle is good. Just when it comes to reality, 80–90% of people failed to stick to it. Then what is the point?” (HK8)

| “The biggest challenge is that people give up easily if they feel that it is not effective to do it after a week or two.” (HK10)

Participants with significant CMD symptoms also expressed concerns about their ability to consistently adhere to and sustain lifestyle modifications over time. These concerns were largely driven by the anticipation of slow and gradual clinical improvements typically associated with lifestyle-based interventions, coupled with the impact of their CMD symptoms. A considerable number of participants noted that the slow progress of improvement might result in feelings of frustration and discouragement, posing challenges in maintaining their motivation and potentially leading to abandoning lifestyle recommendations entirely.

Discussion

LM is an emerging treatment approach for CMDs, but the existing research on the perceptions of potential service users has predominantly been conducted in Western contexts, thus limiting our understanding of how these interventions are perceived and adopted in Eastern societies. To the best of our knowledge, this is the first qualitative study to explore perspectives on LM as a means to improve CMD symptoms among the Hong Kong Chinese population.

Consistent with previous studies conducted in Western contexts(11–15), the majority of participants in our study expressed positive attitudes toward the LM approach for addressing CMD symptoms. Participants generally perceived LM interventions as effective, easy to implement, safe, acceptable, and practical for improving CMD symptoms.

While the clinical utility of the LM approach was widely recognized, some participants regarded it as traditional and somewhat outdated due to its perceived association with traditional Chinese medicine. Importantly, this unique association, which has not been identified in studies from Western settings(11–15), appeared to act as a barrier to the uptake of LM interventions. One potential reason for the association between LM and traditional Chinese medicine may arise from their conceptual similarities(29, 30), as both emphasize holistic lifestyle modifications, such as dietary changes, physical activity, and sleep management. Additionally, the perception linking LM with traditional Chinese medicine in Hong Kong could be influenced by the Chinese translation of LM (i.e., yangsheng yi xue). The term “yangsheng” translates to “health cultivation” or “life nourishment” in English and represents a fundamental principle in traditional Chinese medicine deeply rooted in Chinese culture and healthcare practices (31–33). As a result, participants might view LM as an extension of these longstanding traditions, reinforcing the perception that it is conventional and lacks novelty.

The general perception that LM is associated with traditional Chinese medicine presents both advantages and challenges in promoting the LM approach for CMDs in Hong Kong. On the positive side, this perception can enhance cultural acceptance and engagement, particularly among individuals who place trust in traditional Chinese medicine. However, on the flip side, it may serve as a determinant for certain individuals seeking access to LM interventions. To navigate this duality, future promotional strategies should aim to clarify the empirical underpinnings of the LM approach while leveraging its alignment with the holistic ethos of traditional Chinese medicine to resonate with diverse audiences. By crafting messaging that strikes a balance between these aspects, it may help mitigate skepticism among those who perceive LM merely as an extension of traditional practices. This approach could ultimately facilitate wider acceptance and uptake of LM interventions for CMDs in Hong Kong.

Another notable finding was that, although participants generally recognized the benefits of LM interventions for enhancing both physical and mental health, there was a clear distinction in the primary motivations for engagement between individuals with and without significant CMD symptoms. Specifically, participants with minimal to mild symptoms tended to prioritize the physical health benefits of LM as their primary incentive for adoption. In contrast, those with elevated CMD symptoms emphasized the potential of LM to improve both physical and mental health outcomes. This discrepancy can be understood through the Health Belief Model, which posits that individuals’ health behaviors are shaped by their perceived susceptibility to and severity of a health condition(34). It is possible that participants with significant CMD symptoms may perceive greater vulnerability to mental health issues, thereby recognizing immediate and comprehensive benefits from adopting LM interventions. Conversely, those with minimal to mind symptoms may perceive lower vulnerability and consequently prioritize the physical health advantages. Future promotional strategies and LM interventions could be tailored to align with participants’ primary motivations for participation, thereby boosting intervention uptake and adherence. For example, as demonstrated by previous studies, a stepped intervention approach may be particularly appealing to individuals with minimal to mild symptoms(35, 36). Initially emphasizing the clinical benefits of LM interventions on physical health can resonate with participants’ initial motivations and perceived needs. Subsequently. as participants become more engaged and receptive to health behavior change, lifestyle psychoeducation and recommendations related to CMDs can be gradually incorporated. This progression ensures that the intervention remains relevant and supportive throughout, ultimately fostering greater engagement and sustained lifestyle modifications.

Regarding barriers to intervention engagement, participants in the present study articulated a common perception that LM interventions typically yield slow and gradual clinical responses, which may reduce motivation and ultimately lead to discontinuation of the intervention. Although this view is less frequently reported in existing literature, the viewpoint is consistent with previous research examining lifestyle-based interventions for severe mental disorders(37–39). This perception may arise from the historical use of lifestyle modifications primary for illness prevention and overall health promotion, fostering the belief that their benefits manifest predominantly over the long term. While concrete evidence comparing the speed of clinical response between LM interventions and conventional first-line treatments for CMDs remain scarce, some preliminary insights can be gleaned from the literature. For example, a recent randomized controlled trial found that an online LM intervention was non-inferior to cognitive behavioral therapy in improving depressive symptoms after eight weeks of treatment (40), suggesting that LM could offer significant clinical benefits over a similar duration as conventional treatments. Moreover, a meta-analysis found that LM interventions delivered over three months produced a medium clinical effect (d = 0.45) in alleviating depressive symptoms among individuals with major depression, when compared to inactive controls (9). Notably, both the intervention duration and effect size are comparable to those observed with conventional treatments for depression, such as antidepressants and cognitive behavioral therapy, which typically require weeks or months to achieve optimal therapeutic benefits (d = 0.30 to 0.31) (41). Given these findings, it is important for mental health professionals to address this preconception by providing service users with evidence-based information and emphasizing that pace of clinical responses can vary considerably across individuals. This approach can assist in managing expectations and ultimately supporting sustained engagement with lifestyle modifications.

Additionally, consistent with existing literature on lifestyle-based interventions for both mental and physical health conditions (15, 42–44), participants in this study commonly identified the effort, motivation, and commitment required for meaningful lifestyle modifications as significant barriers to engagement with LM interventions. However, this acknowledgment does not diminish the potential value of LM interventions for managing CMD symptoms. Rather, it highlights the importance of addressing these critical challenges to bolster motivation for sustained lifestyle modifications. Based on our findings regarding intervention design and preferences, we recommend several adaptations to enhance motivation for enduring lifestyle modifications in future LM interventions. First, drawing from prior research on lifestyle-based interventions for psychosis, adopting a personalized approach that accounts for individual preferences, symptom profiles, and current lifestyle could potentially enhance both motivation and intervention adherence compared to standard protocols (45, 46). Personalization is likely to increase the relevance of lifestyle recommendations by aligning them more closely with the unique needs and clinical profiles of service users, thereby enhancing the perceived significance and appropriateness of the intervention and ultimately supporting greater engagement and adherence (47, 48). However, given time constraints and the shortage of mental health professionals in the local public mental health system, implementing such personalization in practice may be challenging. Therefore, a promising direction for future research lies in exploring the use of artificial intelligence, such as machine learning and expert systems, to develop personalized LM recommendation systems for CMDs. This approach could enable efficient and scalable delivery of personalized LM interventions in public mental health settings (49). Second, in future LM interventions for CMDs, it is advisable to avoid adopting a formal top-down approach, which participants found demotivating and ineffective in fostering engagement. Instead, some participants expressed a preference for a participatory and client-centered approach that involves collaboration with paraprofessionals or trained facilitators. Such an approach can cultivate a sense of belonging, empowerment, and motivation, which are the critical factors for enhancing intervention uptake and sustaining long-term intervention engagement(9, 50, 51). Third, given the diverse intervention preferences and beliefs expressed by participants, it is essential to offer a spectrum of LM intervention modalities for CMDs, such as smartphone-delivered (8, 9), group-based (52), and web-based LM interventions (53). Additionally, adopting a co-design approach in developing future LM interventions can help ensure that recommendations align with the expectations, needs, and cultural contexts of potential service users (54, 55). Lastly, future intervention implantation could incorporate a range of evidence-based behavioral strategies to empower service users to initiate and maintain meaningful lifestyle modifications. These strategies may include but not limited to goal setting, motivation interviewing, problem-solving, and regular feedback, which have demonstrated effectiveness in enhancing intervention engagement, supporting the adoption of new behaviors, and promoting long-term adherence in lifestyle-based interventions for managing mental and physical health (56–58).

Strengths and limitations

This study is the first qualitative investigation to explore the perspectives on LM for improving CMD symptoms in an Eastern context. Participants were purposively recruited to encompass a range of CMD symptom severity, which allowed direct comparisons between those with significant symptoms and those without. However, our findings should be interpreted in light of the following limitations. First, despite diligent efforts to recruit participants with diverse demographic backgrounds, a potential for selection bias exists, given the exclusion of individuals from older age groups. Future research should aim to include a broader age range to enhance the applicability and relevance of the findings across all age groups. Second, it is important to note that participants in this study had not directly undergone LM interventions for improving CMD symptoms. Thus, their views may not fully capture the attitudes and experiences of individuals who have participated in LM interventions. Lastly, CMD symptoms in this study were assessed solely through self-reported questionnaires using established clinical cut-offs (i.e., PHQ-9 ≥ 10 and GAD-7 ≥ 8), and participants with a formal clinical diagnosis were not systematically included. Although five individuals self-reported a clinical diagnosis of major depression and/or anxiety disorders, our findings predominantly reflect the perspectives of individuals without formal diagnoses. Future research should aim to include a broader representation of clinically diagnosed individuals to enhance the generalizability of the findings.

Conclusions

This study provides the first qualitative insights into the perceptions of the LM approach for managing CMD symptoms among the Hong Kong Chinese population.

Participants generally expressed positive attitudes toward LM interventions, but the unique perceived association between LM and traditional Chinese medicine led to a common perception that LM is traditional and somewhat outdated. These findings underscore the need to consider cultural interpretations and historical practices in future promotion and implementation efforts. Key barriers to intervention engagement identified in the study included perceptions of slow clinical response and the significant motivation required for ongoing lifestyle modifications. To address these barriers, providing evidence-based information is essential to help manage expectations and enhance uptake. Additionally, employing personalized strategies, adopting a co-design approach, incorporating behavioral support techniques, and avoiding formal top-down delivery methods may amplify motivation for sustained lifestyle modifications and adherence to LM interventions. Further research is warranted to validate these findings across more diverse age groups and clinically diagnosed populations to ensure broad applicability and relevance.

Electronic Supplementary Material

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Supplementary Material 1

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Yes