Construct a digital psychological intervention program for organ donor families: An Intervention mapping study

Abstract

Objective

To develop a digital psychological intervention program for organ donor families based on Intervention Mapping.

Methods

Using Intervention Mapping, the program was developed through literature review, questionnaire surveys, and qualitative interviews, and then reviewed and refined by an expert panel.

Results

The quantitative survey results showed 25.81% of 155 participants had co-occurring symptoms of post-traumatic stress, depression, and anxiety; trait mindfulness was negatively correlated with these symptoms (r=-0.423/-0.479/-0.463, p<0.001). Qualitative findings were organized into five themes: organ donation awareness, psychological distress, access to psychological support, psychological support needs, and willingness to use digital psychological interventions. Following the first four steps of Intervention Mapping, from needs assessment to program development, Acceptance and Commitment Therapy and Mindfulness-Based Stress Reduction were integrated in light of the needs of organ donor families, relevant literature, and expert input. Six experts participated in a panel review (collective authority coefficient=0.867) and refined an 8-week WeChat mini-program-based intervention delivered once weekly for 30 minutes per session.

Conclusions

The digital psychological intervention program for organ donor families developed through Intervention Mapping provides a structured, theory- and evidence-informed framework for subsequent psychological support. It may offer a basis for future pilot testing, refinement, and the development of digital mental health support strategies for organ donor families.

Keywords

organ donor families mental health digital interventions intervention mapping trait mindfulness acceptance and commitment therapy

1. Introduction

1.1. Background

Organ transplantation, a pinnacle of 21st-century medicine, offers hope for patients with end-stage organ failure.¹ Approximately 120,000 organ transplants are performed globally each year, with over 75% from deceased donors.² Since 2015, China has ceased using organs from executed prisoners, making voluntary post-death donation the sole source for transplants.³ China has recorded 58,441 donation cases, with 180,953 organs donated⁴ saving over 170,000 patients.⁵ Family consent is a prerequisite for deceased donation in China,^6–8 and most donor families face hasty donation decisions after sudden bereavement, triggering severe psychological distress, depression, anxiety and even post-traumatic stress disorder.⁹ A survey showed depression and anxiety prevalences of 31% and 43% among Chinese donor families,¹⁰ far exceeding the national averages of 2.1% and 4.98% noted in Healthy China Action (2019–2030).¹¹ This 10–15-fold higher prevalence highlights the urgent need for attention to their mental health, yet this group—critical to sustainable organ donation—has not received adequate social focus.

Psychological assistance is a core part of donor family support, effectively preventing and mitigating psychological harm to safeguard their mental health.¹² Mindfulness is the conscious, non-judgmental focus on the present moment,¹³ and mindfulness-based interventions are widely used in clinical practice for diverse mental health issues.¹⁴ Trait (dispositional) mindfulness, an individual’s tendency to maintain non-judgmental present-moment awareness in daily life,¹⁵ benefits various mental health outcomes¹⁶ and can be enhanced through meditation training,¹⁷ serving as a key to optimizing mindfulness-based mental health interventions. Confirmation of its positive association with mental health would further justify its use as a psychosocial intervention for affected populations.

The 5G era has made smartphones primary channels for public health information and services, with Digital Health Interventions (DHIs) embedded in mobile health apps and websites to intervene in patients’ behavior and psychology.¹⁸ Digital Mental Health Interventions (DMHIs)—delivered via apps, websites, wearable devices and other digital tools—adopt self-help,¹⁹ physician-supported²⁰ or online-offline integrated modes,²¹ and their effectiveness is well-documented.²² The WHO’s Global Strategy on Digital Health (2020–2025) prioritized digital health in global healthcare.²³ Thus, developing replicable, scalable digital psychological intervention programs for donor families via internet and digital technologies to improve the organ donation support system is an urgent task for China’s organ donation work.

1.2. Objective

This study aimed to develop a digital psychological intervention program for organ donor families based on Intervention Mapping by integrating relevant theories and empirical evidence. Meanwhile, expert panel meetings were conducted to further align the program with practice and improve its rigor and feasibility.

2. Methods

2.1. Study design and intervention mapping implementation

This study took the Intervention Mapping (IM) framework as the core and adopted a mixed research design to develop a standardized digital psychological intervention program for organ donor families.

Traditional intervention development approaches lack a systematic framework and robust empirical evidence, hindering replication and the identification of effective intervention components.²⁴ To address the lack of theoretical underpinnings in intervention design and outcome evaluation, Bartholomew et al.²⁵ proposed the Intervention Mapping (IM) approach in the 1990s. IM is a theory- and evidence-based systematic approach for developing complex interventions, providing a scientific framework for the development, implementation, and evaluation of interventions.²⁶ IM outlines an iterative pathway from problem identification to solution, comprising six steps: (1)Needs Assessment; (2)Objective Identification; (3)Theory-based methods and practical strategies; (4)Program Development; (5)Refining & Implementing the Program; (6)Evaluating the Program.²⁷ Currently, it has been widely used in disease prevention, chronic disease self-management, and health behavior promotion, and applied in 46 countries/regions to date.²⁸ Therefore, IM was adopted in this study to provide scientific guidance and a theoretical framework for the standardized development of a digital psychological intervention program for organ donor families.

This study employed a combination of literature review, questionnaire survey, and qualitative interview methods to complete the first four key steps of IM, thus preliminarily developing a digital psychological intervention program for organ donor families. Additionally, the expert panel meeting method was used to review and refine the intervention program, with the specific process illustrated in Figure 1.

Figure 1.

IM process in this study.

2.2. Study setting and instruments

This study was conducted from April to September 2022. For data collection, questionnaires were distributed via Wenjuanxing, and qualitative interviews were conducted via telephone calls.

A questionnaire titled Mental Health Questionnaire for Organ Donor Families was developed, including general information and five validated, well-established psychological scales: the Mindful Attention Awareness Scale (MAAS),^29,30 the Perceived Social Support Scale (PSSS),^31,32 the Impact of Event Scale-Revised (IES-R),^33–35 the 9-item Patient Health Questionnaire (PHQ-9)^36,37 and the Generalized Anxiety Disorder Scale (GAD-7).^38,39

An interview outline titled Psychological Experience and Psychological Intervention Needs of Family Members of Organ Donors was developed. Pilot interviews were first conducted with two organ donor families, and the interview outline was revised based on the results of the pilot interviews to form the final interview outline.

2.3. Participants

2.3.1. Eligibility criteria

2.3.1.1. Questionnaire survey

Inclusion criteria: Family members of donors who had undergone citizen posthumous organ donation.

Exclusion criteria: (1) Donation time less than 1 week; (2) Aged under 18 years; (3) A definite diagnosis of severe mental disorders by a psychiatrist.

2.3.1.2. Qualitative interviews

Inclusion criteria: (1) Significant mental health problems identified by questionnaire screening: IES-R score≥35 (defined as significant post-traumatic stress symptoms⁴⁰), PHQ-9 score≥10 (a reasonable cut-off for identifying major depressive disorder cases⁴¹), and GAD-7 score≥10 (the cut-off value with the optimal sensitivity and specificity^38,39); (2) Willingness to discuss the organ donation event; (3) Informed consent to participate in this study.

Exclusion criterion: Refusal to participate in the interview or withdrawal of consent during the interview process.

2.3.2. Sampling and recruitment

The entire process of participant recruitment, inclusion, exclusion and final sample selection for analysis is illustrated in Figure 2.

Figure 2.

Flow diagram of participant recruitment, inclusion, exclusion, and final analytic samples.

2.3.2.1. Questionnaire survey

A convenience sampling method was adopted. With the assistance of organ donation coordinators at the Third Xiangya Hospital of Central South University, we contacted family members of deceased organ donors (mainly from Hunan Province and some other regions) via WeChat and telephone, and distributed online questionnaires. Due to the special nature of the population and limited resources, only 158 family members were contacted to complete the questionnaire. Three invalid questionnaires were excluded because participants failed the attention-check items embedded in the questionnaire, resulting in 155 valid questionnaires for subsequent analysis.

2.3.2.2. Qualitative interviews

Purposive sampling was used for qualitative interviews. Among the surveyed family members with mental health problems, those who left contact information and desired the questionnaire results were selected as interviewees. Data collection was terminated after interviewing 16 family members, as data saturation was achieved (no new themes emerged). For privacy protection, all interviewees were anonymized and coded as D1–D16 (see Table 1 for their general demographic characteristics).

Table 1.

General demographic characteristics of interviewees (n=16).

Code	Relationship to donor	Gender	Age	Educational level	Residential area	Cause of donor’s death	Time since donation completion
D1	Parent	Male	≥60 years	Junior high school or below	Urban	Non-accidental death	≥3 years
D2	Parent	Female	31-40 years	Bachelor’s degree	Urban	Non-accidental death	3-6 months
D3	Offspring	Male	31-40 years	Senior high/technical secondary school	Rural	Non-accidental death	3-6 months
D4	Offspring	Male	18-30 years	Senior high/technical secondary school	Rural	Non-accidental death	1 week-3 months
D5	Offspring	Female	18-30 years	Bachelor’s degree	Urban	Accidental death	3-6 months
D6	Spouse	Female	31-40 years	Junior high school or below	Urban	Accidental death	1 week-3 months
D7	Spouse	Female	31-40 years	Junior high school or below	Rural	Accidental death	≥3 years
D8	Parent	Female	41-50 years	Junior high school or below	Rural	Non-accidental death	≥3 years
D9	Parent	Male	51-60 years	Junior high school or below	Rural	Accidental death	≥3 years
D10	Parent	Female	41-50 years	Junior high school or below	Rural	Accidental death	≥3 years
D11	Parent	Male	51-60 years	Senior high/technical secondary school	Rural	Accidental death	≥3 years
D12	Sibling	Female	41-50 years	Junior high school or below	Rural	Accidental death	≥3 years
D13	Sibling	Female	18-30 years	Junior high school or below	Rural	Accidental death	≥3 years
D14	Parent	Male	≥60 years	Senior high/technical secondary school	Rural	Non-accidental death	1 week-3 months
D15	Spouse	Female	41-50 years	Senior high/technical secondary school	Urban	Non-accidental death	≥3 years
D16	Parent	Female	51-60 years	Senior high/technical secondary school	Urban	Accidental death	≥3 years

2.4. Data collection procedures

2.4.1. Quantitative data collection

Online questionnaires were distributed via Wenjuanxing. Participants read the informed consent form on the first page, which included the research objectives, voluntary participation, estimated completion time, confidentiality assurance and researchers’ contact information, and provided informed consent by clicking the “Next” button.

2.4.2. Qualitative data collection

Interviews were conducted via telephone, with the duration controlled at 20–35 minutes. During the interviews, researchers flexibly adjusted the wording and order of questions in the interview outline according to actual circumstances to ensure the depth and completeness of information collection. All interviews were audio-recorded with participants’ permission, and the audio materials were transcribed into text within 24 hours after the interviews.

2.5. Expert panel meeting

To improve the quality of the intervention program, an expert panel meeting was adopted. A number of experts were invited to collectively analyze, discuss, and review the content of the intervention program so as to refine it.

Expert selection criteria: (1) More than 10 years of research or work experience in organ donation, psychology, nursing or other related fields; (2) Master’s degree or above, or intermediate professional title or above; (3) Voluntary participation in this study.

Meeting Process: (1) Researchers introduced the theme of the meeting and the research background, distributed and collected experts’ general information questionnaire, experts’ authority self-evaluation form and the preliminary draft of the intervention program on site; (2) Experts discussed the program content and proposed revisions; (3) Researchers collated expert comments and revised the program accordingly.

Due to limited time and resources, not all invited experts were available or agreed to participate. Therefore, only 6 experts finally participated in the expert meeting, but we still ensured that the participating experts were experienced. All 6 experts had doctoral degrees, with 13-32 years working experience (Table 2).

Table 2.

General demographic characteristics of experts (n=6).

No.	Gender	Age	Educational level	Professional title	Research field	Work experience
1	Female	42	Doctoral degree	Associate Chief Physician	Psychiatry	17 years
2	Female	40	Doctoral degree	Chief Nurse	Psychological Nursing	21 years
3	Female	40	Doctoral degree	Associate Researcher	Organ Donation	13 years
4	Female	50	Doctoral degree	Associate Researcher	Doctor-Patient Communication	32 years
5	Female	43	Doctoral degree	Chief Physician	Nursing Science	24 years
6	Female	46	Doctoral degree	Chief Nurse	Nursing Science	29 years

The authority of experts was measured by the expert authority coefficient (Cr), which is calculated as Cr=(Ca+Cs)/2 where Ca represents the experts’ judgment basis and Cs denotes their familiarity with the content. Generally, Cr ≥0.80 signifies high reliability of the opinions. The collective authority coefficient of the 6 experts was 0.867 (Table 3), demonstrating a high level of expert authority and the credibility of their suggestions.

Table 3.

Expert authority coefficients (n=6).

Expert	Basis of judgment (Ci)				Judgment coefficient(Ca)	Familiarity(Cs)	Authority coefficientCr=(Ca+Cs)/2
Expert	Theoretical analysis	Practical experience	Peer understanding	Intuitive feeling	Judgment coefficient(Ca)	Familiarity(Cs)	Authority coefficientCr=(Ca+Cs)/2
A	0.5	0.1	0.1	0.1	0.8	0.8	0.8
B	0.4	0.3	0.1	0.1	0.9	0.8	0.85
C	0.4	0.3	0.1	0.1	0.9	1.0	0.95
D	0.5	0.2	0.1	0.1	0.9	0.8	0.85
E	0.4	0.3	0.1	0.1	0.9	0.8	0.85
F	0.5	0.3	0.1	0.1	1.0	0.8	0.9

2.6. Statistical methods

2.6.1. Quantitative data analysis

Quantitative data were processed and analyzed using SPSS 26.0 software. The Lilliefors-corrected Kolmogorov-Smirnov (K-S) test was applied to test the normality of IES-R, MAAS, PSSS, PHQ-9 and GAD-7 scores (n=155>50). The results showed that the IES-R score conformed to a normal distribution with a significant K-S test P-value of 0.200 (P>0.05), while the PSSS (P=0.002), MAAS (P=0.010), PHQ-9 (P=0.000) and GAD-7 (P=0.000) scores all deviated significantly from the normal distribution (all P<0.05). Histograms of scores for each scale are presented in Figure 3. Therefore, the IES-R score was described as M±SD, the MAAS, PSSS, PHQ-9 and GAD-7 scores were reported as Median (Interquartile Range), and categorical data were expressed as percentages or constituent ratios.

Figure 3.

Trait mindfulness, social support, and mental health status scores of organ donor families. (a) Trait mindfulness scores of organ donor families. (b) Perceived social support scores of organ donor families. (c) Post-traumatic stress scores of organ donor families. (d) Depression scores of organ donor families. (e) Anxiety scores of organ donor families.

χ² test or Fisher’s exact test was used for univariate analysis to compare differences in mental health status of organ donors’ families across different demographic characteristics. Spearman’s correlation analysis was conducted to explore the relationships among social support, trait mindfulness and mental health problems. This correlation analysis was exploratory without multiple comparison correction. A P-value < 0.05 was considered statistically significant.

2.6.2. Qualitative data analysis

The qualitative data were analyzed using thematic analysis with the assistance of NVivo 11 Plus software. Audio recordings from the interviews were transcribed verbatim into textual data, yielding a total of 68,939 words. To enhance analytic rigor, two researchers independently coded and analyzed the interview data and then discussed discrepancies until consensus was reached. The detailed analytic steps are presented in Figure 4.

Figure 4.

Steps of thematic analysis.

2.7. Ethics approval

This study was approved by the Ethics Committee of the Third Xiangya Hospital of Central South University. Questionnaire participants provided informed consent by clicking the “Next” button after reading the consent form on the first page, confirming their voluntary participation. For qualitative interviews, verbal informed consent was obtained: participants were orally informed of the study details, estimated duration and confidentiality assurance before interviews, which started only with their verbal agreement. All textual data were anonymized prior to thematic analysis.

3. Results

3.1. Step 1: Needs assessment

3.1.1. Literature review results

A review of research on organ donor families’ mental health, digital psychological interventions and relevant studies reveals a scarcity of empirical intervention research in this field, with existing studies mostly focusing on theoretical countermeasures. Some scholars have proposed stratified crisis intervention based on the different stages and characteristics of donor families,^42,43 and others have conducted nursing intervention studies.^44,45 Tineke Wind et al.⁴⁶ emphasized that compassionate care for donor families is a core component of organ donation practice.

Traditional psychotherapy, delivered face-to-face by therapists in professional settings such as hospitals and clinics, is costly and time-constrained, which limits its widespread implementation.⁴⁷ Moreover, most existing digital psychological intervention products suffer from poor target specificity, lack evidence-based curriculum design and valid effectiveness data. For donor families, selecting appropriate products is also a great challenge.

Therefore, it is necessary to develop a targeted digital psychological intervention program for organ donor families, featuring evidence-based curriculum design and verifiable effectiveness.

3.1.2. Quantitative research results

Table 4 presents the scores of the 155 valid questionnaires: trait mindfulness 65(56–73), social support 64(55–71), and IES-R 41.34±19.68 (PTSD detection rate 61.94%, score≥35). PHQ-9 score was 8(4–14) (depression detection rate 40.65%, score≥10) and GAD-7 7(1–11) (anxiety detection rate 30.97%, score≥10); 25.81% of participants had all three symptoms (Table 5).

Table 4.

Trait mindfulness, social support, and mental health status scores of organ donor families.

Dimensions		M±SD	Median(IQR)	Range	Frequency	Percentage(%)
Trait mindfulness		63.67±12.76	65(56-73)	0∼90	155	-
Perceived social support	Low social support status	61.62±12.62	64(55-71)	12∼36	7	4.52
	Medium social support status			37∼60	58	37.42
	High social support status			≥61	90	58.06
Post-traumatic stress	Non-existent	41.34±19.68	42(27-54)	0∼34	59	38.06
Post-traumatic stress	Present	41.34±19.68	42(27-54)	≥35	96	61.94
Depression	No depression	9.24±7.31	8(4-14)	0∼4	49	31.61
	Mild depression			5∼9	43	27.74
	Moderate depression			10∼14	27	17.42
	Severe Depression			≥15	36	23.23
Anxiety	No Anxiety	7.51±6.59	7(1-11)	0∼4	59	38.06
	Mild Anxiety			5∼9	48	30.97
	Moderate Anxiety			10∼14	20	12.90
	Severe Anxiety			≥15	28	18.06

Table 5.

Distribution of mental health problems among organ donor families.

Types of psychological problems	Values	Detection rate/co-morbidity rate(%)
Post-traumatic stress	96	61.94
Depression	63	40.65
Anxiety	48	30.97
Post-traumatic stress × depression	55	35.48
Post-traumatic stress × anxiety	44	28.39
Depression × anxiety	42	27.10
Post-traumatic stress × depression × anxiety	40	25.81

MAAS scores represented trait mindfulness levels. For clinical interpretability, IES-R, PHQ-9 and GAD-7 scores were recoded as binary variables (symptom presence/absence), and Spearman correlation analysis revealed that trait mindfulness in donor families was significantly negatively correlated with PTSD (r=-0.423, p<0.001), depression (r=-0.479, p<0.001) and anxiety (r=-0.463, p<0.001) (Table 6). (Consistent results were obtained when IES-R, PHQ-9 and GAD-7 were analyzed as continuous variables; see Appendix B for details.)

Table 6.

Correlations between trait mindfulness, perceived social support, and post-traumatic stress, depression, and anxiety.

	1	2	3	4	5
Trait Mindfulness	1	0.357**	-0.423**	-0.479**	-0.463**
Perceived Social Support	0.357**	1	-0.192*	-0.239**	-0.139
Post-traumatic Stress	-0.423**	-0.192*	1	0.432**	0.410**
Depression	-0.479**	-0.239**	0.432**	1	0.639**
Anxiety	-0.463**	-0.139	0.410**	0.639**	1

Note. **At the 0.01 level (bilateral), correlations are significant. *At the 0.05 level (bilateral), correlations are significant.

1=Trait Mindfulness, 2=Perceived Social Support, 3=Post-Traumatic Stress, 4=Depression, 5=Anxiety.

This study indicated that organ donor families experience varying levels of post-traumatic stress, depressive and anxiety symptoms, highlighting the necessity of implementing psychological interventions to alleviate their mental health problems and improve their mental well-being.

3.1.3. Qualitative interview results

Through coding analysis, five core themes were identified: organ donation cognition, psychological distress, access to psychological support, psychological needs, and willingness to use digital psychological interventions (Table 7).

Table 7.

Organ donor families qualitative research themes.

Modules	Topic (Frequency)	Sub-themes (Frequency)
Organ Donation Awareness	Whether regretted organ donation decision (16)	Regret (3)
	Whether regretted organ donation decision (16)	No regret (13)
	Whether willing to donate organs after death (16)	Willing (15)
	Whether willing to donate organs after death (16)	Unwilling (1)
Psychological distress	Post-traumatic stress disorder (6)	Trauma re-experiencing (1)
		Avoidance (1)
		Increased alertness (4)
	Emotional distress (13)	Emotional depression (2)
		Emotional instability (2)
		Sadness (5)
		Self-blame (4)
	Stress (8)	Life stress (4)
	Stress (8)	Moral stress (4)
	Social avoidance (4)	Low self-esteem (1)
		Social sensitivity (1)
		Decreased interest (2)
Access to Psychological Support	Self-support (4)	Self-emotion regulation (2)
	Self-support (4)	Leisure and entertainment (2)
	Environmental support (1)	Social environment support (1)
	Other people support (4)	Professional psychological support (3)
	Other people support (4)	Peer support (1)
Psychological Support Needs	Information Support Needs (8)	Recipient status information (4)
	Information Support Needs (8)	Policy Information (4)
	Material support needs (16)	Economic assistance (8)
		Old age security (3)
		Children’s Schooling Needs (4)
		Medical Service Demand (1)
	Emotional support needs (4)	Psychological Support (3)
	Emotional support needs (4)	Grief rituals (1)
Willingness to use digital psychological interventions	Willingness to use (10)	Acceptable frequency of use (10)
	Unwilling to use (3)	Avoidance psychology (2)
	Unwilling to use (3)	Self-emotion regulation effective (1)

Key findings: (1) Most families acknowledged the value of organ donation and also described distress related to social stigma surrounding donation; (2) In addition to PTSD-, depression-, and anxiety-related symptoms, the interviews also reflected experiences of high stress and social avoidance; (3) Only a few had obtained psychological support through self-help, environmental, or external assistance; (4) Their psychological support needs focused on informational and material support, and awareness of mental health support was limited; (5) Some interviewees expressed willingness to try digital psychological interventions and preferred brief weekly sessions of around 30 minutes.

Taken together, these findings support the need for a targeted digital psychological intervention for organ donor families.

3.2. Step 2: Identifying objectives

Intervention objectives were determined by integrating relevant theories with the aforementioned quantitative and qualitative research results.

3.2.1. Theoretical basis

According to the ABC Theory of Emotion, events (A) influence consequences (C) through people’s beliefs and cognitions (B). For organ donor families, A refers to the loss of a loved one together with donation-related experiences. Different cognitions may be associated with different emotional and behavioral responses, which in turn may contribute to psychological distress.

Relational Frame Theory states psychological inflexibility causes emotional suffering, emphasizing acceptance and adaptation to enhance psychological flexibility. Donor families’ distress (PTSD, depression, anxiety) reflects psychological inflexibility (experiential avoidance, cognitive fusion, etc.), preventing adaptive responses. Thus, enhancing psychological flexibility may help them cope with distress effectively.

3.2.2. Mixed research results

Beyond theoretical support, the quantitative and qualitative findings of this study provide further empirical data for setting intervention goals. Quantitative results showed PTSD was the primary mental health issue among donor families (61.94%), with a comorbidity rate of 25.81% for depression and anxiety; trait mindfulness had a stronger negative correlation with PTSD, depression and anxiety than perceived social support did. Qualitative research identified social avoidance in families, suggesting potential impairment of their social functioning.

Drawing on literature, quantitative, and qualitative findings, the intervention’s change goals are defined as: (1) enhancing trait mindfulness; (2) responding effectively with psychological distress; (3) gradually restoring socialization and social functioning.

3.3. Step 3: Theory-based methods and practical strategies

Based on the identified intervention objectives, combined with relevant theoretical models and empirical studies, suitable intervention strategies were screened out, as shown in Table 8.

Table 8.

Digital psychological intervention strategies for organ donor families.

Objective (PO)	Methodology	Basis	Practical application
PO1. Increasing Trait Mindfulness	Mindfulness Therapy	Mindfulness-Upward Spiral Model	(1) Introduction to Mindfulness Practice
			(2) Mindfulness Practices: Eating a Raisin, Mindful Breathing, Body Scan, Mindful Listening, Mindful Walking, Mindful Meditation, etc.
			(3) Provide mindfulness audio for post-class practice
PO2. Responding Effectively to Psychological Distress	Acceptance and Commitment Therapy	Relational Frame Theory	(1) Video explanation of Acceptance and Commitment Therapy: Acceptance, Cognitive Defusion, Self as Context, Contact with the Present Moment, Living a Value-Oriented Life, Committed Action
PO3. Gradually Restoring Socialization and Social Functioning	Mindfulness Therapy, Acceptance and Commitment Therapy	Self-Emotion Regulation Model	(2) Guide participants through experiential exercises
	Mindfulness Therapy, Acceptance and Commitment Therapy	Self-Emotion Regulation Model	(3) Participants engage in daily mindfulness practice

3.4. Step 4: Development and expert revision results of the intervention program

3.4.1. Design of the preliminary program draft

The initial intervention program was developed by referencing books on Acceptance and Commitment Therapy (ACT) and Mindfulness-Based Stress Reduction (MBSR): ACT Made Simple: An Easy-to-Read Primer on Acceptance and Commitment Therapy⁴⁸ and The Mindful Way Through Depression: Freeing Yourself from Chronic Unhappiness.⁴⁹ Delivered via a WeChat mini-program with a self-directed learning model, it includes 8 weekly 30-minute sessions, matching the families’ preferred frequency. To boost adherence and reduce dropouts, modules are unlocked only upon completion and can be revisited, with weekly learning reminders sent. Participants are also encouraged to practice daily mindfulness and finish check-ins during and after the course.

This intervention program comprises 8 sessions (with key components: mindfulness practice, review, core intervention, homework) and progresses by building rapport with organ donor families, guiding them to abandon ineffective pain-coping strategies, introducing acceptance, adjusting their thinking patterns, helping them connect with a transcendent self, enhancing present-moment awareness, clarifying life meaning, and finally supporting them in setting value-based action goals and committing to implementation—all to achieve psychological intervention outcomes. Detailed program information is provided in Appendix A.

3.4.2. Expert review and revision

Following expert discussion, the revised suggestions for the draft digital mental health intervention program for organ donor families are as follows:

(1) Arrange professionally trained staff to provide ongoing support during the program for timely resolution of participants’ learning difficulties;

(2) Replace mindful raisin eating with body scanning (the simplest mindfulness practice) as the introductory exercise for beginners; adjust the order of mindful meditation (guided by mindful breathing and body scanning) and split its practice duration into two sessions;

(3) Simplify the program (in view of the families’ generally low educational level) by eliminating complex worksheets and overly technical theoretical explanations;

(4) Add more rapport-building approaches to boost intervention adherence.

Drawing on prior research findings and expert suggestions, the program was revised as follows:

(1) Intervention format: Changed from self-help to human-supported—professionally trained researchers monitored the discussion section regularly to answer participants’ questions promptly;

(2) Intervention content: Removed worksheets (e.g., “Life Compass,” “Target Diagram”) and content on “Clarifying Values” and “Three Selves”; adjusted mindfulness practices’ content and order to “Body Scan,” “Mindful Breathing,” “Seated Meditation,” “Mindful Listening,” “Standing Meditation,” “Mindful Walking”; moved “Living a Value-Oriented Life” to Week2 to enhance participants’ intervention engagement motivation.

3.4.3. Content of the final program

3.4.3.1. Curriculum structure and content

Details of the revised program are shown in Table 9.

Table 9.

Revised digital psychological intervention program for organ donor families.

Week	Course topics	Content summary	Post-class practice
First week	Introduction	(1) Paying Tribute to Organ Donor Families: Screen the promotional video “The Gift of Life” to express gratitude for the contributions made by organ donor families.
		(2) Introduction to the Program’s Functions: Explain the purpose of using the program, its functions, and how to use it.
		(3) Introduction to Acceptance and Commitment Therapy: Introduce Acceptance and Commitment Therapy, its core processes, the importance of experiential exercises and practice skills, and possible adverse experiences.
		(4) Introduction to Mindfulness Practice: Introduce mindfulness practice and the importance of practicing mindfulness daily.
Second week	Living a Value-Oriented Life	(1) Mindfulness Practice: Body Scan.	Practice body scanning daily.
		(2) The Importance of Living a Value-Oriented Life: The Compass Metaphor.
		(3) Experiential Exercise: Imagine Your 80th Birthday.
Third week	Challenging Common Emotion Control Strategies	(1) Mindfulness Practice: Mindful Breathing.	Practice mindful breathing daily.
		(2) Ineffective Avoidance: The Pushing Papers Metaphor.
		(3) Guided Reflection: All the ways participants try to avoid or get rid of unwanted feelings, the effectiveness of these methods, and the costs associated with them.
		(4) Control as the Problem: The Struggling in Quicksand Metaphor.
Fourth week	Acceptance	(1) Mindfulness Practice: Seated Meditation.	Practice seated meditation daily.
		(2) Review of Previous Session Content.
		(3) Beginning Acceptance: The Pushing Papers Metaphor.
		(4) Psychoeducation: The Evolutionary Origins of Emotions.
		(5) Experiential Exercise: Turning Off the Struggle Switch.
Fifth week	Cognitive Defusion	(1) Mindfulness Practice: Mindful Listening.	(1) Practice mindful listening daily.
		(2) Review of Previous Session Content.	(1) Practice mindful listening daily.
		(3) How Fusion Impedes Effective Action: The Thoughts on Cards Metaphor.	(2) Try defusion exercises: Whenever you feel stressed, down, or whatever the feeling, identify the most distressing thought and then try to defuse from it.
		(4) Experiential Exercise: I’m Having This Thought Right Now.
Sixth week	Self as Context	(1) Mindfulness Practice: Standing Meditation.	Practice standing meditation daily.
		(2) Review of Previous Session Content.
		(3) Experiencing Self as Context: The Chessboard Metaphor.
		(4) Experiential Exercise: Watching a Stage Play.
Seventh week	Contact with the Present Moment	(1) Mindfulness Practice: Mindful Walking, Integrating Mindfulness into Daily Life.	Try informal mindfulness practices daily, such as mindful cooking, mindful walking, and mindful tooth brushing.
		(2) Review of Previous Session Content.
		(3) Why Engage with the Present: The Time Machine Metaphor.
		(4) How to Engage with the Present: Mindfulness Practices.
		(5) Experiential Exercise: Anchoring.
Eighth week	Commitment to Action	(1) Mindfulness Practice: Review of previous mindfulness practices, explanation of sustainable mindfulness practice.	Participants choose their own suitable or preferred mindfulness practice methods for long-term mindfulness practice.
		(2) Review of Previous Session Content
		(3) Why Take Action: The Bus Metaphor.
		(4) Strategies.
		(5) Setting Value-Based Action Goals.
		(6) Public Commitment.

3.4.3.2. Functional module design

The functional modules of the digital psychological intervention program for organ donor families are shown in Table 10. The program has two interfaces: user service and administrator. The user service interface includes six modules: mental health assessment, psychological intervention courses, post-course practice, health education and course reminders, discussion board, and personal center. The administrator interface equips the research team with management tools to organize and track user usage data.

Table 10.

Design of functional modules for digital psychological intervention for organ donor families.

Functional modules	Functional description
Mental Health Assessment	Provide mental health assessment tools, including the Impact of Event Scale-Revised, the Patient Health Questionnaire-9, the Generalized Anxiety Disorder-7 scale, etc.
Psychological Intervention Course	Specific intervention courses, consisting of eight units, presented through videos and interactive dialogues.
Post-course Practice	Post-class practice assignments that open with the unit courses, including learning guides and worksheets needed to complete the assignments, and a check-in feature for families of organ donors after completion.
Health Education and Course Reminders	Mental health education information push, with weekly course reminders and post-class practice check-in reminders.
Discussion Board	A communication platform for families of organ donors, to facilitate communication among donor families and provide feedback to the project research team.
Personal Center	Personal records for donor families, including mental health assessment results, course completion records, and post-class practice check-in records.
Ethical safety	Informed consent was obtained prior to intervention. Graded safety alerts and risk guidance were provided based on psychological assessment results.

3.4.4. Specifications for intervention reproducibility

To guide future implementation and improve reproducibility, the intervention will be implemented and reported in accordance with the TIDieR framework as follows: (1) Participants: Organ donor families; (2) Content: Digital psychological intervention integrating MBSR and ACT; (3) Duration: 8 weeks, 1 session/week; (4) Setting: WeChat mini-program; (5) Dosage: approximately 30 minutes per session; (6) Tailoring: No personalized adjustments; a unified standardized module process for all participants to ensure consistent implementation; (7) Fidelity: Ensured by providing implementers with standardized operation manuals, conducting pre-intervention training, setting a progress unlock mechanism, and enabling automatic weekly intervention reminders via the WeChat mini-program.

4. Discussion

4.1. Mental health status and psychological intervention needs of organ donor families

The findings of this study suggest that deceased organ donor families in this sample experienced substantial psychological distress during bereavement, with some participants showing co-occurring post-traumatic stress, depressive, and anxiety symptoms. These findings may partly reflect the psychological burden of bereavement after the loss of a loved one, with donation-related decision-making, public attitudes, and post-donation experiences potentially contributing additional emotional stress for some families. Qualitative interviews likewise highlighted life stress, moral distress, and social avoidance, suggesting that bereavement in this context may be associated with emotional burden and reduced social engagement, and underscoring the need for targeted psychological support for this vulnerable group.

Trait mindfulness was significantly negatively correlated with the three symptoms, consistent with the Mindfulness-Upward Spiral Model⁵⁰ and suggesting that mindfulness-related capacities may represent an important intervention target. By contrast, the relatively limited protective effect observed for perceived social support may indicate that available support was not always translated into usable emotional, professional, or peer support. This highlights the need to improve not only the availability but also the accessibility and utilization of social support resources in subsequent program development.

Qualitative findings suggested that some family members preferred brief digital psychological support delivered once weekly for about 30 minutes, indicating that a WeChat mini-program may be a suitable format for this group. Its convenience and privacy may be particularly valuable for geographically dispersed or privacy-sensitive families. The identified needs, including emotion regulation and trauma coping, also provided clear targets for intervention development.

4.2. Rationality of intervention objectives and strategy selection

The three intervention objectives are based on the core tenets of the ABC Theory of Emotion and Relational Frame Theory, and fully respond to empirical findings. Theoretically, the two theories provide a robust foundation for the intervention by emphasizing cognitive adjustment and psychological flexibility enhancement. Empirically, the strong protective effect of trait mindfulness, high incidence of psychological distress, and impaired social function determine that the objectives must balance emotional improvement and functional recovery, forming a clear logic of enhancing psychological capacity, alleviating distress, and restoring normal social function. Notably, social skills training is not set as an independent objective; instead, MBSR and ACT are used to reduce avoidance behaviors and strengthen value-oriented actions, thereby indirectly restoring social functioning at a more fundamental level.⁵¹

The integration of the two strategies yields a synergistic effect: MBSR provides basic awareness for core ACT practices (e.g., being present, self-as-context), while ACT transforms mindfulness practice into long-term behavioral changes through value clarification and committed action, helping families move from symptom relief to proactively pursuing a meaningful life.⁵² In addition, the strategies are well-adapted to digital delivery: mindfulness practice can be implemented via audio guidance, and core ACT concepts via videos and interactive exercises—both suitable for the WeChat mini-program.

4.3. Highlights of the design and revision of the intervention program

The preliminary program adopted an 8-week structured curriculum, which conforms to the classic intervention cycle of MBSR and ACT, and aligns with families’ preference for weekly sessions. Adherence-enhancing designs (progress unlocking, repeat learning, check-in reminders) improve the sustainability of participation through behavioral activation and feedback reinforcement; the unified curriculum structure (mindfulness practice + review + core intervention + homework) ensures the standardization and reproducibility of intervention implementation.

Review comments from 6 interdisciplinary experts (psychiatry, psychological nursing, organ donation, etc.) enhanced the rigor and feasibility of the program. Revised in response to expert suggestions (simplifying complex theories and worksheets, adjusting the order of mindfulness practices, adding human support and an experience sharing module), the program retains the core elements of the evidence-based framework while being more in line with the actual needs and usability of organ donor families.

4.4. Strengths and limitations

Based on findings from literature reviews, questionnaires and qualitative interviews, the digital psychological intervention program for organ donor families developed in this study was informed by this group’s mental health status and intervention needs. However, the study may have certain sample biases: the questionnaire sample was mainly drawn from donor families in Hunan Province, China, with some participants from other regions, and qualitative interviews focused on those with prominent mental health problems, so the findings should be generalized with caution. Additionally, the correlation analysis only examined bivariate associations without controlling for potential confounders (e.g., age, education, time since donation), which may affect the strength of the link between trait mindfulness and mental health outcomes. While the program is grounded in an evidence-based framework and has undergone expert review and refinement, its feasibility, acceptability, safety, and effectiveness remain unvalidated. Future pilot testing should therefore incorporate explicit safety monitoring and referral procedures for participants reporting marked distress or other mental health risks, while also completing Steps 5 and 6 of the IM framework.

5. Conclusion

Based on IM, this study developed a digital psychological intervention program for organ donor families through a systematic process from problem identification to program design. The program integrates ACT and MBSR and was informed by literature review, mixed-method needs assessment, and expert review, which strengthened its relevance, feasibility, and rigor. The resulting WeChat mini-program-based program provides a preliminary intervention framework for this population. Its feasibility, acceptability, safety, and preliminary effects should be examined in future pilot studies before wider implementation.

Footnotes

Acknowledgments

We wish to thank the participants in the study for their time and commitment.

ORCID iD

Yibo Yang

Ethical considerations

This study was approved by the Ethics Committee of Xiangya Third Hospital, Central South University, with all procedures adhering to the Declaration of Helsinki’s ethical standards. All participants’ personal information was kept confidential; all data were used solely for scientific research. All data were anonymized prior to statistical analysis.

Consent to participate

Informed digital consent was obtained from each participant in the questionnaire survey. In addition, verbal informed consent was obtained from those participating in the interview study.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the National Natural Science Foundation of China (72204272); Natural Science Foundation of Hunan Province (2025JJ50447).

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the first authors.*

Contributorship

YY: Methodology, Data curation, Investigation, Data analysis, Writing-original draft. HX: Methodology, Conceptualization, Data curation, Investigation, Data analysis. QL: Investigation, Literature search. SK: Conceptualization, Investigation. WX: Conceptualization, Project administration, Writing review and editing, Supervision.

Appendix

Appendix A.

Draft of the digital psychological intervention program for organ donor families.

Week	Course topics	Content summary	Post-class practice
First week	Introduction	(1) Paying Tribute to Organ Donor Families: Screen the promotional video “The Gift of Life” to express gratitude for the contributions made by organ donor families.	Practice mindful eating daily.
		(2) Introduction to the Program’s Functions: Explain the purpose of using the program, its functions, and how to use it.
		(3) Introduction to Acceptance and Commitment Therapy: Introduce Acceptance and Commitment Therapy, its core processes, the importance of experiential exercises and practice skills, and possible adverse experiences.
		(4) Introduction to Mindfulness Practice: Introduce mindfulness practice, the importance of practicing mindfulness daily, and try mindful eating of a raisin.
Second week	Challenging Common Emotion Control Strategies	(1) Mindfulness Practice: Mindful Breathing.	Practice mindful breathing daily.
		(2) Ineffective Avoidance: The Pushing Papers Metaphor.
		(3) Guided Reflection: All the ways participants try to avoid or get rid of unwanted feelings, the effectiveness of these methods, and the costs associated with them.
		(4) Control as the Problem: The Struggling in Quicksand Metaphor.
Third week	Acceptance	(1) Mindfulness Practice: Body Scan.	Practice body scanning daily.
		(2) Review of Previous Session Content.
		(3) Beginning Acceptance: The Pushing Papers Metaphor.
		(4) Psychoeducation: The Evolutionary Origins of Emotions.
		(5) Experiential Exercise: Turning Off the Struggle Switch.
Fourth week	Cognitive Defusion	(1) Mindfulness Practice: Mindful Listening.	(1) Practice mindful listening daily.
		(2) Review of Previous Session Content.	(1) Practice mindful listening daily.
		(3) How Fusion Impedes Effective Action: The Thoughts on Cards Metaphor.	(2) Defusion exercise: Whenever you feel stressed, down, or whatever the feeling, identify the most distressing thought and then try to defuse from it.
		(4) Experiential Exercise: I’m Having This Thought Right Now.
Fifth week	Self as Context	(1) Mindfulness Practice: Mindful Seated Meditation.	Practice mindful seated meditation daily.
		(2) Review of Previous Session Content.
		(3) Experiencing Self as Context: The Chessboard Metaphor.
		(4) Psychoeducation: The Three Selves.
		(5) Experiential Exercise: Watching a Stage Play.
Sixth week	Contact with the Present Moment	(1) Mindfulness Practice: Mindful Walking.	Try informal mindfulness practices daily, such as mindful cooking, mindful walking, and mindful tooth brushing.
		(2) Review of Previous Session Content.
		(3) Why Engage with the Present: The Time Machine Metaphor.
		(4) How to Engage with the Present: Mindfulness Practices.
		(5) Experiential Exercise: Anchoring.
Seventh week	Living a Value-Oriented Life	(1) Mindfulness Practice: Mindful Meditation.	(1) Complete the “Life Compass” and “Target Diagram” worksheets.
		(2) Review of Previous Session Content.
		(3) The Importance of Living a Value-Oriented Life: The Compass Metaphor.	(2) Try formal mindfulness practice combined with informal mindfulness practice daily.
		(4) Clarifying Values: Five Key Points of Values, Distinguishing Goals from Values, Pleasing Others, When Goals Are About Changing Others.
		(5) Experiential Exercise: Imagine Your 80th Birthday.
Eighth week	Commitment to Action	(1) Mindfulness Practice: Explanation of Sustainable Mindfulness Practice.	(1) Complete the “Willingness and Action Plan” worksheet.
		(2) Review of Previous Session Content.
		(3) Why Take Action: The Bus Metaphor.
		(4) Overcoming Barriers to Action: Identifying Barriers to Taking Committed Action and Strategies to Overcome These Barriers.	(2) Participants choose their own suitable or preferred mindfulness practice methods for long-term mindfulness practice.
		(5) Setting Value-Based Action Goals: SMART Goals.
		(6) Public Commitment.

Appendix B.

Correlations between trait mindfulness, perceived social support, and post-traumatic stress, depression, and anxiety (IES-R, PHQ-9 and GAD-7 as continuous variables).

	Trait mindfulness	Perceived social support	Post-traumatic stress	Depression	Anxiety
Trait Mindfulness	1.000
Perceived Social Support	0.381**	1.000
Post-traumatic Stress	-0.475**	-0.147	1.000
Depression	-0.599**	-0.159*	0.608**	1.000
Anxiety	-0.565**	-0.146	0.652**	0.892**	1.000

**.Correlation is significant at the 0.01 level (2-tailed).

*.Correlation is significant at the 0.05 level (2-tailed).

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