The term sexual and gender minority (SGM) comprises a broad range of identities related to sexual orientation and gender identity including, but not limited to, lesbian, gay, bisexual, and transgender individuals [1]. Many studies have documented that SGMs are faced with a multitude of health disparities, particularly within the emerging adulthood period (ie, ages 18-29 years) [2,3]. In particular, depression, anxiety, and suicidality continue to be disproportionately high throughout the emerging adulthood period among SGMs relative to older SGMs and non-SGMs [3]. Moreover, emerging adulthood is a key developmental period in which interventions designed to buffer the negative effects of stress on health may be particularly relevant, as emerging adulthood is characterized by rapid changes in psychological, social, and familial environments (eg, college) that greatly affect the development and maintenance of stress-coping mechanisms [4].

One pathway through which mental health disparities are posited to arise among SGMs is through sexual minority stress [5]. The sexual minority stress theory posits that sexual minority individuals experience many distal and proximal stressors related to the negative social valuation of sexual minority identity, resulting in exacerbated stress beyond the levels that people generally experience [5]. Over time, individuals may internalize minority stressors (eg, internalized homophobia), which in turn may contribute to poor mental health among SGMs [5]. Furthermore, SGMs who experience intersectional discrimination (eg, gender-based, racial- or ethnic-related, and sexual orientation–related discrimination) are more likely to report poorer mental health as compared with their White SGM and non-SGM counterparts [6-8]. Although the sexual minority stress theory also suggests that endemic structural-level processes contribute to the perpetuation of poor mental health among SGMs, it is imperative that interventions not only focus on reducing mental health inequalities at the societal level but also focus on reducing the impact of discrimination in the everyday lives of SGMs, particularly SGMs of color.

Researchers using daily diary methodologies have found that emerging adulthood SGMs who report more daily discriminatory experiences have more negative mood, poorer emotional states, and report more depressive symptoms and suicidal ideation on average than those who report fewer daily discriminatory experiences [9]. In addition, young SGMs of color who experience intersectional discrimination based on race or ethnicity, gender identity, or sexual orientation report more negative mood than young White SGMs [9].

Research suggests that increasing the practice of mindfulness may be useful for reducing the impact of daily stress on poor mental health among emerging adults who experience discrimination [10]. Mindfulness meditation is a practice that focuses on an individual’s attention on the present moment, leading to reduced levels of stress [11]. Web-based mindfulness interventions among SGMs have been associated with lower levels of perceived stress compared with baseline readings in both men and women, as well as reduced sexual minority stress in SGM women [12]. Mindfulness interventions can also lead to increased individual resilience toward discriminatory experiences [13,14]. By allowing the SGM individual to disengage with the discriminatory experience by focusing on the present moment, negative feelings may be less likely to occur, which can lead to improved psychological well-being [13]. Past research provides evidence that mindfulness acts as a protective factor against the negative psychological effects of school-based victimization based on sexual orientation and age-based discrimination [14,15]. In particular, higher levels of mindfulness buffered the association between discrimination events and negative psychological outcomes, such as anxiety and depression [14,15]. Although there is a critical number of observational and intervention studies showing the effectiveness of mindfulness in reducing stress from discrimination and promoting well-being [16], the key features of mindfulness interventions that are the most effective, efficient, and scalable remain unclear. Thus, an approach to empirically examine the key features of mindfulness that are effective in reducing stress from discrimination among SGMs is imperative for creating culturally relevant and impactful well-being interventions for diverse populations of SGMs. In particular, there are three specific mindfulness-based practices, that is, awareness, connection, and purpose, that may lead to reductions in levels of stress and increased well-being.

Awareness through meditation promotes well-being through self-awareness, reducing the mind’s ability to be distracted and instead be present in the moment, not allowing the mind to wander to negative thoughts that cause stress. Practicing awareness brings you to the present moment and allows you to become aware of your thoughts. Should the thoughts become negative, awareness practice teaches individuals to let those thoughts wander without judgment. Furthermore, this practice teaches people to be present in the current moment rather than in thoughts regarding the past or the future [17]. The impact of awareness-based practice on mental well-being is supported by the overarching research literature [11,18]. For example, 1 study found that those who did not engage in awareness-based practices reported lower levels of happiness as compared with those who engaged in awareness-based practices [11]. Moreover, in another study of 717 students, Parto and Besharat [19] found that awareness was positively associated with mental well-being in their study sample. Thus, there is evidence to support that awareness is associated with positive mental health outcomes.

Connection through meditation supports empathy, compassion, and kindness in daily activities. The practice of connection emphasizes connections with oneself and with others. The mindfulness-based practice of connection with oneself highlights the need to be aware of oneself and one’s emotions or feelings, to accept oneself owing to this awareness, and to orientate one’s behaviors in conjunction with this awareness of oneself [20]. Moreover, mindfulness-based practices can also foster connections with others through compassion meditation, which begins with attention training and mindfulness, and goes on to contemplative practices with the goal of highlighting connection with others and self-compassion. Research shows that mindfulness-based self-connection is associated with well-being. Indeed, 1 study found that mindfulness predicted self-connection, which in turn was associated with increased well-being [20]. Moreover, previous work demonstrates that engagement in compassion meditations based on mindfulness and compassion is associated with reduced psychological distress and lower depressive symptoms [21,22].

Purpose through meditation encourages daily meaning in life through the encouragement of goal-making and behavior management in accordance with these goals [23]. The mindfulness-based practice of purpose allows emotions to be better regulated when an individual acknowledges the meaning in their life, leading to clearer values and persistence in the face of adversity. This practice guides overarching goals and daily behaviors by offering direction to oneself in alignment with one’s goals and needs [23]. Much research documents the benefits of committing to the mindfulness-based practice of purpose. For instance, a systematic review found that meaning in life (ie, purpose) was associated with better overall physical health [24]. In addition, in a longitudinal study, Disabato et al [25] found in a sample of 797 adults that meaning in life predicted decreases in depressive symptoms over a 6-month period.

Figure 1 displays the study’s overarching conceptual framework. This framework describes how intersectional identities may lead to increased levels of stress and reduced well-being among young SGMs of color. SGMs of color possess multiple marginalized identities (ie, sexual or gender minority status and race or ethnicity). The possession of multiple marginalized identities, in turn, may lead to exposure to stigma and discrimination at the intersection of these identities (eg, they may experience discrimination based on both their gender identity and race or ethnicity). Exposure to stigma or discrimination may lead to increased stress levels in the form of minority stress, which may interact with other forms of stress (eg, chronic stress and financial hardship), which, in turn, may lead to poor mental health outcomes, including increased perceived stress and decreased well-being. However, the practice of mindfulness in the domains of awareness, connection, and purpose may buffer the negative effects of minority stress on perceived stress and well-being among young SGMs of color such that those who engage in these practices may experience improved mental health in the form of reduced perceived stress and increased well-being.

The primary goal of this study is to use an innovative optimization design (ie, the multiphase optimization strategy [MOST]) to evaluate different components of mindfulness interventions and the interaction between the components to build an effective, efficient, and scalable intervention to reduce daily stress from discrimination among SGMs of color. MOST is a systematic method for identifying the optimized combination of intervention components before testing an intervention in a resource-intensive randomized controlled trial (RCT) [26,27]. The MOST consists of three stages: preparation, optimization, and evaluation of the optimized intervention in an RCT. In this study, participants will be randomized into 1 of 8 conditions, and interventions will be administered using the MOST design. The participants will be randomized to at least one of the 3 intervention components of awareness, connection, and purpose for this optimization study, which comprises the 8 conditions. Each of these components is known to be effective in reducing stress and promoting well-being among populations that experience high rates of discrimination (eg, SGMs) [12-14]. These components will be administered via the Healthy Minds Program (HMP) app with the goal of examining which combination of components most effectively reduces stress from discrimination among racial or ethnic SGMs.

In this study, the goal is to use the MOST to evaluate different components of mindfulness interventions and the interaction between the components to build an effective, efficient, and scalable intervention to reduce daily stress from discrimination among SGMs of color. The overall objective of this study is to identify which combination of the three components (ie, purpose, connection, and awareness) meaningfully contributes to improvement in the primary outcomes of interest among SGMs, which are perceived stress reduction (ie, one’s feeling about how stressed they are at a current moment) and improved well-being (ie, the state of feeling comfortable, happy, and healthy).

The aims of this study are as follows: (1) to assess the efficacy of the intervention components separately and in combination on mean change in stress and well-being among SGMs and (2) to determine the most effective intervention, based on the different combinations of the intervention components, which leads to the greatest reductions in perceived stress and the greatest improvement in mental well-being among SGMs. The 5-day period has been used in previous studies and demonstrates that mindfulness-based practice is effective at reducing stress over this brief period [28]. Furthermore, as a secondary aim, we will examine the feasibility and acceptability of the Reduce Stress from Discrimination among Young Sexual and Gender Minorities of Color (REDUCE) study. Feasibility and acceptability will be measured via retention rates and debriefing interviews, where we ask participants about their experiences with the study.

REDUCE is a single-site, pilot optimization study with the primary goal of assessing which component or components of a mindfulness-based smartphone app, the HMP, most effectively reduces the effects of stress from discrimination among young SGMs of color. The study will use the MOST [26,27] framework to examine which combination of the well-being intervention components (ie, awareness, connection, and purpose; see the Intervention section) leads to the most optimal behavioral intervention. The most optimal behavioral intervention in this context is defined as one that yields the greatest improvement in mental health outcomes (ie, perceived stress and mental well-being) [29].

This pilot study will consist of 80 young SGMs (ie, between the ages of 18 and 29 years) who identify as a racial or ethnic minority (eg, Black or Hispanic). Participants will be randomized to 1 of 8 conditions (including a control condition; explained in detail in the Study Procedures section). The HMP app was developed by Dr Richard Davidson and others at the University of Wisconsin-Madison’s Center for Healthy Minds in affiliation with the nonprofit Healthy Minds Innovations [30]. The HMP smartphone app is compatible with both the iPhone Operating System (iOS) and Android. The REDUCE study will be web- and smartphone-based, with study staff communicating with participants through Zoom (Zoom Video Communications), text message, phone, or email, depending on participant preference.

Participation in the study will last for 6 days, consisting of a web-based baseline survey (day 1), 5 days of self-guided practices completed through the HMP app (days 2-6), and 5 days of web-based daily diaries (days 2-6). In addition, we will collect data pertaining to feasibility and acceptability through a debriefing interview to be completed after completion of the 6-day study protocol. The Institutional Review Board of New York University at Washington Square has reviewed and approved this study (IRB-FY2020-4338).

Young SGMs of color who are aged between 18 and 29 years and who live in the New York metropolitan area will be eligible to participate in the study. The eligibility criteria were as follows: (1) be aged between 18 and 29 years; (2) must identify as a sexual minority (gay, bisexual, etc); (3) must identify as an underrepresented racial or ethnic minority (eg, Black or Hispanic); (4) must have an active smartphone and be able to access the smartphone 7 days a week between 6 PM and 6 AM the next morning; (5) must be willing and able to receive up to 6 text messages or emails per day; (6) must have consistent internet access 7 days a week between 6 PM and 6 AM; (7) must have the ability to understand, read, and speak English; (8) must reside in the New York metropolitan area; and (9) must be willing to provide written informed consent. We will exclude individuals who do not meet any of the eligibility criteria (eg, White participants).

If a prospective participant screens eligible through the web-based study screener, they will be contacted by trained study staff via email to schedule their informed consent session, which will take place over Zoom. During the informed consent session, trained study staff will first check identification to confirm identity and then go over the informed consent form with prospective participants. During this meeting, interested individuals will be given the opportunity to ask study staff any questions they may have to address concerns and to ensure comprehension among any and all prospective participants. The informed consent form will be programmed into REDCap, and all responses will be stored in a password-protected study folder separate from other study responses (eg, the baseline survey). Only trained study staff will have access to the REDCap responses.

There are 2 main study outcomes for this study, which are described in detail in subsequent sections.