Preliminary Efficacy of AWARE in College Health Service Centers: A Group Psychotherapy Intervention for Asian American Women

Abstract

Objective:

Asian Women’s Action for Resilience and Empowerment (AWARE) is a psychotherapy intervention designed to improve the mental health of Asian American women. This study documented the feasibility and preliminary efficacy of AWARE at three university health service centers in Massachusetts.

Participants:

174 female Asian American college/graduate students were screened, and 48 (64%) met the eligibility criteria and enrolled in the study.

Methods:

This study was a non-randomized, pre-post design at three university/college health service centers in Massachusetts. Retention rates and changes in depression, anxiety, and PTSD symptoms were measured.

Results:

Results demonstrated high feasibility and significant preliminary efficacy of AWARE across the sites. After the completion of AWARE, participants showed statistically and clinically significant reduction of depression, anxiety, and PTSD symptoms (p-values <.001).

Conclusions:

This study provides strong evidence that AWARE can be successfully implemented in university settings and provides a promising model of mental health treatment for Asian American women.

Introduction

Though Asian Americans (AAs) are viewed as an academically and professionally-successful “model minority,” a substantial body of research indicates high mental health needs among AA women. For AA women between the ages of 20-24, suicide is the leading cause of death, accounting for a greater proportion of deaths by suicide (27.8%) compared to women in the U.S. overall (11.5%).¹ Despite their mental health needs, young AA women’s mental health care utilization rates are particularly low. AA female college students have the greatest treatment disparities out of all racial/ethnic groups.² A lack of empirically-based, culturally-appropriate intervention models further complicates the high rates of treatment underutilization within this population, thus underscoring the need for alternative coping methods.^3,4

Asian Women’s Action for Resilience and Empowerment (AWARE), a group psychotherapy intervention, was developed to address the mental health issues of young AA women. AWARE consists of 8 weekly, 90-minute in-person sessions and daily text message reminders reinforcing session content.^5,6 To our knowledge, AWARE is the first culturally-grounded intervention specifically designed to address mental health problems among young AA women that combines in-person and technology-based methods (see Hahm et al⁵ for more details).

The current study expands on previous work by examining the feasibility and clinical efficacy of AWARE in higher education settings, through student health service centers at three colleges/universities in Massachusetts.^5,6 As AAs have the highest college enrollment rate (65%) out of all racial/ethnic groups, university health centers are ideal settings for reaching young AA women.⁷

AWARE is culturally grounded both in terms of 1) the content addressed, including disempowering parenting, intergenerational conflict, racial discrimination, interpersonal violence, and substance use--areas that have been empirically identified as salient experiences to AA women, and 2) a theory-driven intervention strategy, referred to as the “Model of Healing: Dismantling Disempowerment Traps for Asian-American Women,”⁶ an approach informed by Bronfenbrenner’s theory of ecological systems,⁸ minority stress theory,⁹ and cognitive theories of stress and coping¹⁰ that speaks directly to the experiences of AA women. The model specifically highlights four levels of mental health risk factors, or “traps,” faced by AA women: inner voice trap, family trap, race trap, and suffering alone trap which are all incorporated throughout AWARE. The intersection of these traps is hypothesized to lead to depression, anxiety, and PTSD symptoms. For instance, one session focuses on body image, model minority stereotypes, and racism. Often caught in between a racial hierarchy, AAs experience racism not only from the majority, White Americans, but also from other minority groups, struggling with structural discrimination. Following this session, participants receive the following validating text message, “Racism or microaggressions can upset you. It is important to realize that discrimination is not a reflection of you, but the culture surrounding you” (see our prior publications for additional details on the AWARE sessions).^5,6,11

Through AWARE, AA women participate in interactive skill-building exercises, weekly check-ins, and goal-setting to develop healthy coping skills and improve daily functioning. AWARE aims to change the underlying meaning of traumatic events, solidifying participants’ dual cultural identities as children of immigrants, and developing skills to combat negative cognitions. This study consists of two objectives. First, we tested the feasibility of AWARE in college/university settings, measured by recruitment and retention across three sites in Massachusetts. Second, we tested its efficacy in reducing depression, anxiety, and PTSD symptoms.

Methods

Sample

AA female students at three colleges/universities in Massachusetts (herein referred to as Schools A, B, and C) were recruited through email, word-of-mouth, and poster campaigns. This selection was based on private institutions where Asian students comprised more than 20% of the student body, and which had at least one AA therapist at the health center at the time the study was initiated. Participants were screened using an electronic demographic survey. Respondents between the ages of 18-35 years who had never been married and self-identified as AA women were invited to participate in a baseline clinical assessment. Unlike our previous study which targeted only Chinese, Korean, and Vietnamese American women, we expanded our sample to all self-identified AA women, including South Asian students, the third largest Asian subgroup among the student population. Doing so ensured that AWARE, as an intervention for AA women, would better represent the true student body of the college campuses with findings generalizable to our target population. While we did not exclude international students from study participation, we focused our recruitment on immigrant children given the acculturative gaps and being perceived as “a perpetual foreigner” that can occur within the childhood experiences of children of immigrants.¹²

Participants who met one of the following clinical criteria were eligible to participate: moderate to severe depression (Center for Epidemiologic Studies Depression Scale score (CES-D) ≥ 16), anxiety (Hospital Anxiety and Depression Scale (HADS) score ≥ 11), PTSD diagnosis (PTSD Checklist-Civilian Version score ≥ 30), or exposure to traumatic events (Adverse Childhood Events International Questionnaire (ACE-EQ), any item).^13,14,15,16 The Columbia Suicide Severity Rating Scale (C-SSRS) was administered to measure suicidal ideation and intent.¹⁷ Participants reporting active suicidal intention or behavior in the past month were not enrolled in the study and referred immediately to individual psychotherapy at their health service center. At each institution, IRB approval was obtained prior to study initiation.

AWARE & Training

Participants attended AWARE sessions in small groups (n≤12) led by female Asian staff therapists at the respective sites. All AWARE therapists completed a one-day training by Dr. Hahm and Dr. Lee, a psychologist who led previous AWARE sessions. The trainers also provided regular supervision that was identical across the sites with focus on adherence to treatment models, session quality, and clinical concerns. The therapists were expected to cover the clinical contents in the manual but were allowed to skip some exercises depending on the time left in the session. Additionally, they reported weekly progress notes and attended regular supervision meetings with the principal investigators.

Measures

Outcome 1: Feasibility

Similar to our previous study, the intervention completion was defined by an attendance rate of at least 75% (6 out of 8 sessions).⁵ This threshold is higher than other studies which define completion as 40% of session attendance.¹⁸

Outcome 2: Fidelity

Implementation fidelity was assessed at each site using a rating scale modified from the Seeking Safety intervention.¹⁹ The therapists were evaluated in each session along two dimensions, “adherence to the manual” and “helpfulness to the participants,” on a Likert scale (0-poor to 3-excellent). Our threshold of acceptable fidelity was 2-good.^5,6 For Schools A and B, four trained AA female research assistants rated fidelity post-hoc using audio recordings. For each intervention group, two full sessions of recordings (25%) were randomly selected and assessed independently by two research assistants. For School C, two trained AA female research assistants each observed and rated one intervention group for all sessions.

Outcome 3: Efficacy

In the week following completion of AWARE, participants completed a computerized self-reported post-intervention clinical assessment, consisting of the same metrics as the baseline.

• Depressive symptoms. The 20-item Center for Epidemiological Studies Depression Scale (CESD-R) assessed depressive symptomatology (0–3). The sum of responses represented a total symptom score between 0 and 60 (α=0.97).

• Anxiety symptoms. The 7-item Hospital Anxiety and Depression Scale-Anxiety subscale (HADS-A) measured symptoms of anxiety and fear with a score range of 0–21 (α=0.85).

• PTSD symptoms. The 17-item PTSD Checklist-Civilian version (PCL-C) measured PTSD symptom severity using a 5-point scale. The sum indicated the overall symptom severity ranging from 17–85 (α=0.93).

Results

Sample

Across the three colleges/universities, 174 AA female students completed the initial demographic survey. Among these, 157 (90%) were eligible for the baseline clinical assessment. In scheduling assessment and intake appointments, 72 students (46%) did not respond to communications, had scheduling conflicts, or chose not to continue (due to concerns about anticipated lack of time, the group format, or other unspecified reasons). Among the 85 students who completed the baseline assessment, 75 (88%) were clinically eligible for participation in AWARE. Of these, 48 participants (64%) enrolled in the intervention. Reasons for not enrolling included scheduling conflicts, anticipated lack of time, and rarely preferring not to participate. The overall enrollment rate out of all initial respondents was 28%. Participants were ethnically diverse (Chinese: 48%, Korean: 27%, Southeast Asian: 9%, South Asian: 7%, multi-racial/multi-ethnic: 9%). The median age was 21.5 years.

Retention

School A and C conducted two AWARE groups (n=8 and 12 each, respectively) and School B conducted one group (n=10). Of the 48 participants enrolled in AWARE, 4 dropped out before the first session. Out of the 44 participants who started, 35 (80%) attended at least 6 of the 8 intervention sessions, which is greater than our internal goal of 33 (75%) based on earlier pilot studies. Participant retention was high; of the 44 participants who started, 37 (84%) went on to complete the post-intervention clinical assessments. Among these, 34 (92%) completed at least 6 of the 8 sessions. Retention throughout the intervention differed by site; however, within each institution, there was no statistically significant difference between the ages, ethnicities, and baseline clinical symptoms of those who completed the intervention and post assessment, compared to those who did not.

Intervention Fidelity

Fidelity scores (rated 0-3 points) for the intervention were similar across the schools and consistently above our goal of 2. For School A, adherence to the manual was rated 2.36 and 2.39 for each group, and helpfulness to participants was rated 2.35 and 2.47, respectively. For School B, adherence and helpfulness were rated 2.44 and 2.25, respectively. For School C, adherence ratings were 2.67 and 2.40 for each group, and helpfulness ratings were 2.11 and 2.49, respectively.

Efficacy

The pre-post intervention comparison showed statistically significant improvements for all clinical measures. Effect size analysis indicated large differences in pre-post intervention clinical measures (Cohen’s d=0.92, 1.28, and 0.78, respectively).

Prior to intervention, participants exhibited symptoms that exceeded the diagnostic thresholds for moderate or severe depression, anxiety, and PTSD. Following the intervention, depression and PTSD symptoms were reduced to just above threshold, and anxiety symptoms dropped below clinical thresholds. Results of McNemar’s tests also supported significant changes from pre- to post-intervention. Together, these results suggest AWARE is efficacious at improving participants’ mental health from clinical to subclinical levels.

Discussion

To our knowledge, this is the first study to assess the feasibility and efficacy of a culturally-grounded, gender-specific group psychotherapy model for AA female college/graduate students, across multiple sites. We found high feasibility and statistically and clinically significant improvements in mental health outcomes among participants, demonstrating its promise as an effective intervention for young AA women.

The high retention rates for this study were comparable to those of the previous AWARE studies, and are substantially higher than other group therapy interventions with college students.^20,21 Fidelity scores were equivalent across sites, and the average fidelity scores were similar to our previous study, demonstrating that the therapists were able to deliver the treatment with acceptable levels of adherence and helpfulness.⁶ The high implementation feasibility across the three sites suggests that AWARE can be successfully replicated at other college or university health service settings. Among those who completed the intervention, all outcomes showed statistically and clinically significant reductions post-intervention, suggesting efficacy.

We acknowledge the following limitations. Our intervention relied on a small sample, in a non-randomized manner, without a control group for comparison. Although we did not account for protocol adherence in the efficacy analysis due to the small sample, compliance and fidelity were fairly high across all sites. As all measures were self-reported, they are susceptible to social desirability. Moreover, the sample was from selective and competitive private institutions in Massachusetts, which may limit the generalizability of our findings to higher socioeconomic groups. Despite these limitations, the high feasibility and general pattern of changes in mental health outcomes supports AWARE as a promising psychotherapy intervention for AA women. Further research will allow us to evaluate treatment effects over time and verify the potential of AWARE to prevent relapsing symptoms. If more broadly implemented, AWARE may serve as a step toward reducing mental health treatment disparities among young AA women.

Table 1:

Pre-post intervention clinical measures for AWARE participants across three colleges/universities (n=37).

Variables	School A		School B		School C		All sites		Pre/ Post Change	P-value	Cohen’s d
	Baseline	Post intervention	Baseline	Post intervention	Baseline	Post intervention	Baseline	Post intervention
	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)
CESD-R (0-80, ψ = 16)	35.8 (19.2)	26.8 (20.7)	25.7 (13.3)	6.43 (3.78)	19.2 (11.9)	12.4 (8.17)	26.2 (16.5)	16.3 (15.5)	−9.95 (10.9)	<.001	0.92
HADS-A (0-21, ψ = 11)	13.6 (4.48)	11.0 (4.58)	12.0 (2.24)	5.57 (2.88)	11.1 (4.45)	6.35 (2.69)	12.1 (4.20)	7.84 (4.15)	−4.30 (3.36)	<.001	1.28
PCL-C (17-85, ψ = 30)	43.4 (13.8)	39.2 (15.9)	45.4 (9.50)	26.1 (6.72)	38.2 (10.3)	29.8 (8.75)	41.4 (11.6)	32.4 (12.4)	−8.95 (11.5)	<.001	0.78

^Ѱ=clinical threshold