Feasibility and Efficacy Trial for Asian Women's Action for Resilience and Empowerment (AWARE) Intervention at Three University Health Services Centers

Background and Purpose:  Asian American women (AAW) who are children of immigrants experience higher rates of depression, anxiety, and trauma-related symptoms compared to their White counterparts.  Despite this, AAW are least likely of all racial groups to seek treatment for psychological distress.  To address this, we developed the Asian Women’s Action for Resilience and Empowerment (AWARE) intervention.  This is the first culturally-grounded intervention that specifically addresses the mental health of young AAW.  AWARE consists of in-person and technology-based methods: 8 weekly face-to-face group psychotherapy sessions led by AAW therapists, and daily text messages that include reminders of session content and discussion summaries.  Previously, AWARE has been tested for clinical efficacy in a community-based clinical trial.  This study examines the feasibility and efficacy of AWARE in higher education settings, as provided through the student health services centers of colleges/universities.

Methods:  AAW students at three colleges/universities in Massachusetts were recruited and screened using a demographic survey.  Those who passed the screening (age 18 - 35, never married, self-identifying as AAW) were invited to participate in a baseline clinical assessment.  Eligibility for the AWARE intervention included those who met any one of the following criteria: moderate to severe depression (Center for Epidemiologic Studies Depression Scale (CESD-R) ≥ 16), anxiety (Hospital Anxiety and Depression Scale (HADS-A) ≥ 11), post-traumatic stress diagnosis (PTSD CheckList - Civilian Version (PCL-C) ≥ 30), or childhood exposure to traumatic events (Adverse Childhood Events International Questionnaire (ACE-IQ), any item).  Once enrolled, AWARE intervention sessions were conducted in small groups (n ≤ 11) led by the respective student health services centers’ staff therapists.  Participants completed a post-intervention clinical assessment. Pre/post- intervention clinical outcomes were assessed using two tailed paired t-test.  This study took place from August 2016 to December 2018.

Results:  Across three higher education institutions, 174 AAW students voluntarily filled out the demographic screener, 75 students eligibilized for the study, 50 initiated the AWARE sessions, and 37 (74%) completed the pre- and post-intervention clinical assessments.  Among those who completed, the median age was 21 years (IQR: 19-24 years).  Post-intervention results indicated statistically significant improvements in depression (ΔCESD-R = -9.95 ± 10.86, p < 0.0001), anxiety (ΔHADS-A = -4.30 ± 3.36, p <.0001), and PTSD scores (ΔPCL-C = -8.95 ± 11.52, p < 0.0001).  AWARE also significantly improved mental well-being, as assessed by the SF-12 Mental Health Composite Scale (ΔMCS-12 = 9.20 ± 10.71, p < 0.0001).

Conclusions and Implications:  This study demonstrates AWARE’s high feasibility, acceptability, and clinical efficacy for young AAW in higher education settings.  Culturally-grounded and empirically-based interventions such as AWARE may significantly improve the overall mental health of college and graduate students.