An Affirmative Coping Skills Intervention to Improve Mental Health of Sexual and Gender Minority Youth (AFFIRM): Interim Results of a Stepped Wedge Trial

Background and Purpose: Sexual and gender minority youth (SGMY, aged 14-29 years) face increased risks for depression, suicide, and other mental and behavioural issues compared to their cisgender, heterosexual peers. Affirmative cognitive behavioral therapy (CBT) has improved SGMY wellbeing and reduced psychosocial distress in an open pilot feasibility study but more rigorous methods are needed. AFFIRM is an 8-session, manualized, CBT tailored group intervention designed to reduce depression and improve stress appraisal and coping among SGMY. AFFIRM, created by social work researchers, is midway through a five-year community–based implementation trial in Ontario, Canada.

Methods: SGMY were conveniently and purposively recruited via agencies and online advertising. Participants (SGMY; 14-29; screened for group suitability) were allocated in a 2:1 fashion to AFFIRM intervention or a waitlisted control in a stepped wedge waitlist crossover design (SWWCD). SWWCD is an ethical approach to intervention research with marginalized populations (Joag et al., 2019) as all participants receive the treatment condition. For AFFIRM, SWWCD meant that two-thirds of participants received AFFIRM immediately, with one-third receiving AFFIRM after a two-month wait. AFFIRM is hosted by community-based agencies and delivered by trained social work co-facilitators. Feasibility was assessed by intent-to-treat proportions of screening, enrollment, and completion. Acceptability was assessed through a 17-item satisfaction scale at postintervention. Exploratory outcomes of the Stress Appraisal Measure for Adolescents (SAMA), Beck’s Depression Inventory-II (BDI-II), modified Adult Hope Scale, and the Brief COPE subscales of emotional support, instrumental support, positive framing, planning, and reflective coping were analyzed using hierarchical linear modeling (HLM) from assessments at waitlist, preintervention, and postintervention.

Results: Since April 2018, 249 SGMY have been screened for AFFIRM with 61% (n=152) enrolled to the intervention (n=102) and the waitlisted control (n=50). The remaining youth either declined to participate (n=65) or AFFIRM was not available in their location (n=32). Among the youth enrolled, 72.3% (n=110) of participants completed the intervention. Screened participants (n=249) were 14-29 years old (M=22.08), with a wide range of gender (top three identities: gender non-binary: 21.5%; cis man: 17.7%; cis woman: 17.3%), sexual (gay: 24.9%; queer: 21.7%; pansexual: 15.3%), and ethnic/racial identities (White: 49.8%; Asian: 20.9%; Black: 18.1%). Nearly all (96.8%) participants (n=110) agreed that AFFIRM was helpful and applicable to their life with high scores on the satisfaction scale (M=3.63, out of 4). The HLM model found that AFFIRM participants reported significantly lower depression scores (time*condition: B=-0.22, p=.010) and higher scores in reflective coping (B=0.26, p=.005), emotional support (B=0.50, p=.001), instrumental support (B=0.61, p<.001), positive framing (B=0.44, p=.001), planning (B=0.42, p=.001) and hope (agency: B=0.63, p=.004; pathway: B=0.64, p=.002) postintervention, compared to control. Also compared to control, AFFIRM participants were more likely to perceive stress as a challenge (B=0.53, p=.001) and resource (B=0.32, p=.024), and less as a threat (B=-0.33, p=.005) postintervention.

Conclusions and Implications: Based on these interim findings, AFFIRM is a potentially scalable community-based intervention for SGMY to reduce depression and foster coping skills and hope. Intervention design and outcomes, with considerations for social work implementation science research to impact social change, will be discussed.