Chwa C. Subtle Asian glow: a digital substance use prevention platform for Asian populations. HPHR. 2021;50. 10.54111/0001/WW6
Despite the influx of digital mental health interventions addressing substance use among young people, there is a need for leveraging cultural sensitivity in the context of substance use within the Asian college student populations, particularly with MDMA, vaping, and alcohol use. While the stigma among Asian populations is increasingly high in regards to substance use, it makes it more challenging if the interventions are not appropriate in respect to the cultural and familial norms that Asian college students experience on a daily basis. Furthermore, public health research and interventions often dismisses the needs and substance use problems that exist among Asian populations.
To propose a digitally based intervention for promoting safe substance use practices and incorporates social support, social media influence, accessibility, and de-stigmatization through a culturally sensitive lens for Asian college students.
We used the Theory of Planned Behavior to leverage the attitudes towards the behavior, perceived behavioral control, and subjective norms for substance use behavior change, and this will be executed through a peer mentorship program, an online community discussion board, a social media campaign, and a curated list of resources.
This proposed intervention hopes to encourage existing substance use interventions to integrate cultural sensitivity into their material and dismantle the xenophobic narratives of the model minority myth. It is critical for existing interventions to acknowledge how to become a more inclusive and accessible platform for Asian populations, and evaluate these intervention strategies through the common risk factors that are specific to this population.
The Asian American population has grown exponentially over the past decades, with 19.3 million Asians currently residing in the United States and making up 5.9% of the total demographic population.1 Despite the 43% increase of Asian individuals migrating into the United States from 2000 and 2010,1 Asian American and Pacific Islander (AAPI) individuals have been historically portrayed in the United States as the “model minority”, a xenophobic narrative that has led to an underreporting and a low priority need for developing culturally sensitive substance abuse related care for this population.1 The model minority myth is a problematic construct that imposes Asian Americans as a homogeneous group, and assumes that all individuals in this population are high achieving recipients of academic and professional success.2 This not only obscures the vast disparities in this so-called “monolithic” group, but also diminishes representation in conversations about public health and politics.3
AAPI youths and young adults have also been identified as the group with the most substance-free use, as compared to their peers from other racial and ethnic groups.1,3 However, population-based or national surveys are administered in English, and are likely to underrepresent AAPIs who are not proficient in the English language.3 The West and Pacific coast tend to have higher populations of AAPIs as compared to the East coast, and it is crucial for surveys and studies to be conducted in AAPI-dense populations to yield more accurate findings for health and substance use behaviors.3
The risk factors associated with substance use disorders and high risk substance use behavior among AAPIs include parental attitudes on drug abuse and dependency, peer alienation, high expectations from parents, lack of communication, generational trauma and differences, cultural perspective change, low education aspiration, poor school adjustment, rebelliousness, low self-esteem, antisocial behavior, emotional distress, low religiosity, and meaningless in life.5 Specifically among Asian immigrants, the most common risk factors include housing challenges, crowdedness, socioeconomic difficulties, adaptation to the English language, loss of vocational and social skills, loss of social networks, and dysfunctional families.5
Protective factors associated with safe substance use practices and decreased prevalence of substance use disorder and include social bonding, socialization, strong family relationships, family involvement and attachment, high commitment to academia and GPA, positive learning environment, low peer pressure to use drugs, limited time spent with friends after school, high religiosity, low depression, high self-acceptance/esteem, and general social norms of disapproval in use.5
The Theory of Planned Behavior (TPB) is the foundational framework for Subtle Asian Glow. This framework suggests that intentions result from perceived attitudes towards the behavior, subjective norms can affect engagement in the behavior, and these norms extend to address perceived behavioral control.6 In TPB, attitudes towards the behavior are either positive or negative. In this intervention, positive attitudes towards substance use correlate with substance use behavior among college students.6 Subjective norms are defined as whether one perceives if others approve or disapprove of a health-related behavior.6 Peer influence is influential, especially during a formative phase of growth in adolescence and emerging adulthood. Peer groups play a major role in predicting substance use behaviors and level of risk associated with those behaviors. TPB’s last construct, perceived behavioral control, involves indirect (intent) and direct influence on behavior, and addresses both internal and external control factors.6 Perceived behavioral control is defined as an individual’s perception of facility or hassle of performing the health behavior, and involves perception of one’s personal control over internal or external factors that may motivate or impede pursuit of the behavior.6 Therefore, having perceived difficulty adopting safer substance use practices when attending raves or college parties may significantly contribute to an increase in risky substance use behaviors among college students, and can be examined within the TPB framework.5
Prior to implementation of Subtle Asian Glow, discussions with relevant stakeholders is critical in the stages of development and dissemination. The key stakeholders will include executive board members at the university, Student Health Center Directors, Associated Student Body, local community based organizations and clinics, local AAPI therapists, and executive boards of AAPI-led student organizations. We will be conducting a needs assessment and utilizing a collaborative approach to determine the substance use landscape among AAPIs at each university. We will focus on understanding the norms around substance use behaviors, as well as successes and challenges faced by the university administration or student leaders who have been implementing substance abuse or promoting strategies in the past or currently.
Our research team will be leveraging five tools to shape our formative research: medical records, focus groups, key informant interviews, town hall meetings, and survey research. Input will be obtained through focus groups, key informant interviews, and existing survey data collection. We will also conduct town hall meetings that can engage stakeholders from various venues to congregate and express their concerns related to substance use in this population.
Subtle Asian Glow (SAG) is inspired by the Facebook group, Subtle Asian Traits,6 and the mutation of specific genes in many Asian populations that cause redness and “glow” after consuming alcoholic beverages or substances.7 Glow is also meant to colloquially refer to the somatic effects of MDMA and vaping.8 The four primary components of SAG are as follows:
Alcohol, smoking, and substance involvement (ASSIST): ASSIST contains 8 items measuring lifetime and recent substance use of various drugs.8 After completion, a substance involvement score (SSI) is calculated for each substance, in addition to a total substance involvement score (TSI).8 ASSIST will be utilized to measure the primary outcome of substance use frequency.
Patient Health Questionnaire-9 (PHQ-9): PHQ-9 contains 9 items and measures frequency, extent, and intensity of depressive symptoms, as well as one suicidal ideation item.9
Generalized Anxiety Disorder-7 (GAD-7): GAD-7 measures frequency and severity of anxiety symptoms, behaviors, and thoughts within the past two weeks.10
Multidimensional Scale of Perceived Social Support (MSPSS): MPSS consists of 12 items and is divided into three subscales of family, friends, and significant others.11,12
Subtle Asian Glow will employ a 2-arm randomized controlled trial (Fig. 2) during the rollout of Phase 1. This pilot trial will recruit 500 Asian college undergraduate students who attend a public or private university in the United States. The intervention group will receive full access to the SAG, including the peer networking and group forums at no cost. The control group will receive a digital pamphlet containing information about SAMHSA’s substance abuse-related resources. The proof of concept evidence will be conducted through pre- and post-measures of ASSIST, and a significant decrease in scores will signify the intervention’s feasibility among this population.
Short-term outcomes assessed after administration of Phase 1 include:
Long-term outcomes after administration of Phase 1 include:
Our key markers for evaluating the efficacy and feasibility of SAG include: 1) number of students signed up to become a SAG Hub Mentee; 2) number of students who stay as a mentee for the entirety of the study intervention; 3) number of website view counts from baseline to end of study; 4) number of messages posted on SAGA; 5) number of times #SAG is used on social media; 6) number of times someone on SAGS clicks on a source that is hyperlinked on the webpage; 7) number of universities who execute the plan thoroughly from proposed start to end date. We will determine a standard value of success before employing this intervention, and compare that expected value with the documented value after Phase 1.
The pilot study’s aim is to recruit 500 Asian college undergraduate students who attend a public or private university in the United States. Because this recruitment strategy does not focus on a specific school or coast, the next phase can focus on specific universities to ensure that SAG is an ongoing campaign that the university can partner with. An idea is to trial SAG at a select few universities for Phase 2 and assess the constructs of Theory of Planned Behavior within that specific site. The research team can find ways to partner with representatives on campus to figure out the best way to integrate SAG into the mental health campus climate.
Maintenance of the website’s interventions and maintaining consistency across all universities is important. For example, the website and services should be accessible to all participants in the study. There should not be any limitations to the website that may prevent some participants or clusters from access. Training of SAG mentors must be standardized across all universities. Each university will have their cohort of university-specific SAG mentors, and each of them will be trained by a SAG Staff Member on specific roles and expectations of this mentorship position. University SAG Mentors will keep a digital log of all their activities and notes from their conversations with their SAG mentee. They will also attend check-ins from the SAG Hub Director and team, who will require that attendance sheets, hours worked, and meetings (both group and one-on-one) to be documented on a weekly report Excel sheet. SAGA and #SAG will be uniform across all organizations. SAGS may be customizable, and a unique dashboard can include sources that are specific to the organization-specific.
All elements of Subtle Asian Glow can be adapted by the community, but some changes are necessary to suit the underrepresented folks who are not fluent in English, do not have a college education, and other external factors. Strategies to navigate variability among groups include:
As this intervention begins to expand after the first couple of phases, we will conduct a longitudinal study with a university-based cohort of students. Assuming that the intervention already exists by the time this sample of students start university, we will be assessing outcomes of substance use, depression, anxiety, and perceived social support. Outcomes will be assessed yearly, over the course of 8 years after baseline assessment. The goal is to assess the long-term effects of our intervention and whether decreased exposure to SAG (after graduating from university) causes discontinuity in effect trajectory.
While this intervention employs many strengths from the Truth Initiative, an evidence-based campaign that Subtle Asian Glow is modeled off of, there are limitations. Targeting the Asian population is necessary in the substance use intervention stage, but this approach could perpetuate the stigma that Asians are a homogeneous group and experience the same levels of substance use problems. Therefore, it is crucial to ensure that the intervention strategies in SAG allow for Asian subgroups to identify with each other and share safe spaces within their cultures. It is also important to collect disaggregated ethnicity and race data during process tracking and evaluation.
Subtle Asian Glow’s theoretical framework and intervention strategies are inspired by the Truth Initiative, a nonprofit organization that is well known for their evidence-based campaign and efforts to end tobacco use. Their target population is young people, and the mission is to battle nicotine addiction through community support and subjective norms surrounding smoking behaviors.15 SAG Hub models the Truth Initiative’s “Become An Ex” program, which places a strong emphasis on community networking and mentorship. In 2021, truth partnered with TikTok influencers on a social media hashtag, #QuitTogether, where influencers utilized the hashtag to discuss strategies that the campaign promotes to stop smoking.15 This construct of subjective norms aligns with the #SAG hashtag, where we will leverage the power and influence of Asian celebrities to communicate to the general population on substance use. The success of the Truth Initiative has been promising, and as Subtle Asian Glow hopes to ground their framework to align with Truth’s, there is expectation of success that SAG will reach the Asian population effectively and promote behavior change through community support and ease of access to resources.
Setting the program free will be incredibly difficult for researchers, especially in a digital intervention context where it already is quite tricky to navigate follow up assessments over time. The SAG Mentorship program may be the easiest to assess, and measures can be administered after a series of meetings with the mentors. On the other hand, the other services may be slightly more difficult, but we hope that partner community organizations can set the foundation for expanding our intervention on a larger scale while maintaining an organized evaluation strategy, as individuals living within communities are easier to measure intermittent utilization from those living in various communities. While there may be evaluation hurdles after performing small-scale dissemination, it is critical to provide equitable access to all Asian populations, and Subtle Asian Glow aims to eliminate barriers that prevent folks from accessing adequate care pertaining to their substance use behaviors.
Cindy Chwa is a MPH Candidate in the Department of Social and Behavioral Sciences at Harvard T.H. Chan School of Public Health. Her research focuses on leveraging digital technologies to increase equity and access to community-based resources among minority and immigrant populations.