|Year : 2022 | Volume
| Issue : 3 | Page : 131-137
Brief resilience interventions for mental health among college students: Randomized controlled trial
Shabnam Kadian1, Jaison Joseph2, Sat Pal3, Rajeshwari Devi2
1 Department of Psychiatry, College of Nursing, Pt. B. D. Sharma University of Health Sciences, Rohtak, Haryana, India
2 Department of Psychiatric Nursing, College of Nursing, Pt. B. D. Sharma University of Health Sciences, Rohtak, Haryana, India
3 Department of Physiology, Pt. B. D. Sharma University of Health Sciences, Rohtak, Haryana, India
|Date of Submission||07-Feb-2022|
|Date of Decision||13-Jun-2022|
|Date of Acceptance||14-Jul-2022|
|Date of Web Publication||9-Aug-2022|
Department of Psychiatric Nursing, College of Nursing, Pt. B. D. Sharma University of Health Sciences, Rohtak - 124 001, Haryana
Source of Support: None, Conflict of Interest: None
Introduction: The resilience interventions have the potential to enhance the protective factors to prevent mental health problems in young adolescents. The present study evaluated the feasibility of brief resilience interventions in a sample of college students. Methods: The present randomized controlled study was conducted among 220 college students and the study protocol was registered in the Clinical Trials Registry of India (Ref.No.CTRI/2021/04/032716). The participants were randomly allocated to two groups: (i) A brief resilience intervention program group and (ii) a resilience self-help pamphlet group. The brief resilience intervention program is based on positive psychology and consists of two sessions, delivered on a 2-week interval period. The outcome measures were changes in the scores of the Brief Resilient Coping Scale (BRCS), Perceived Stress Scale, and Patient Health Questionnaire-4. Results: The mean age of the participants was 19.31 years (standard deviation – 1.17) and both the study groups were comparable during baseline (P > 0.05). At the 1-month follow-up, there was a slight increase in the mean BRCS scores of the brief resilience intervention group (15.57 vs. 15.87) as compared to the resilience self-help pamphlet group (16.15 vs. 15.79). There was no evidence that brief resilience intervention was superior to the self-help booklet in any of the outcome measures (P > 0.05). Conclusion: Brief resilience interventions have the potential to promote resilience and coping skills among college-going students in this setting. The integration of brief resilience interventions among college-based cohorts would appear to be an appropriate strategy for building protective factors to bolster resilience.
Keywords: Brief interventions, college students, mental health, resilience
|How to cite this article:|
Kadian S, Joseph J, Pal S, Devi R. Brief resilience interventions for mental health among college students: Randomized controlled trial. Asian J Soc Health Behav 2022;5:131-7
|How to cite this URL:|
Kadian S, Joseph J, Pal S, Devi R. Brief resilience interventions for mental health among college students: Randomized controlled trial. Asian J Soc Health Behav [serial online] 2022 [cited 2022 Sep 29];5:131-7. Available from: http://www.healthandbehavior.com/text.asp?2022/5/3/131/353635
| Introduction|| |
The transition from a school to a college environment poses many psychosocial changes among students and can be associated with social and academic pressures, lifestyle changes, and changes in personal relationships. This might place them vulnerable to psychological morbidities that might have an important role in determining their future developmental outcomes. According to the world mental health survey (2016), the prevalence of mental health problems including anxiety and depressive disorders among college students is approximately 20% of which only 6%–23.1% of college students received treatment for their mental health problems. There are many barriers to treatment-seeking behaviors among college-going students such as low levels of help-seeking behaviors, lack of time, and overgeneralization of stress as a normal phenomenon during college life. Strikingly, the long-term negative impact of these problems might be poor individual and social functioning, and academic functioning. Therefore, it is worth developing effective strategies to increase psychological well-being and prevent depression and anxiety disorders in college students.
European Commission health policy of the World Health Organization (2013) suggested that the adoption of prevention-oriented interventions may be particularly attractive to college students to promote mental well-being and resilience in this population. There is a growing popularity of resilience programs that are especially found to be relevant for school- and college-going adolescents. Although much variation exists in the operationalization of resilience, researchers commonly refer to this construct as the regaining of positive mental health during adverse life situations using internal and external protective factors. The approaches to the majority of these interventions may include positive psychology and cognitive behavioral therapy which are influential to enhance protective factors for better adaptation to adverse situations. Several studies have demonstrated the modest effectiveness of resilience interventions in building positive psychological well-being among college students. There is limited evidence regarding resilience interventions for college students in the Indian setting. Therefore, the main goal of this study is to explore the feasibility of brief resilience interventions for promoting the mental health and well-being of college students.
| Methods|| |
Design and participants
The present randomized controlled study was conducted among 220 college students in which the date of first enrollment of the study participants was on April 15, 2021. The potential participants were college students pursuing different courses in two publicly funded educational institutions in Rohtak, Haryana, India. The study settings and participants were conveniently selected based on the sampling criteria. The students above the age of 18 years registered for any of the courses were included in this study. Those who have known mental illness, currently taking treatment for any mental health problems, and refused to provide informed consent were excluded from this study.
A sampling frame was prepared based on the list of students meeting the sampling criteria. Out of the 220 eligible participants, 80 participants were pursuing nonmedical courses (BSc and BA) and the remaining 140 were medical students (medical and nursing). For ensuring the equal distribution of participants, we stratified the participants based on their courses of the study (i.e., medical vs. nonmedical courses). Hence, the eligible participants were divided into the following groups: 80 nonmedical participants (i.e., 40 for the intervention program and 40 for the pamphlet group) and 140 medical participants (i.e., 35 for the intervention program and 35 for the pamphlet group) forming a total sample of 220. [Figure 1] depicts the CONSORT flow diagram for the trial.
We used an allocation ratio of 1:1 and allocation to the study groups was decided based on odd and even numbers as per the student's list in the sampling frame. The participants were randomly allocated to two groups: (i) a brief resilience intervention program group and (ii) a resilience self-help pamphlet group.
Resilience self-help pamphlet group
The study participants in the resilience self-help pamphlet group provided a self-help pamphlet emphasizing the power of positive thinking targeting to promote resilience.
Brief resilience interventions
The present study explored the feasibility of brief resilience interventions in the college setting. Those who were in the brief resilience intervention program received two sessions each lasting 30 min on a 2-week interval period. Brief resilience interventions are psychological approaches that are aimed to promote psychological well-being. The present study designed a brief resilience intervention program and a self-help pamphlet to build resilience among study participants. The PowerPoint slides of the intervention program are prepared according to the objectives of each session which were delivered to a group of participants. The content of the brief resilience program is described as follows.
Session 1 – Initially the participants were asked to express their views and opinions related to the term “resilience.” The following questions were asked to commence the intervention in a nonconfrontational way: “Do you look for creative ways to alter difficult situations?” Further, the importance of setting vision and passion and the influence of imposed expectations to alter difficult situations were discussed. The first session is tailored to help the individual strike out the best strategies, while encountering difficult situations. Therefore, an understanding of the specific information related to the creative ways of bouncing back to adverse life situations was provided. This was encountered by asking a question such as “Do you believe you can grow positive ways by dealing with difficult situations?” During this phase, the major coping approaches including different modes of passive and active coping were explained.
Session 2 – The major goal of the second session is to provide an idea regarding the importance of building protective factors to bolster resilience. The following question was asked to provide general brief information regarding the importance of setting goals: “Are you SMART in setting goals?” Further, the students were encouraged to list their priorities in current life which have to be rated according to their importance and satisfaction. The outcome of this self-reflection exercise was to enrich the student's insight regarding the identification of their biggest priorities based on one's satisfaction. Besides, the participants were provided general feedback regarding various protective factors such as the development of a support system, the art of confronting failures, and the practice of “self-talk” to bolster resilience. The present study also included a resilience self-help pamphlet group in which a pamphlet was provided to the study participants emphasizing the power of positive thinking targeting to promote resilience. The pamphlet was not distributed to those in the brief resilience intervention group. The content validity of the brief resilience interventions including the PowerPoint slides and self-help pamphlet was established through expert validation. A total of eight experts from medicine, psychiatry, clinical psychology, and psychiatric nursing were involved in the content validity of the module. The following criteria were kept for expert validation for the psychoeducation module: suitability as per objectives of the study, content coverage as per target population, and time management as per the study setting. Based on the expert's opinion, the overall quality and relevance of the module were evaluated in which the content validity index was 0.75. The brief resilience interventions were conducted by a nurse who had completed an online certificate training program on positive psychology: resilience skills from the University of Pennsylvania offered through course era (Available from https://www.coursera.org/learn/positive-psychology-resilience).
The outcome measures were changes in the scores of the Brief Resilient Coping Scale (BRCS), Perceived Stress Scale (PSS-10), and Patient Health Questionnaire-4 (PHQ-4).
The Brief Resilient Coping Scale
It is a 4-item measure designed to estimate the tendencies to cope with stress. Individual scores on the BRCS can range from 4 to 20 with higher scores indicating high resilient coping. The BRCS has adequate internal consistency (r = 0.76) and test–retest reliability (r = 0.71).
Patient Health Questionnaire-4
It is an ultra-brief self-report questionnaire that consists of a 2-item depression scale (PHQ-2) and a 2-item anxiety scale Generalized Anxiety Disorder-2. Scores are rated as normal (0–2), mild (3–5), moderate (6–8), and severe (9–12). A total score ≥3 for the first two questions suggests anxiety. A total score ≥3 for the past two questions suggests depression.
The Perceived Stress Scale-10
The PSS-10 is a commonly used scale to assess stress. Individual scores on the PSS can range from 0 to 40 with higher scores indicating higher perceived stress.
Measurement time points
Considering the heterogeneities of the study population and the imposed time limitations as per norms of the study setting, the assessment with BRCS, PHQ-4, and PSS-10 was not possible immediately after each intervention. Moreover, there was no incentive, financial aid was provided for the study participants. Therefore, the postassessment was restricted to 1 month after the baseline assessment.
Ethical permission was obtained from the Institutional Review Board (Ref No-BREC/2021/004 dated February 18, 2021). The study protocol was registered in the Clinical Trials Registry of India (Ref.No.CTRI/2021/04/032716). The students filled in the self-administered paper version of the outcome measures and the interventions were held on the campus. Written informed consent was obtained from each study participant. Privacy and confidentiality were ensured and there was no provision of any incentive or financial support for the study participants.
Data were analyzed using Statistical Package for Social Sciences (SPSS for Windows, Version 16.0. Chicago, SPSS Inc.). Descriptive statistics were presented by the mean, standard deviation (SD), and proportion. The difference between the scores was analyzed using paired t-test or independent sample t-test. Nominal data were analyzed using the Pearson's Chi-square test/Fisher's exact test.
| Results|| |
The mean age of participants was 19.31 years (SD-1.17). The majority of participants were female (n = 191; 86.8%). Most of them pursued medical and nursing courses (n = 140; 63.6%). A major proportion of the participants were utilizing hostel facilities (n = 136; 61.8%). Concerning the education of the head of the family, approximately 30% of them had education up to the 12th standard. According to, approximately 3% (n = 8) of them were found to have illiterate. [Table 1] describes the sociodemographic characteristics of the study participants.
Both the study groups were comparable as per the sociodemographic profile at baseline [P > 0.05; [Table 2]]. Further, there was no statistical difference between the brief resilience intervention program group and the resilience self-help pamphlet group in terms of any of the outcome measures (BRCS, PSS, and PHQ-4 scores) at baseline assessment (P > 0.05). However, there was a slight increase in the mean BRCS scores in the brief resilience intervention program group (15.57 vs. 15.87) together with a decrease in the control group (16.15 vs. 15.79) during 1-month postassessment. In the brief resilience intervention program group, there was a decrease in the mean PSS scores during the 1-month follow-up (16.75 vs. 15.87). This change was also observed during follow-up in the resilience self-help pamphlet group (16.09 vs. 15.64). A similar reduction in the PHQ-4 scores was also noted in both the study groups during the postassessment period. All these findings suggest that there was no evidence that brief resilience intervention was superior to the self-help booklet in any of the outcome measures [P > 0.05; [Table 3]].
|Table 2: Comparison of the characteristics of the study participants at baseline|
Click here to view
To evaluate the feasibility and acceptability of brief resilience interventions among college students, we evaluated the univariate changes in the BRCS individual items in the total participants. The examination of responses revealed the following statistically significant differences in the BRCS items. BRCS (Q.1) – I look for creative ways to alter difficult situations (t = 3.406, P < 0.01), BRCS (Q.2) – Regardless of what happens to me, I believe I can control my reaction to it (t = 4.254, P < 0.01), BRCS (Q.3) – I believe I can grow in positive ways by dealing with difficult situations (t = 0.865, P < 0.01), and BRCS (Q.4) – I actively look for ways to replace the losses I encounter in life (t = 1.929, P < 0.01). In short, there was a statistically significant difference in all the items of BRCS among total participants irrespective of their types of intervention at 1-month postassessment [Table 4].
|Table 4: Pre- and post-univariate changes in Brief Resilient Coping Scale variables|
Click here to view
| Discussion|| |
The present study provided some pioneer information on the feasibility of brief resilience interventions for college students of North India. However, our findings should be taken with caution based on the duration and frequency of the intervention. The major findings of this study were the slight increase in the mean BRCS scores in the brief resilience intervention program group together with the decrease in the control group. However, we did not observe a statistically significant superior benefit for the brief resilience intervention program group as compared to the self-help pamphlet group in any of the outcome measures (P > 0.05). A meta-analysis on the efficacy of resiliency programs reported a small-to-moderate effect in improving the resilience and other mental health outcomes of study participants. However, these findings need to be interpreted based on several grounds of uncertainties that might confound the additional results associated with individual resilience-based studies. The inconsistency in the effects of brief resilience interventions within the present study reflects its inconsistent effects across studies. Several studies reported a reduction in the outcome measures relative to control during the follow-up period., However, other studies failed to replicate these findings., To cite, Gillham et al. evaluated the effectiveness Penn Resiliency Program as compared with an alternate intervention called Penn Enhancement Program and a no-intervention control in a large sample (baseline n = 697) over a 3-year follow-up. During follow-up, the researchers did not observe any reduction in the mean levels of depressive symptoms relative to either comparison group. Therefore, the effectiveness of any resilience-based interventions is mediated by research methodological and clinical-driven factors. In other words, as research on resilience moves along the scientific path from efficacy to real-world scenarios, intervention effects subside or become inconsistent. This pattern of real-world utilization of research has been consistent with the findings of the Resourceful Adolescent Program which evaluated its effectiveness when implemented under real-world conditions in a school setting. It is also worth noting that psychological interventions that yield substantial effects in research settings often produce small or no effects when applied in the real target setting. Together with the findings of our study, resilience research needs a critical priority in the development of effective dissemination strategies.
We assessed the short-term outcome of brief resilience interventions of short duration in which the intervention was delivered in two sessions, each lasting approximately 30 min delivered at the interval of 2 weeks. A previous study on resilience and coping intervention delivered their intervention in three sessions. They observed a significant improvement in the outcomes of resilience sessions focused on the specific problem that was shared by the group and led by one or more group facilitators, lasting approximately 45 min, delivered over three subsequent weeks. We did not evaluate the true competency of the intervention agent who was involved in the delivery of interventions in both the study groups. An assessment of competence might be helpful to explain our findings. The training and supervision for interventions will improve the competency and integrity of the intervention agents. Future research may also benefit from more clarity regarding the content of the resilience studies before intervention implementation. Although we followed structured and standard protocol in the brief resilience intervention program, it is worth noting that some skills are more beneficial or require more explanation and discussion than others. An examination of the relationship between specific content covered and intervention outcome could yield valuable information about the mechanisms of resilience-based interventions.
Our study had several limitations. The outcome measures were based on self-report and thus could have been underreported. The majority of the participants were female and the long-term effect of reinforcement of interventions with subsequent visits was not assessed due to logistic reasons. The intervention agent was a nurse with a modest level of training which further limits the integrity of the findings. The sample size calculation was not performed and the outcome assessor was not blinded to the intervention. Finally, this research was carried out at two public-funded educational institutions in Northern India, further limiting the generalizability of the study findings. Despite these limitations, the current study provides preliminary evidence regarding the feasibility of college-based resilience interventions in this setting.
| Conclusion|| |
Brief resilience interventions have the potential to promote resilience and coping skills among college-going students in this setting. The integration of brief resilience interventions among college-based cohorts would appear to be an appropriate strategy to enhance protective factors of resilience.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bayram N, Bilgel N. The prevalence and socio-demographic correlations of depression, anxiety and stress among a group of university students. Soc Psychiatry Psychiatr Epidemiol 2008;43:667-72.
O'Neill S, Auerbach RP, Alonso J, Axinn WG, Cuijpers P, Ebert DD, et al
. Mental disorders among college students in the WHO World Mental Health Surveys. Psychological Med 2016;46:2955-70.
Downs MF, Eisenberg D. Help seeking and treatment use among suicidal college students. J Am Coll Health 2012;60:104-14.
Ibrahim AK, Kelly SJ, Adams CE, Glazebrook C. A systematic review of studies of depression prevalence in university students. J Psychiatr Res 2013;47:391-400.
Leppin AL, Bora PR, Tilburt JC, Gionfriddo MR, Zeballos-Palacios C, Dulohery MM, et al.
The efficacy of resiliency training programs: A systematic review and meta-analysis of randomized trials. PLoS One 2014;9:e111420.
Fergus S, Zimmerman MA. Adolescent resilience: A framework for understanding healthy development in the face of risk. Annu Rev Public Health 2005;26:399-419.
Macedo T, Wilheim L, Gonçalves R, Coutinho ES, Vilete L, Figueira I, et al.
Building resilience for future adversity: A systematic review of interventions in non-clinical samples of adults. BMC Psychiatry 2014;14:227.
Helmreich I, Kunzler A, Chmitorz A, König J, Binder H, Wessa M, et al
. Psychological interventions for resilience enhancement in adults. Cochrane Database Syst Rev 2017;2017:CD012527.
Sonika S, Kumar R. Resilience, psychological well-being, and coping strategies in medical students. Indian J Psy Nsg 2019;16:92-7.
Kocalevent RD, Zenger M, Hinz A, Klapp B, Brähler E. Resilient coping in the general population: Standardization of the brief resilient coping scale (BRCS). Health Qual Life Outcomes 2017;15:251.
Kroenke K, Spitzer RL, Williams JB, Löwe B. An ultra-brief screening scale for anxiety and depression: The PHQ-4. Psychosomatics 2009;50:613-21.
Reis RS, Hino AA, Añez CR. Perceived stress scale: Reliability and validity study in Brazil. J Health Psychol 2010;15:107-14.
Joyce S, Shand F, Tighe J, Laurent SJ, Bryant RA, Harvey SB. Road to resilience: A systematic review and meta-analysis of resilience training programmes and interventions. BMJ Open 2018;8:e017858.
Gillham JE, Reivich KJ, Jaycox LH, Seligman ME. Preventing depressive symptoms in schoolchildren: Two year follow-up. Psychol Sci 1995;6:343-51.
Yu DL, Seligman ME. Preventing depressive symptoms in Chinese children. Prev Treat 2002;5:9a.
Pattison C, Lynd-Stevenson RM. The prevention of depressive symptoms in children: The immediate and long-term outcomes of a school based program. Behav Change 2001;18:92-102.
Roberts C, Kane R, Bishop B, Matthews H. The prevention of depressive symptoms in rural children: A follow-up study. Int J Ment Health Promot 2004;6:4-16.
Gillham JE, Reivich KJ, Freres DR, Chaplin TM, Shatté AJ, Samuels B, et al.
School-based prevention of depressive symptoms: A randomized controlled study of the effectiveness and specificity of the Penn Resiliency Program. J Consult Clin Psychol 2007;75:9.
Harnett PH, Dadds MR. Training school personnel to implement a universal school-based prevention of depression program under real-world conditions. J Sch Psychol 2004;42:343-57.
Weisz JR, Donenberg GR, Han SS, Weiss B. Bridging the gap between laboratory and clinic in child and adolescent psychotherapy. J Consult Clin Psychol 1995;63:688.
First J, First NL, Houston JB. Resilience and coping intervention (RCI): A group intervention to foster college student resilience. Soc Work 2018;41:198-210.
McGlinchey JG, Dobson KS. Treatment integrity concerns in cognitive therapy for depression. J Cogn Psychother 2003;17:299-317.
[Table 1], [Table 2], [Table 3], [Table 4]