Transcript Slide 1

Public Health Intervention and
High Risk Populations
TANYA NIERI, PHD
JENNIFER L. MATJASKO, PHD
KIRK R. WILLIAMS, PHD
NANCY GUERRA, PHD
Funding for the Southern California Academic Center of Excellence on Youth
Violence Prevention at UC Riverside (ACE-UCR) is provided by a cooperative
agreement with the Centers for Disease Control (Grant # 5U49CE000734).
Our presentation
 Provides an overview and examples of public health
interventions
 Presents case studies of public health intervention
with high risk populations:

two delinquency interventions
 Reviews contemporary questions and ideas for future
research
Public Health Interventions
 Focus on:
 The health of the population
 Prevention through health promotion
 Using:
 Data driven/evidence-based approaches
 Comprehensive, multi-level approaches
Public Health and the Social Ecological Model
Individual
Societal
Community
Relationship
RelationshipSociety
Individual
Community
The Public Health Approach to Prevention
4. Assure
Widespread
Adoption
3. Develop
and Test
Prevention
Strategies
2. Identify Risk
and Protective
Factors
1. Define the
Problem
1. Define the Problem
 Who is being affected?
 Are rates are increasing or decreasing?
 How do the data compare across communities and time?
Example: Surveillance data from Santa Ana, CA
Demographics:
Total population
Santa Ana (Citywide)
61,363
(337,977)
522
( 5,749)
Latino
56,464
(257,097)
Asian
897
( 29,778)
3,224
( 41,984)
67
( 4,014)
199
( 1,160)
46,203
(115,507)
African American
White Non Latino
Native American
Other Pac Islander
Youth under 18
Example: Surveillance data from Santa Ana, CA
Education level:
(for 25 years and over)
Less than 9
th
Santa Ana (Citywide)
48.1%
(36.3%)
21.7%
(20.5%)
12.6%
(16.0%)
Some College
9.3%
(13.9%)
Associate Degree
2.8%
( 4.1%)
Bachelor’s Degree
3.6%
( 6.4%)
Graduate or Professional Degree
2.0%
( 2.8%)
th
9 to 12
th
High School Graduate
Example: Surveillance data from Santa Ana, CA
Well Being:
Median household income
Santa Ana (Citywide)
$33,728
($43,412)
Example: Surveillance data from Santa Ana, CA
Risk factors
Santa Ana (Citywide)
Female Headed Household with Children
10.4%
( 7.6%)
Foreign Born
Unemployed
59.5%
5.6%
(53.3%)
( 4.7%)
Families under the poverty level
26.4%
(16.1%)
Example: Surveillance data from Santa Ana, CA
2003 Youth crime:
(counts)
All crime
Santa Ana (Citywide)
574
(1,028)
Homicide
2
(
3)
Rape
9
(
16)
Robbery
26
(
35)
Assault
42
(
63)
Drug Crimes
98
( 197)
Misdemeanors
397
( 714)
1,455
(3,957)
Child abuse reports
2. Identify Risk and Protective Factors
 What protects youth/what increases their risk?
 What prevents youth from/what increases their risk
of perpetrating violence?
 Which factors (i.e. attitudes and behaviors, policies)
are modifiable?
 Which groups (i.e. age, gender, ethnicity, income,
location) are most at risk?
Example: Youth problem behavior
 Identified risk and protective factors:
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
Poor emotional and behavioral regulation
Poor decision-making skills
Lack of concern about fairness, justice, integrity, responsibility
and the welfare of others
Self esteem
Self efficacy
Social relationships characterized by caring and trust
3. Develop and Test Prevention Strategies
 Efficacy versus effectiveness trials
 Entire programs to smaller components
 Content
 Scope
 Audience
Social Ecological Model
Societal Community Family/Peer
Individual
Example: Individual-level Intervention
 Positive Life Choices: Building Core Competencies
for Youth


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
Developer: Nancy Guerra
Cognitive-behavioral mindfulness program for adolescents
(aged 14-21) in schools or alternative settings
Promotes core competencies of youth development and
prevention of problem behaviors: positive sense of self, self
control, moral system of belief, pro-social connectedness,
decision-making skills
Three components (10 lessons each) can be delivered
separately or together
Social Ecological Model
Societal Community Family/Peer
Individual
Example: Family-level Intervention
 Triple P: Positive Parenting Program
 Developer: Matthew R. Sanders
 Aims to prevent social, emotional and behavioral problems in
childhood, prevent child maltreatment, and strengthen
parenting and parental confidence
 Draws on social learning, cognitive-behavioral and
developmental theory and research into risk and protective
factors associated with the development of children’s social
and behavioral problems
 Multi-level and organized for population dissemination
 Can be tailored to family needs through flexible formats and
delivery
Social Ecological Model
Societal Community Family/Peer
Individual
Example: Community-level Intervention
 Prevention of HIV in Women and Infants
Demonstration Project s (WIDP)
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Developers: B. Person , J. Adams, M. Stark, & J. L. Lauby
Aims to increase positive community norms, attitudes, and
behaviors concerning condom use among women at risk for
HIV infection
Activities: development & distribution of HIV prevention
materials, mobilization of peer network of community
volunteers & network of community orgs and businesses that
supported the project, & delivery of prevention messages by
trained outreach specialists thru individual contacts and small
groups
Good public health interventions are…
 Based on “Theory of Change” that outlines
mechanisms thru which program has effects and
targets risk/protective factors, mediating
mechanisms, and behavioral outcomes
 Adaptable to individuals’/groups’ needs
 Matched to target population
 Implemented by/in communities ready for them
Case Studies: Delinquency Interventions
 An illustration of public health interventions that
affect delinquency
 Efforts of the Academic Center of Excellence on
Youth Violence Prevention at UC Riverside,
(http://www.stopyouthviolence.ucr.edu)


Families and Schools Together (FAST)
Arlanza Neighborhood Initiative
Families and Schools Together (FAST)
 Santa Ana, CA
 SAMHSA model program developed by L. McDonald,
adapted by investigators for local community
 Promotes healthy youth development by jointly
engaging students, families and schools
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Connects parents and kids to their schools & communities
Promotes community service & voluntary participation
(promotora model)
Guides parents in building their kids’ personal success assets
and in remaining their kids’ primary agents of protection
Builds skills & changes attitudes thru experiential learning
Preserves classroom time through school-focused,
extracurricular parental involvement and after-school
programming for kids
FAST Design
 Quasi-experimental effectiveness trial
 4 communities in Santa Ana, CA (2 Tx, 2 C)
 Implementation at Latino Health Access
 Surveys of parents and children: pretest, 3-month and 9-month
posttests
 Evaluation focus groups with parents & promotoras
 240 low-income immigrant Latino parents & their elementary school-
aged children
FAST Survey Results-Parents
Means (Standard Deviations)
Time 1
Collective efficacy
Intervention
Control
Support from neighbors
Intervention
Control
Social support
Intervention
Control
Time 2
Time 3
FAST Survey Results-Parents
Means (Standard Deviations)
Time 1
Time 2
Time 3
Collective efficacy
Intervention
Control
19.09 (6.33)
18.99 (6.62)
20.84 (5.89)
19.39 (6.68)
21.01 (5.88)
20.57 (6.65)
Support from neighbors
Intervention
Control
2.04 (1.02)
2.14 (1.12)
2.37 (1.02)
2.39 (1.04)
2.60 (1.05)
2.25 (1.00)
Social support
Intervention
Control
31.18 (11.20)
32.43 (11.16)
35.40 (9.84)
34.38 (11.19)
36.10 (10.03)
34.15 (10.49)
FAST Survey Results-Parents
Means (Standard Deviations)
Time 1
Time 2
Time 3
Collective efficacy
Intervention
Control
19.09 (6.33)
18.99 (6.62)
20.84 (5.89)
19.39 (6.68)
21.01 (5.88)
20.57 (6.65)
Support from neighbors
Intervention
Control
2.04 (1.02)
2.14 (1.12)
2.37 (1.02)
2.39 (1.04)
2.60 (1.05)
2.25 (1.00)
Social support
Intervention
Control
31.18 (11.20)
32.43 (11.16)
35.40 (9.84)
34.38 (11.19)
36.10 (10.03)
34.15 (10.49)
FAST Survey Results-Children
Means (Standard Deviations)
Time 1
Social cohesion
Intervention
Control
Problem solving
Intervention
Control
Victimization
Intervention
Control
Bullying
Intervention
Control
Time 2
Time 3
FAST Survey Results-Children
Means (Standard Deviations)
Time 1
Time 2
Time 3
Social cohesion
Intervention
Control
30.43 (6.47)
30.14 (7.19)
32.89 (6.64)
32.16 (6.69)
32.89 (6.71)
32.06 (7.13)
Problem solving
Intervention
Control
14.91 (4.37)
16.15 (4.01)
16.36 (3.88)
16.32 (4.06)
15.76 (4.99)
15.25 (4.53)
Victimization
Intervention
Control
5.03 (3.03)
4.58 (3.92)
4.34 (3.39)
4.01 (3.10)
3.55 (3.16)
3.87 (3.32)
Bullying
Intervention
Control
1.88 (2.36)
1.80 (2.39)
1.46 (2.36)
1.33 (2.12)
1.55 (2.35)
1.58 (3.1)
FAST Survey Results-Children
Means (Standard Deviations)
Time 1
Time 2
Time 3
Social cohesion
Intervention
Control
30.43 (6.47)
30.14 (7.19)
32.89 (6.64)
32.16 (6.69)
32.89 (6.71)
32.06 (7.13)
Problem solving
Intervention
Control
14.91 (4.37)
16.15 (4.01)
16.36 (3.88)
16.32 (4.06)
15.76 (4.99)
15.25 (4.53)
Victimization
Intervention
Control
5.03 (3.03)
4.58 (3.92)
4.34 (3.39)
4.01 (3.10)
3.55 (3.16)
3.87 (3.32)
Bullying
Intervention
Control
1.88 (2.36)
1.80 (2.39)
1.46 (2.36)
1.33 (2.12)
1.55 (2.35)
1.58 (3.1)
FAST Focus Group Results
 Intervention cultivated social support
“Social capital. It is very important because here, you feel alone,
don’t have your extended family to rely on, that you could
leave your kids with or things like that. So if you have a group
of friends that you can trust…. If you would see the stories that
the moms tell us…, as A told me the other day, one of the
moms lose her kid (kid got lost) and all of the mothers that
lived there and that had attended FAST helped her find her
kid. So imagine, you don’t feel you are alone anymore. At least
you know that you can go to your neighbor or the one 3
buildings away and you can count on them. So you don’t feel as
lonely as when you arrived to this country….”
FAST Focus Group Results
 Intervention culturally appropriate
“What a mom from FAST comment me is that the FAST team
speaks their own language: Spanish, that you can be touched
(they can touch you, rub your back), that they feel welcome. So
it’s not just somebody talking to them behind a desk (podium).
It’s a very fraternal contact with them. ‘Don’t worry; we are
here. Don’t worry; we are here’.”
FAST Focus Group Results
 Intervention promoted father involvement in family
 “So with FAST I told him the same as I told my daughter. ‘Go
and see if you like it. I will not force you to go.’ So he tried to
attend the meetings even if it was late. Like the other day that
my high school daughter got a D, I made the appointment with
the counselor on a Saturday to force him to go because he
always tells me that he has to work, and my daughter was very
proud that her father went. So I want him to get involved
because when my daughter is receiving her doctors degree, he
will then want to go and I won’t let him! (laughing)”
FAST Focus Group Results
 Intervention taught specific helpful strategies – e.g., 15
Minutes
“She got into a fight with her daughter …and it was a big one. So she
started shouting at her daughter, and her daughter calmed down and
said to her, ‘Mami, so soon did you forgot to give me my 15 minutes?’
So the mom said that when her daughter told her that, everything
inside her got removed. Everything that she was told in the program.
‘So I stopped what I was doing, left my other kid with someone, and
gave to my daughter her 15 minutes.’ They were talking, and the
daughter said, ‘You have to continue in the program even if it’s over.
You have to continue doing what you learned in FAST.’ So that
daughter had seen that those 15 minutes that she shared with her
mother made a huge difference. So when they graduated and all that
and the first situation that showed up that she lost control and that
her daughter remind her, she doesn’t forget. She says it’s an
experience she will not forget.”
FAST Focus Group Results
 Intervention facilitators also benefitted
“Many things of the FAST program I’ve taken (applied) into my
personal life. What’s more difficult for me is to coach, because
while I’m talking to them, is as if I would be talking to my
interior (to myself). Many things I have told the parents have
helped me. So I say to myself, if that program that I’m helping
to implement has helped me, and when I listen to the parents
experiences, it’s worth it to be here! ”
FAST Summary & Comments
 No effects on youth behavior
 Explained by intervention timing: Implementation during high
stress period due to ICE raids
 However, significant effects on collective efficacy and
social cohesion among parents and children
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Intervention effectively connected parents and children to
community and reduced isolation, two factors influencing
juvenile delinquency
Intervention facilitated resilience
 Implications?
 Evidence-based program with marginal effects – why?
Arlanza Neighborhood Initiative
 Riverside, CA
 Neighborhood-level intervention to promote well-
being of children aged 0-5
 Neighborhood mobilization to build social capital
 Background: neighborhood decline in 90s when
industry replaced residential areas and
neighborhood turnover increased due to loss of
major employer
Arlanza Intervention
 Mapped institutional assets
 Formed Riverside Youth Violence Prevention Policy Board
 Established Eric M. Solander Arlanza Youth and Family
Resource Center
 Provided services through the Center:
Child care, gang prevention, WIC nutritional and health services,
counseling services, community meeting space, parenting classes
 Formed Arlanza Area Clergy Team (neighborhood
engagement and beautification)
 Formed English Learning Advisory Committee (for
monolingual parents to engage in schools)
Arlanza Results
 Participation
 15 agencies involved in Board
 Evidence of collective and collaborative action
 Services provided
 Childcare provided to 300/352 eligible families
 WIC services provided to 3,883 women, infants, and children
 Delinquency reduction
 Juvenile arrests in neighborhood dropped by 41% post
intervention
 Outcome evaluation under way, using 2008 crime data
4: Assure Widespread Adoption
 Identification of effective programs
 Dissemination
 Replication
 e.g., ACE-UCR’s use of FAST
Contemporary Questions/Future Research
Need to assess effects of public health interventions
 Across time
 Across ecological levels
 Across outcomes
 Across subgroups
Contemporary Questions/Future Research
 Across time – examine the life course
 Multiple points of intervention


e.g., FAST age-specific versions
Multiple points of assessment
e.g. Good Behavior Game (see Drug and Alcohol Dependence,
Volume 95 Supplement, June 2008)
 Need longitudinal data – multiple, long-term time points

Contemporary Questions/Future Research
 Across levels of the social ecology
 Assess outcomes beyond individual level … family, community,
aggregate individual, etc.
Effects: More than just the sum of individual units!
 Challenge: statistical power for community-level interventions
effectiveness analyses


Recognize difference between assessing outcomes and
intervening at each level of social context
Contemporary Questions/Future Research
 Across outcomes
 Assess whether program effects crossover to other outcomes
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e.g. Botkin’s LifeSkills Training
Assess program effects on syndromes

Considering multiple outcomes simultaneously (e.g. using cluster
analysis)
Contemporary Questions/Future Research
 Across subgroups – effective for whom?
 Risk status
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Ethnicity/acculturation
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e.g. keepin’ it REAL youth substance use prevention intervention effects moderated by prior substance use (Kulis et al., 2007)
e.g. keepin’ it REAL - effects moderated by acculturation
(Marsiglia et al., 2005)
Intervention responsiveness

Cluster analysis – what participant profile is associated with
highest responsiveness?
Conclusion
Public health interventions & high risk populations
 We’ve come along way
 Know lots re: intervention efficacy & effectiveness
 Have many evidence-based interventions to employ
 Recognize need to link research, policy, & practice
 We still face challenges
 Lots ineffective or not-yet-proven effective interventions in use
(and funded!)
 Evidence-based programs sometimes don’t work
 We must move forward
 Study how interventions perform across time, ecological levels,
outcomes, & subgroups
 Study how to better translate research in to policy and practice
Thank you
Tanya Nieri, PhD
Assistant Professor, Sociology
Academic Center of Excellence on Youth Violence Prevention
Presley Center for Crime and Justice Studies
University of California, Riverside
[email protected]
Jennifer L . Matjasko, PhD
Behavioral Scientist
National Center for Injury Prevention and Control
Centers for Disease Control and Prevention
[email protected]