Public Health Intervention and High Risk Populations

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).

2. 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

3. Public Health Interventions • Focus on: • The health of the population • Prevention through health promotion • Using: • Data driven/evidence-based approaches • Comprehensive, multi-level approaches

4. Public Health and the Social Ecological Model Community Relationship Individual Societal Individual Relationship Community Society

5. 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

6. 1. Define the Problem Who is being affected? Are rates are increasing or decreasing? How do the data compare across communities and time?

7. Example: Surveillance data from Santa Ana, CA

8. Example: Surveillance data from Santa Ana, CA

9. Example: Surveillance data from Santa Ana, CA

10. Example: Surveillance data from Santa Ana, CA

11. Example: Surveillance data from Santa Ana, CA

12. 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?

13. Example: Youth problem behavior Identified risk and protective factors: 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

14. 3. Develop and Test Prevention Strategies Efficacy versus effectiveness trials Entire programs to smaller components Content Scope Audience

15. Social Ecological Model Societal Community Family/Peer Individual

16. Example: Individual-level Intervention • Positive Life Choices: Building Core Competencies for Youth • 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

17. Social Ecological Model Societal Community Family/Peer Individual

18. 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

19. Social Ecological Model Societal Community Family/Peer Individual

20. Example: Community-level Intervention • Prevention of HIV in Women and Infants Demonstration Project s (WIDP) • 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

21. 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

22. 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

23. 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 • 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

24. 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

25. FAST Survey Results-Parents

26. FAST Survey Results-Parents

27. FAST Survey Results-Parents

28. FAST Survey Results-Children

29. FAST Survey Results-Children

30. FAST Survey Results-Children

31. 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….”

32. 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’.”

33. 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)”

34. 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.”

35. 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! ”

36. 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 • 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?

37. 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

38. Arlanza Intervention • Mapped institutional assets • Formed Riverside Youth Violence Prevention Policy Board • Established Eric M. SolanderArlanza 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)

39. 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

40. 4: Assure Widespread Adoption Identification of effective programs Dissemination Replication e.g., ACE-UCR’s use of FAST

41. Contemporary Questions/Future Research Need to assess effects of public health interventions • Across time • Across ecological levels • Across outcomes • Across subgroups

42. 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

43. 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

44. Contemporary Questions/Future Research • Across outcomes • Assess whether program effects crossover to other outcomes • e.g. Botkin’sLifeSkills Training • Assess program effects on syndromes • Considering multiple outcomes simultaneously (e.g. using cluster analysis)

45. Contemporary Questions/Future Research • Across subgroups – effective for whom? • Risk status • e.g. keepin’ it REAL youth substance use prevention intervention - effects moderated by prior substance use (Kulis et al., 2007) • Ethnicity/acculturation • 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?

46. ConclusionPublic 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

47. 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 tanyan@ucr.edu Jennifer L . Matjasko, PhD Behavioral Scientist National Center for Injury Prevention and Control Centers for Disease Control and Prevention Jmatjasko@cdc.gov