TANYA NIERI , PHDJENNIFER L . MATJASKO, PHD

KIRK R. WILLIAMS, PHDNANCY GUERRA, PHD

Public Health Intervention and High Risk Populations

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 Relationship Community SocietySocietal Community Relationship Individual

The Public Health Approach to Prevention

3. Develop and Test

Prevention Strategies

4. Assure Widespread

Adoption

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: Santa Ana (Citywide)

Total population 61,363 (337,977)

African American 522 ( 5,749)

Latino 56,464 (257,097)

Asian 897 ( 29,778)

White Non Latino 3,224 ( 41,984)

Native American 67 ( 4,014)

Other Pac Islander 199 ( 1,160)

Youth under 18 46,203 (115,507)

Example: Surveillance data from Santa Ana, CA

Education level:(for 25 years and over)

Santa Ana (Citywide)

Less than 9th 48.1% (36.3%)

9th to 12th 21.7% (20.5%)

High School Graduate 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%)

Example: Surveillance data from Santa Ana, CA

Well Being:  Santa Ana (Citywide)

Median household income $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 59.5% (53.3%)

Unemployed 5.6% ( 4.7%)

Families under the poverty level 26.4% (16.1%)

Example: Surveillance data from Santa Ana, CA

2003 Youth crime:(counts)

Santa Ana (Citywide)

All crime 574 (1,028)

Homicide 2 ( 3)

Rape 9 ( 16)

Robbery 26 ( 35)

Assault 42 ( 63)

Drug Crimes 98 ( 197)

Misdemeanors 397 ( 714)

Child abuse reports 1,455 (3,957)

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:

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 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) 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, CASAMHSA 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

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 Time 2 Time 3

Collective efficacy Intervention Control

Support from neighbors Intervention Control

Social support Intervention Control

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 Time 2 Time 3

Social cohesion Intervention Control

Problem solving Intervention Control

Victimization Intervention Control

Bullying Intervention Control

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 raidsHowever, 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 resilienceImplications?

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 assetsFormed Riverside Youth Violence Prevention Policy

BoardEstablished Eric M. Solander Arlanza Youth and

Family Resource CenterProvided 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 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

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?

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

Thank you

Tanya Nieri, PhDAssistant Professor, Sociology

Academic Center of Excellence on Youth Violence PreventionPresley Center for Crime and Justice Studies

University of California, Riverside tanyan@ucr.edu

Jennifer L . Matjasko, PhDBehavioral Scientist

National Center for Injury Prevention and Control Centers for Disease Control and Prevention

Jmatjasko@cdc.gov