Health Education & Behavior Change Mary Jane Rotheram-Borus, Ph.D.
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Transcript of Health Education & Behavior Change Mary Jane Rotheram-Borus, Ph.D.
Health Education
&
Behavior Change
Mary Jane Rotheram-Borus, Ph.D.
Sequential Intervention Strategies
• Causal Agent Identified
• National Campaign
• Targeted Social Marketing
• Providers
• High-Risk Person
• Treatment
% People Changing Actions
0
100
Causal Agent Identified
National Campaign
Targeted SocialMarketing
Providers High-Risk Group
Treatment
Time
% P
eo
ple
Ch
ang
ing
Ac
tio
ns
Interpersonal Levels
Organizations
Families
Couples
Persons
Multiple Problem Behavior
• Sex• Drugs• School Trouble• Delinquency/
Juvenile Justice• Emotional Distress
Social Cost of Runaways Requiring Social Services
Service n %Social
Cost/Month*
Foster Care 91/302 30% $188,097
Mental Health 36/302 12% $337,752
Jail 56/301 19% $272,160
Homeless(Street)
83/302 27% $12,699
* Social cost/month - NYC cost/child x N of runaways who have received service (e.g., for foster care, n = 91)
Institutional Placements:% Lifetime
Runaway Females(n = 148)
Runaway Males(n = 154)
Foster Family 26 34
Institution 45 55
Psychiatric Hospital 16 8
Jail 11 26
Street Life 23 32
Friends/Adults 70 49
Interventions
Universal
Selected
Indicated
Condoms
• Higher nationally over time(46% 53%)
• Consistent use (10% - 20%)• Anglo & African American > Latino• Males > Females• Relationship status influences
> if perceived peer use> if physician discusses
School-based Programs
• 78% of states mandate
• 37% include use of condoms
• Unsuccessful = general, unspecific
• No successful abstinence programs
Interventions
Universal
Selected
Indicated
Vulnerable Subgroups
–Gay/Bisexual–African American Women in Inner Cities–East Coast Latino Adolescents–Homeless–Youth in Jail–Severely Mentally Ill–Abused Youth
Problem Populations InterventionProgram parameters
Strategies
Techniques
Reinforcement
Participation in Intervention
Behavior Change
Maintenance of Behavior Change
Populations Domains of Change Interventions Outcomes
Figure 1. Integrated Framework for Preventive and Treatment Interventions
Relationships
• Interventionist- Consumer relationship• Social relationships
Intentions/Motivations
• Emotional reactions• Perceived consequences• Normative beliefs• Self-standards• Self-efficacy• Attitudes
Learned Competencies
•Framing the problem•Problem-solving skills•Regulation of affect• Interpersonal skills
Environment
•Barriers
•Facilitators
Behavior Predispositions
•Temperament•Serotonin Regulation
• n = 307
• 25 to 70 years old
• Participation criteria:
Not institutionalized
At least one adolescent,
aged 11 to 18 years old
• 77% recruited; 84% traceable
Parents with HIV
Model Underlying the Program
Parent
Health
Lifestyle:
Substance Use
Sex
Adolescent
Ethnicity
Age
Gender
Parent Disclosure Custody Parenting Illness-Related Tasks
Adolescent Family Relations Grief Custody
Adolescent
Behavioral
Social
Mental Health
Intermediate Primary Outcomes Outcomes Background Intervention
Intervention
Roles
Rules
Routines
Project TALC: PLWAAssessment
Months0
6
12
18
24
36
42
48
54
60
Enhanced Care Standard Care
PLWAdies
PLWAdies
Module 3:Bereavement
Module 3:Bereavement
Module 2:Custody
Module 2:Custody
Module 1:DisclosureModule 1:Disclosure
A Coping Skills Intervention for Parents with HIV & their Adolescent Children
Module I: Preparation
Adapting to AIDS
Disclosure
Parenting
Custody Planning
Daily Routines
Saying Goodbye
Module II: Pre-Death
New Families
Healthy Daily Routines
Future Goals
Module III: New Caregivers
0.3
0.35
0.4
0.45
0.5
0.55
0.6
3 6 9 12 15 18 21 24
Months
BSI Overall
Intervention Control
0.65
0.7
0.75
0.8
0.85
0.9
0.95
3 6 9 12 15 18 21 24
Months
Multiple Problem Behaviors
Intervention Control
0.15
0.2
0.25
0.3
0.35
0.4
0.45
0.5
3 6 12 15 18 21 24
Intervention Control
Adolescent Family Events
2.95
3
3.05
3.1
3.15
3.2
3 6 9 12 15 18 21 24
Intervention Control
Adolescent Self Esteem
Emotional Distress
Multiple Problem Behaviors
Family Stressful Events
Self Esteem
Effectiveness – 2 Years
Impact of Intervention: 4 Year Outcomes
0.55
0.6
0.65
0.7
0.75
0.8
0.85
0.9
0.95
1
3 6 9 12 15 18 21 24 30 36 42 48
Months
Intervention Outcome4 Year Data: Parents - Multiple Problem
Behaviors
Intervention Control
Parent BSI Global Scores
0.5
0.6
0.7
0.8
0.9
1
1.1
3 6 9 12 15 18 21 24 30 36 42 48
Months
Intervention Control
4 Year: Parents - Emotional Distress
3.3
3.35
3.4
3.45
3.5
3.55
Intervention Standard Care
6 Year Outcome: Youth Quality of Romantic Relationships
40%
45%
50%
55%
60%
65%
70%
75%
80%
85%
Intervention Standard Care
6 Year Outcome: Youth In School/Employed
10%
15%
20%
25%
30%
35%
40%
Intervention Standard Care
6 Year Outcome: Youth Receiving Public Assistance
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Intervention Standard Care
6 Year Outcome: Youth Alcohol, Last 30 Days
0
5
10
15
20
<15 15-17 18-19 >19
Intervention No Intervention
First Childbearing in Adolescent
Females
40
45
50
55
60
65
2 3
Baby Age
Intervention Control
Bab
y C
BC
LIntervention Outcomes Across Three
Generations
Youth's Babies: Adjustment Problems
Youth's Babies: Home Environment
75
80
85
90
95
100
1 2 3
Baby Age
Intervention Control
Bab
y M
DI
Survival of parent was associated with disorganized
child attachment
15%
58%
0%
10%
20%
30%
40%
50%
60%
Typical Disorganized Attachments
pro
po
rtio
n
• Intergenerational impact for parents, adolescents, & babies
• Long-term benefits of intervention• Ongoing maintenance needed due to relapse
at 4 years• Methods to scale-up
Project TALCFamilies:
• 4-5% of adolescents have lost a parent
• 5-15% have a parent with a chronic illness
Bereavement
<-1 -1 to 0 0 to 1 >1
1.0
0.8
0.6
0.4
0.2
0.0
BSITotal
DepressionSomatization
Be
rea
ved
-No
nb
ere
ave
d
Parent Death (years)
Parental Death and Emotional Distress
At least 1 disorder 45%
Depressive disorders 20%
Anxiety disorders 39%
Post traumatic stress disorder 24%
Psychiatric Diagnosis n= 339
Bereavement and Mental Health Outcomes
• Longitudinal analysis of emotional distress highlight important period for intervention delivery
• High PTSD prevalence suggests enhanced intervention needs
0
20
40
60
80
<=5 6--14 >=15
Age category
Cum
ulat
ive
havi
ng p
lan
(%)
baseline
1-yr
3-yr
5-yr
Cu
mu
lati
ve h
avin
g p
lan
(%
)
Age category
Custody Plans Over Time
15% Always; 37% Never
54% Change plans; 12% Siblings
4.9 Changes per child
81% Other Family Members
93% Guardians Agreed
Stability of Custody Plans
Problem Populations InterventionProgram parameters
Strategies
Techniques
Reinforcement
Participation in Intervention
Behavior Change
Maintenance of Behavior Change
Populations Domains of Change Interventions Outcomes
Figure 1. Integrated Framework for Preventive and Treatment Interventions
Relationships
• Interventionist- Consumer relationship• Social relationships
Intentions/Motivations
• Emotional reactions• Perceived consequences• Normative beliefs• Self-standards• Self-efficacy• Attitudes
Learned Competencies
•Framing the problem•Problem-solving skills•Regulation of affect• Interpersonal skills
Environment
•Barriers
•Faciliators
Behavior Predispositions
•Temperament•Serotonin Regulation
Summary
Health Education = Information
Behavior Change =
Skills
Perceptions
Environment
Predispositions
Emotions