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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).
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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
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Public Health Interventions
Focus on: The health of the population Prevention through health promotion
Using: Data driven/evidence-based approaches Comprehensive, multi-level approaches
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Public Health and the Social Ecological Model
Individual Relationship Community SocietySocietal Community Relationship Individual
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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
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1. Define the Problem
Who is being affected?
Are rates are increasing or decreasing?
How do the data compare across communities and time?
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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)
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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%)
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Example: Surveillance data from Santa Ana, CA
Well Being: Santa Ana (Citywide)
Median household income $33,728 ($43,412)
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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%)
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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)
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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?
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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
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3. Develop and Test Prevention Strategies
Efficacy versus effectiveness trials
Entire programs to smaller components
Content
Scope
Audience
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Social Ecological Model
Societal Community Family/Peer Individual
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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
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Social Ecological Model
Societal Community Family/Peer Individual
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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
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Social Ecological Model
Societal Community Family/Peer Individual
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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
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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
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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
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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
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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
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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
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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)
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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)
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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
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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)
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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)
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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….”
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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’.”
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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)”
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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.”
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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! ”
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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?
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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
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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)
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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
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4: Assure Widespread Adoption
Identification of effective programs
Dissemination
Replication
e.g., ACE-UCR’s use of FAST
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Contemporary Questions/Future Research
Need to assess effects of public health interventions
Across time
Across ecological levels
Across outcomes
Across subgroups
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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
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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
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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)
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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?
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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
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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 [email protected]
Jennifer L . Matjasko, PhDBehavioral Scientist
National Center for Injury Prevention and Control Centers for Disease Control and Prevention