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