Innovative Strategies for Behavioral Change in High-Risk Populations: Insights from Mary Jane Rotheram-Borus

1. Health Education & Behavior Change Mary Jane Rotheram-Borus, Ph.D.

2. Sequential Intervention Strategies • Causal Agent Identified • National Campaign • Targeted Social Marketing • Providers • High-Risk Person • Treatment

3. 100 % People Changing Actions 0 Causal Agent Identified National Campaign Targeted Social Marketing Providers High-Risk Group Treatment Time % People Changing Actions

4. Interpersonal Levels Organizations Families Couples Persons

5. Multiple Problem Behavior • Sex • Drugs • School Trouble • Delinquency/ • Juvenile Justice • Emotional Distress

6. Social Cost of Runaways Requiring Social Services * Social cost/month - NYC cost/child x N of runaways who have received service (e.g., for foster care, n = 91)

7. Institutional Placements:% Lifetime

8. Interventions Universal Selected Indicated

9. 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

10. School-based Programs • 78% of states mandate • 37% include use of condoms • Unsuccessful = general, unspecific • No successful abstinence programs

11. Interventions Universal Selected Indicated

12. Vulnerable Subgroups • Gay/Bisexual • African American Women in Inner Cities • East Coast Latino Adolescents • Homeless • Youth in Jail • Severely Mentally Ill • Abused Youth

13. Figure 1. Integrated Framework for Preventive and Treatment Interventions Populations Domains of Change Interventions Outcomes Problem Populations Intervention Program parameters Strategies Techniques Reinforcement • 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 Participation in Intervention • Behavior Predispositions • Temperament • Serotonin Regulation Behavior Change Maintenance of Behavior Change

14. Parents with HIV • 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

15. Model Underlying the Program Parent Health Lifestyle: Substance Use Sex Parent Disclosure Custody Parenting Illness-Related Tasks Adolescent Family Relations Grief Custody Adolescent Behavioral Social Mental Health Intervention Roles Rules Routines Adolescent Ethnicity Age Gender Intermediate Primary Outcomes Outcomes Background Intervention

16. A Coping Skills Intervention for Parents with HIV & their Adolescent Children Project TALC: PLWA Assessment Months 0 6 12 18 24 36 42 48 54 60 Enhanced Care Standard Care Module 1: Disclosure Module 2: Custody Module 3: Bereavement PLWA dies PLWA dies

17. Module I: Preparation Adapting to AIDS Disclosure Parenting

18. Module II: Pre-Death Custody Planning Daily Routines Saying Goodbye

19. Module III: New Caregivers New Families Healthy Daily Routines Future Goals

20. Intervention Control BSI Overall

21. Intervention Control Multiple Problem Behaviors

22. Adolescent Family Events

23. Adolescent Self Esteem

24. Effectiveness – 2 Years Emotional Distress Multiple Problem Behaviors Family Stressful Events Self Esteem

25. Impact of Intervention: 4 Year Outcomes

26. Intervention Outcome4 Year Data: Parents - Multiple Problem Behaviors Intervention Control

27. 4 Year: Parents - Emotional Distress

28. 6 Year Outcome: Youth Quality of Romantic Relationships

29. 6 Year Outcome: Youth In School/Employed

30. 6 Year Outcome: Youth Receiving Public Assistance

31. 6 Year Outcome: Youth Alcohol, Last 30 Days

32. First Childbearing in Adolescent Females

33. Intervention Outcomes Across Three Generations Youth's Babies: Adjustment Problems Baby CBCL

34. Baby MDI

35. Survival of parent was associated with disorganized child attachment proportion Typical Disorganized Attachments

36. Project TALCFamilies: • Intergenerational impact for parents, adolescents, & babies • Long-term benefits of intervention • Ongoing maintenance needed due to relapse at 4 years • Methods to scale-up

37. Bereavement • 4-5% of adolescents have lost a parent • 5-15% have a parent with a chronic illness

38. Parental Death and Emotional Distress 1.0 0.8 0.6 0.4 0.2 0.0 BSITotalDepressionSomatization Bereaved-Nonbereaved <-1 -1 to 0 0 to 1 >1 Parent Death (years)

39. Psychiatric Diagnosisn= 339 At least 1 disorder 45% Depressive disorders 20% Anxiety disorders 39% Post traumatic stress disorder 24%

40. Bereavement and Mental Health Outcomes • Longitudinal analysis of emotional distress highlight important period for intervention delivery • High PTSD prevalence suggests enhanced intervention needs

41. Custody Plans Over Time Cumulative having plan (%) Age category

42. Stability of Custody Plans 15% Always; 37% Never 54% Change plans; 12% Siblings 4.9 Changes per child 81% Other Family Members 93% Guardians Agreed

43. Figure 1. Integrated Framework for Preventive and Treatment Interventions Populations Domains of Change Interventions Outcomes Problem Populations Intervention Program parameters Strategies Techniques Reinforcement • 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 Participation in Intervention • Behavior Predispositions • Temperament • Serotonin Regulation Behavior Change Maintenance of Behavior Change

44. Summary Health Education = Information Behavior Change = Skills Perceptions Environment Predispositions Emotions