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 Causal Agent Identified National Campaign Targeted Social Marketing ProvidersHigh-Risk Group Treatment Time % People Changing Actions

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

Institutional Placements: % Lifetime

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 Intervention Program parameters Strategies Techniques Reinforcement Participation in Intervention Behavior Change Maintenance of Behavior Change PopulationsDomains of ChangeInterventionsOutcomes 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 = 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: PLWA Assessment Months Enhanced CareStandard Care PLWA dies PLWA dies Module 3: Bereavement Module 3: Bereavement Module 2: Custody Module 2: Custody Module 1: Disclosure Module 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

BSI Overall Intervention Control

Multiple Problem Behaviors Intervention Control

Adolescent Family Events

Adolescent Self Esteem

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

Impact of Intervention: 4 Year Outcomes

Intervention Outcome 4 Year Data: Parents - Multiple Problem Behaviors InterventionControl

4 Year: Parents - Emotional Distress

6 Year Outcome: Youth Quality of Romantic Relationships

6 Year Outcome: Youth In School/Employed

6 Year Outcome: Youth Receiving Public Assistance

6 Year Outcome: Youth Alcohol, Last 30 Days

First Childbearing in Adolescent Females

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

Baby MDI

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

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 TALC Families:

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

BSI Total Depression Somatization Bereaved-Nonbereaved Parent Death (years) Parental Death and Emotional Distress

At least 1 disorder 45% Depressive disorders20% Anxiety disorders 39% Post traumatic stress disorder24% 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

Cumulative having plan (%)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 Intervention Program parameters Strategies Techniques Reinforcement Participation in Intervention Behavior Change Maintenance of Behavior Change PopulationsDomains of ChangeInterventionsOutcomes 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