UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 1 Broadening Prevention Research: Linking

AAHB Conference, Napa, CA, March 25, 2002 1 UIC University of Illinois at Chicago

Health Research and Policy Centers

Broadening Prevention Research:

Linking Schools, Families, and Communities in Promoting Positive Behavior, Character, Mental Health

and Academic Achievement

Brian R. Flay, D.Phil., FSBM, FSCRA, FAAHB Distinguished Professor

Health Research and Policy Centers University of Illinois at Chicago

Presented at American Academy of Health Behavior Conference in acceptance of the Research Laureate

Award

Napa, CA, March 25, 2002



Outline of Presentation

1. The importance of linking behavior, character, mental health, and academic achievement

2. Behaviors are related.Also predict and are predicted by each otherMust work towards a comprehensive, coherent, integrated approach to youth development.

3. All behaviors have common predictors/causesRisk and Protective FactorsThe Theory of Triadic Influence (Integrates theories)Importance of Community, Family and SchoolMust work toward comprehensive and coherent classroom, school-wide, family and community programs

4. Implications for prevention science, programs and policies



PART 1:

The importance of linking behavior, character, mental

health and academic achievement



Linking behavior, character, mental health and academic achievement are important

because ...• Demands on education require that prevention be tied

to academic achievement• Most prevention and promotion programs to date have

neglected the link with academic achievement– Exceptions: Hawkins & Catalano, Positive Action (Carol Allred),

Weissberg’s recent statements re Social-Emotional Learning

• Academic Achievement depends, in part, on positive youth development– Most prevention researchers recognize that early school failure

predicts later problem behavior, but rarely the reverse

• Prevention needs to fit into the whole educational picture of improving student behavior, character and achievement.



Other factors demanding positive youth development

• Most education dollars target reading and testing– E.g., $900 million to “Reading First”– This is probably short-sited– Education is in crisis

• Loud calls/demands for science-based programs of proven effectiveness– Is our science of effectiveness advanced enough?

• Increasing demands for community-based and after-school programs– Communities are in crisis– But don’t leave out schools. Education is key to youth

development.

• Positive youth development• = Positive behavior, character, mental health, academic

achievement• = A successful and happy life



Unfortunately ... Behaviors that prevent success and

happiness are far too prevalent among youth

today• Problem/Risky Behaviors

– Substance use and abuse, violence, and unsafe sex

• Other health-compromising behaviors– Poor eating habits and inadequate physical activity

• Unacceptable and anti-social behavior• Poor character development• Psychological and mental disturbances• School failure



Trends in Annual Prevalence of an Illicit Drug Use IndexEighth, Tenth, and Twelfth Grades, 1975-2001.

Monitoring the Future data, http://monitoringthefuture.org



Violence among our Youth• On a typical day, 6 or 7 youth are slain in this country, mostly inner-

city, minority youth.• Males account for more than 90% of incidents involving those 10-17

years of age.• Handgun homicides committed by young males (15-18) between

1980 and 1995 increased by more than 150%. • Youth are three times more likely than adults to be victims of

violence. • 5% of students reported feeling too unsafe to attend school at least

once in the thirty days preceding the National Youth Risk Behavior Survey.

• 20% of high school students reported carrying a weapon (e.g., gun, knife, or club) at least once in the thirty days preceding the National Youth Risk Behavior Survey.

• ~8% reported carrying a gun, and 10% reported having carried a weapon on school property on one or more occasions in those 30 days.

– Factoids from Center for the Study and Prevention of Violence, U Colorado, www.colorado.edu/cspv/factsheets



Teen sexual behavior?• One quarter of high school freshman girls and just over

half (52%) of senior girls have had sex.

• Almost a third (27%) of high school freshman boys and almost two-thirds (59%) of senior boys have had sex.

• Nearly 9 of 10 students enrolled in alternative high schools have had sex.

• Only about 1 in 5 young people do not have intercourse while teenagers.

– Factoids from ETR: www.etr.org/recapp/stats

AAHB Conference, Napa, CA, March 25, 2002 10 UIC University of

Illinois at Chicago


Mental Health Statistics for Children

• One in five children have a diagnosable mental, emotional or behavioral disorder. And up to one in 10 may suffer from a serious emotional disturbance (SGRMH, 2001).

• Attention deficit hyperactivity disorder (ADHD), one of the most common mental disorders in children, affects 3 to 5 percent of school-age children (NIMH, 1999).

• As many as one in every 33 children and one in eight adolescents may have depression, more likely for girls than boys (CMHS, 1998).

• Children and teens who have a chronic illness, endure abuse or neglect, or experience other trauma have an increased risk of depression (NIMH, 2000).

• Once a child experiences an episode of depression, he or she is at risk of having another episode within the next five years (CMHS, 1998).

• More than half of young persons with a substance abuse diagnosis also have a diagnosable mental illness (NAMI, 2001).


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Conclusion #1:

• Prevention research, program development, and dissemination must

– Link multiple behaviors with school success or failure

– Link prevention with other educational functions (mental health and achievement)


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PART 2:

Behaviors are Highly Correlated


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Substance Use and Abuse Behaviors are Highly Correlated and Predict

Each Other

IllicitAlcohol

TobaccoSubstanc

e

Ab/Use

And can be thought of as a latent variable


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Problem/Risky Behaviors are Highly Correlated and Predict Each

Other

Substance

Ab/Use

Tobacco

Alcohol

Illicit

Weapons

Inter-personal

Violence

Fighting

Threats

Unsafe

Sex

No Condoms

Early

Multiple partners

Problem/Risky

Behavior


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Mental Health Behaviors are Highly Correlated and Predict Each

Other

ADHD

Conduct Disorder

Anxiety/ Depression

Mental Health


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Health-Promoting Behaviors are Highly Correlated and Predict Each

Other

Health

Care

Hygiene

Teeth

Visits

Physical

Activity

ExerciseWalking

Sports

Eating/

Diet

Fruits & Veges

Meat/Dairy

Junk

HealthyBehaviors


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Conventional/Social Behaviors areHighly Correlated and Predict Each

Other

Academic Achieveme

nt

Skills

School

Family

Community

Obey Rules

and Laws

Home

School

Community Bonding &

Involvement

Sport/Cultural

ServiceVoting

FamilySchool

Conventional and Social

Behaviors


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Positive, Health and Social Behaviors are Highly Correlated and Predict

Each Other

Healthy

Behaviors


Behaviors

Eating/Diet

Health

Care

Physical

Low Risk, non-

Problem Behaviors

No Drugs

Nonviolent

Safe SexCommunity

BondingLaw Abiding

Achievement

Mental

Health

ADHA

Conduct Anxiety/Dep

Successful and Happy

Citizens


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Conclusion #2Future prevention programs need to comprehensively and coherently address multiple behaviors and outcomes

- Prevention of Problem/Risky BehaviorsSubstance use and abuse, violence, and unsafe sex

- Promotion of health-enhancing behaviors

Good eating habits and adequate physical activity

- Psychological and mental health

- Positive character development Positive moral and social behavior

-School success


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BUT, should we target single

or multiple behaviors?- We used to believe that effects would be larger if we targeted a single behavior, or a single domain, such as substance use

- Increasing evidence that many behaviors and domains are interrelated, and that programs should deal with them together

- Increasing evidence that programs that address multiple issues are effective

- Particularly if they address related issues -- problem behaviors, health behaviors, school behaviors


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Two Programs As Examples

• ABAN AYA– Who: Flay et al., University of Illinois– What: Social & Emotional Skills Development

• Double Protection (ABAN) and Self-Determination (AYA!)

– Why: Violence, Drug Use, Unsafe Sex– Where: Inner-city African-American Schools

• POSITIVE ACTION– Who: Carol Allred, Twin Falls, ID– What: Comprehensive Character Education & SEL– Why: Improve all behaviors and academics– Where: 8,000 schools nationwide and internationally


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C opyri ght Aban Aya Proj ec t, UIC , 2001

UIC University ofI llinois at Chicago


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ABAN AYA Classroom Content

• INFORMATION

– Prevalence and nature of risky behaviors

– Consequences of engaging in risky behaviors

– On the proper use of medicines

• SOCIAL INFLUENCES

– Awareness of social influences from peers, family, media, etc

– Corrections of normative misperceptions

• PROBLEM SOLVING

– Decision making– Goal setting

• SOCIAL SKILLS

– Assertiveness/Resistance skills– Risk management or

avoidance– Conflict resolution, mediation– Social networking

• CULTURAL PRACTICES AND VALUES

– Cultural pride/history (Kwanzza - Nguzo Saba)

– Articulation of community roles


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10

11

12

13

14

15

0 1 2 3 4

Control Treatment

Violence: Predicted Means


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ABAN AYA significantly improved multiple behaviors

• Physical Violence• Provoking Behavior• Alcohol and Drug Use• School Delinquency• Frequency of sexual intercourse• Condom Use• Healthy & junk food

consumption• Physical Exercise• Standardized Test Scores


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ABAN AYA significantly improved multiple behaviors

…

Though only for males!• Physical Violence• Provoking Behavior• Alcohol and Drug Use• School Delinquency• Frequency of sexual intercourse• Condom Use• Healthy & junk food consumption• Physical Exercise• Standardized Test Scores


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Males’ behavior was brought down

to the level of females’ behavior

8

9

10

11

12

13

14

15

0 0.5 1 1.5 2 2.5 3 3.5

Males C Males Tx All Females


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After adjusting for pretest differences, there were also effects on standardized test scores (males &

females)


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The Positive Action Program Targets Multiple Behaviors

• By teaching that doing positive actions helps:– individuals develop a positive self identity.

– families develop a positive family identity.

– schools develop a positive school identity.

– communities develop a positive community identity.

• By teaching that:– When you do good, you feel good

Thoughts

Feelings

Actions


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In the classroom curriculum and in all other materials, the Positive Action content is taught school-wide through

six units:• Unit 1. Self-Concept: What It Is, How It’s Formed,

and Why It’s Important.• Unit 2. Physical and Intellectual Positive Actions

for Body and Mind• Unit 3. Social/Emotional Positive Actions for

Managing Yourself Responsibly• Unit 4. Social/Emotional Positive Actions for

Getting Along with Others by Treating Them the Way You Like to be Treated (Character Education)

• Unit 5. Social/Emotional Positive Actions for Being Honest with Yourself and Others (Mental Health)

• Unit 6. Social/Emotional Positive Actions for Improving Yourself Continually


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Positive Action Others

ES % ES %

Drug Use 0.54 26 0.24 12

Violence 1.49 60 0.16 8

Disciplinary 1.79 67 -- --

Absenteeism 0.41 20 -- --

Reading 0.58 28 0.5 25

Effect Sizes and percent improvement forPositive Action (with training)

and other social and skills-based programs

And Has Multiple Effects:


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PART 3:

All Behaviors Have Common

Predictors/Causes


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All Behaviors Have Common Causes

PERSONALGeneticPersonality

SELF-EFFICACY

SITUATIONALCommunityFamilySchool

SOCIAL NORMATIVE BELIEFS

ENVIRONMENTALBroader socio-cultural environment

VALUES/ ATTITUDES


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All Behaviors Have Common Causes:The Basics of the Theory Of Triadic Influence

BEHAVIOR

Decisions/Intentions

& PersonalityBiology

Sense of Self

SocialSkills

SelfDetermin-

ation

SELFEFFICACY

SocialCompetence

DNA

ValuesEvaluations

Environment

ReligionCulture

ATTITUDES

InformationalEnvironment

CulturalKnowledgeExpectancies

EvaluationsValues

Environment

Bonding

PerceivedNorms

Motivationto Comply

Others'Beh&&Atts

SOCIALNORMATIVEBELIEFSContext

Social


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Not to be confused with ...

my Audi TT


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References re TTI• Petraitis, J., Flay, B.R., & Miller, T.Q. Reviewing theories of

adolescent substance abuse: Organizing pieces of the puzzle. Psychological Bulletin, 117(1), 67-86. 1995.

• Flay, B.R. & Petraitis, J. The theory of triadic influence: A new theory of health behavior with implications for preventive interventions. In Albrecht, G.S. (ed.) Advances in Medical Sociology, Vol IV: A Reconsideration of models of health behavior change (pp. 19-44). Greenwich, CN: JAI Press, 1994.

• Flay, B.R., Petraitis, J., Hu, F. The theory of triadic influence: Preliminary evidence related to alcohol and tobacco use. In Fertig, J.B., Allen, J.P. (eds.) NIAAA Research Monograph - Alcohol and Tobacco: From Basic Science to Clinical Practice (pp. 37-57). Bethesda, MD: U.S. Government Printing Office, 1995.

• Flay, B.R. Understanding environmental, situational and intrapersonal risk and protective factors for youth tobacco use: the Theory of Triadic Influence. Discussant Comments. Nicotine & Tobacco Research, 1, S111-S114, 1999.


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“All Behaviors Have Common Causes”

NationalSocio-

Cultural Environment

Political, Economic,Media, Religious.

Values, Attitudes

Local Community,Families, SchoolsRelationships with Others.

Others’ Attitudes, Behaviors.

Social Normative BeliefsSelf-Concept,Social Skills.

Self-Efficacy

Intrapersonal Biology,

Personality

Risky Behavior, Healthy Behavior, Mental Health, Academics

EVERYBODY NOW ….


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All Behaviors Have Common CausesNationalSocio-

Cultural Environment

Political, Economic,Media, Religious.

Values, Attitudes

Local Community,Families, SchoolsRelationships with Others.

Others’ Attitudes, Behaviors.

Social Normative BeliefsSelf-Concept,Social Skills.

Self-Efficacy

Intrapersonal Biology,

Personality

Low Risk, non-

Problem Behaviors

Nonviolent

Safe Sex

Successful and Happy Citizens


Behaviors

Community Bonding

Law Abiding

AchievementNo Drugs

Health

Care

Physical

Healthy Behavior

s

Eating/Diet

Health

Care

Physical

Mental Health

Eating/Diet


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BUT, Note the Critical Importance of Community,

Family and School

CommunityFamily & School

Relationships with Others.Others’ Attitudes, Behaviors.

Social Normative BeliefsValues, Attitudes Self-Efficacy

Risky Behavior, Healthy Behavior, Mental Health, Academics


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The Critical Importance of Community, Family and

SchoolCommunity

Family School

Student Health,

Behavior and Academic

Performance


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Conclusion #3Future prevention programs need to involve whole schools, families and communities in an integrated and coherent way- Classroom curricula can teach content and skills

Should be school-wide, scoped and sequenced for every grade

- Teacher training can address class/behavior management and teaching effectiveness

- School-wide climate change can provide a safe learning environmentprovide common language and consistently reinforce desired behaviors

- Family programs can improve parenting skills provide common language and consistently reinforce positive behaviors

- Community programs canlink schools and communitiesget students observing and doing community serviceprovide common language and consistently reinforce positive behaviors


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• Comprehensive classroom program• Enhanced parent involvement• Parent Training/Education• School Health Promotion Task Force• School-wide staff development• Community-Based Organization involvement• Institutionalization in schools & communities

ABAN AYA:INTENSIVE SCHOOL/COMMUNITY

INTERVENTION


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Construct and model Curriculum Estimate Std Reduction p† EffectErr (%)* size‡

Violence SDC 2.8 0.53 35 0.026 0.31Continuous outcome, mixed SC 2.2 0.60 47 0.008 0.41

Provoking SDC 3.4 0.98 40 0.059 0.27Continuous outcome, mixed SC 2.3 1.15 59 0.017 0.40

School delinquency SDC 2.1 0.32 27 0.049 0.25Continuous outcome, mixed SC 1.3 0.35 54 0.001 0.49

Substance use SDC 1.5 0.28 37 0.016 0.50Ordinal outcome, GEE SC 1.3 0.31 47 0.005 0.63

Recent sexual intercourse SDC 1.0 0.27 44 0.039 0.44Binary outcome, GEE SC 0.6 0.34 65 0.009 0.65

Condom use SDC 1.4 0.47 95 0.138 0.38Ordinal outcome, GEE SC 1.9 0.41 165 0.022 0.66

Combined model SDC 4.7 1.66 0.002 0.37Continuous outcome, SC 7.9 1.82 <.0001 0.62doubly-repeated measures SC-SDC 3.2 1.77 0.036 0.35

* [HEC growth - (SDC or SC growth)] / HEC growth. For condom use % increase is shown.† p-values are 1-tailed.

‡ Effect size for GEE models is [HEC - (SDC or SC) growth] / √(π2/3)§ Combined model effect size accounts for variance between behaviors.

Growth Program effect

ABAN AYA: SDC and SC Effects on Males by 8th Grade


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The POSITIVE ACTION Program Components

K–12 classroom curriculumover 1,200 lessons - using Teacher’s Kits (manuals and materials for each grade), classroom teachers present 15–20-minute lessons

Principal’s Kits (Elementary and Secondary)a school-climate program to promote the practice and reinforcement of positive actions in the whole school population (students and staff)

Counselor’s Kitused with selected individual students, small groups and families

Family Kit contains prepared weekly home lessons paralleling the school program along with school parent-involvement activities

Community Kitmanuals and materials that align and encourage collaboration of all the environments (schools, families and community) involved in the program


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Positive Action Others

ES % ES %

Drug Use 0.54 26 0.24 12

Violence 1.49 60 0.16 8

Disciplinary 1.79 67 -- --

Absenteeism 0.41 20 -- --

Reading 0.58 28 0.5 25

Effect Sizes and percent improvement forPositive Action (with training)

and other social and skills-based programs

And Has Multiple Effects:


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PART 4:

Challenges for Prevention Science,

Prevention Programs and Education


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Is Prevention Science Up To The Challenges

Of ...?Developing comprehensive interventions

That are multi-component, broad-based, deep-structured, and coherent

Evaluating comprehensive interventionsIs very difficult and complexAnd is very expensive

Getting schools to do the seemingly impossible

Be successful in improving multiple behaviors as well as character and achievement

Translating research into practiceSo that it is replicable


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What’s at stake if we don’t meet these challenges?

Disenchantment with preventionThe credibility of prevention researchersPrevention funding for schools

Increased problems for our childrenMore adolescent SU, violence, unsafe sexDeclining virtues, morals, etc.Decreasing academic achievement and increasing school failureIncreasing failures to succeed in life


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Limitations of Most Programs• Domain Specific

– Usually only one behavior or one skill

• Start too late – Upper elementary or middle school

• Limited intensity and dose– Often only once a week for 10-20 sessions

• Ecologically Limited– Usually only classroom.– Also need school-wide, parent, community

• Limited Effect Sizes– Average effect sizes in the 0.2 to 0.4 range

• Effects not Sustained– Few effects beyond one year, let alone H.

S.


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Conclusion #4

• All of the foregone has implications for:

– Prevention and Education Programs

– Prevention and Educational Policy

– Prevention and Education Research


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Promotion Programs of the Future

Must Be Characterized As …• EARLY AND OFTEN

– Start early, scoped and sequenced, many doses, over a long time

• POSITIVE– Focus on asset and strength development– Address protective factors more than risk factors– Include positive reinforcement and environmental contingencies

• COMPREHENSIVE– Multiple domains: behaviors, feelings, thoughts, character,

achievement– Multiple protective/risk factors– Multiple levels: students, teachers, school, families, community

• REPLICABLE– Diverse teaching strategies– Complete materials, user friendly– Minimal training required, but necessary training easily provided

• EFFECTIVE– Large effects that are sustained


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Future Educational Promotion Policy Must ...

• Focus on positive child/youth development

• Rather than focusing on negative behaviors and failures

• Prefer more integrated, comprehensive, coherent, holistic approaches

• Rather than separate, piece-meal approaches to different issues

• Support longer-term, more comprehensive research/evaluation

• Rather than shorter-term, limited studies

• This will require prevention/promotion to align with character education and achievement


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Future Promotion Researchers will ...

1. Analyze for whom programs are most and least effective.

2. Conduct mediation and other analyses to help us understand mechanisms of action.

3. Show long-term effects with school-level data.

4. Have a broader view of acceptable approaches to research.

5. Consider larger replicated effects to be more important than findings from any one study.

6. Conduct more effectiveness trials.

7. Conduct cost-effectiveness analyses.


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Not OR but AND Science AND Passion

Risk Factors AND Protective Factors

White, middle-class AND Diverse cultures

Genetic/Intrapersonal AND Social/Environmental

Individually focussed AND System/Environment

Research Based AND Real World Derived

Scientific Rigor AND Program Characteristics

Courtesy Tony Biglan and colleagues, Stanford Center for Advancement of Behavioral Sciences, 3/01


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SUMMARY

• It is critically important to link behavior, character, mental health, and academic achievement

• Positive, problem, health, and mental health behaviors are all related, and are all related to character and academic achievement

• All behaviors and related outcomes have the same causes, many of which reside in families, schools and communities

• Future prevention/promotion research, programs, and policies need to be comprehensive, integrated and coherent across behaviors, grades/ages, and social ecologies (schools, homes and communities)


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Have

A Positive Action

Evening.

And A Happy and

Successful Life.

Documents

UIC University of Illinois at Chicago Health Research and Policy Centers AAHB Conference, Napa, CA, March 25, 2002 1 Broadening Prevention Research: Linking