Effectiveness of Circle of Life, an HIV-preventive intervention for American Indian middle school youths: a group randomized trial in a Northern Plains tribe

"We don't separate out these things. Everything is related": Partnerships with Indigenous Communities to Design, Implement, and Evaluate Multilevel Interventions to Reduce Health Disparities

Multilevel interventions (MLIs) are appropriate to reduce health disparities among Indigenous peoples because of their ability to address these communities' diverse histories, dynamics, cultures, politics, and environments. Intervention science has highlighted the importance of context-sensitive MLIs in Indigenous communities that can prioritize Indigenous and local knowledge systems and emphasize the collective versus the individual. This paradigm shift away from individual-level focus interventions to community-level focus interventions underscores the need for community engagement and diverse partnerships in MLI design, implementation, and evaluation. In this paper, we discuss three case studies addressing how Indigenous partners collaborated with researchers in each stage of the design, implementation, and evaluation of MLIs to reduce health disparities impacting their communities. We highlight the following: (1) collaborations with multiple, diverse tribal partners to carry out MLIs which require iterative, consistent conversations over time; (2) inclusion of qualitative and Indigenous research methods in MLIs as a way to honor Indigenous and local knowledge systems as well as a way to understand a health disparity phenomenon in a community; and (3) relationship building, maintenance, and mutual respect among MLI partners to reconcile past research abuses, prevent extractive research practices, decolonize research processes, and generate co-created knowledge between Indigenous and academic communities.

A virtual randomized controlled trial of an alcohol-exposed pregnancy prevention mobile app with urban American Indian and Alaska Native young women: Native WYSE CHOICES rationale, design, and methods

BACKGROUND

Fetal Alcohol Spectrum Disorders (FASD) result in lifelong disability and are a leading cause of preventable birth defects in the US, including for American Indian and Alaska Natives (AIANs). Prevention of alcohol exposed pregnancies (AEPs), which can cause FASD, is typically aimed at adult women who are risky drinkers and have unprotected sex. Among AIANs, AEP prevention research has been primarily conducted in reservation communities, even though over 70% of AIANs live in urban areas. Culturally appropriate AEP prevention for urban AIAN young women, regardless of current drinking or sexual behaviors, may maximize the potential for primary prevention at the beginning of the reproductive years for this underserved population.

METHODS

We developed a virtual randomized controlled trial (RCT) - fully implemented through technology - to evaluate Native WYSE CHOICES, a culturally tailored mobile app, with urban AIAN young women ages 16-20 nationally. While virtual RCTs are not new, this is the first engaging a solely urban AIAN population, historically excluded from research. Participants are recruited on a rolling basis through the project social media community, organizational partnerships, and in-person events. Eligible participants complete a baseline survey and are randomized to either the app's intervention or comparison arm - each of which provide about 3 h of content. Follow-up data are collected at 1-, 6-, and 12-months post-baseline.

RESULTS

Our study offers a template for building trust and extending reach to this underserved population while also providing important lessons and insights on advances in virtual or hybrid research approaches.

Evidence of secular trends during the COVID-19 pandemic in a stepped wedge cluster randomized trial examining sexual and reproductive health outcomes among Indigenous youth

BACKGROUND

Nen ŨnkUmbi/EdaHiYedo ("We Are Here Now," or NE) is an intervention to prevent STIs, HIV, HCV, and teen pregnancy among Assiniboine and Sioux youth of the Fort Peck Reservation in the state of Montana in the USA. A cluster-randomized stepped-wedge design (SWD) trial is used to evaluate NE, where clusters are schools. The purpose of this study is to evaluate whether there is evidence of a secular trend associated with the COVID-19 pandemic.

METHODS

The original study design is a cluster-randomized stepped-wedge design (SWD), in which five schools that youth from Fort Peck attend are the clusters to be randomized into the intervention one at a time, with all schools eventually being randomized to the intervention across three steps. N/E is a 5-year study involving 456 15- to 18-year-old youth. For this study, we use a mixed quantitative and qualitative methods approach to understand how the COVID-19 pandemic may have been associated with the study's primary outcome variables. Data were drawn from the first cluster exposed to the intervention and one control cluster that did not yet receive the intervention during the period in which COVID-19 mitigation efforts were being implemented. A pre-post COVID questionnaire was added to core measures administered, and semistructured qualitative interviews were conducted with youths regarding their perceptions of how the pandemic altered their sexual behaviors.

RESULTS

One hundred eighteen youth responded to the questionnaire and 31 youth participated in semistructured qualitative interviews. Youth reporting having sex with less people due to COVID-19 reported more sex acts (incident rate ratio (IRR)=3.6, 95% CI 1.6-8.1) in comparison to those who did not report having sex with less people, and youth who reported having sex with the same amount of people due to COVID-19 reported less sex acts (IRR=0.31, 95% CI 0.14-0.7) in comparison to those who did not report having sex with the same amount of people. Youth reporting having sex less times due to COVID-19 experienced a greater number of sex acts in comparison to those who did not report having sex less times (IRR=2.7, 1.2-6.4). Results suggest that more sexually active individuals reported perceiving having sex with less people and less frequent engagement in sex during the pandemic. It is possible that the COVID-19 pandemic period was associated with a truncation in the distribution of sexual activity that would bias an estimate of the intervention's effect.

CONCLUSION

Findings suggest evidence of a secular trend. This trend must be accounted for at trial end, and sensitivity analyses are recommended. Documenting and reporting on these findings encourages transparent reporting during the implementation of a SWD trial during a global pandemic, and informs endline analyses.

TRIAL REGISTRATION

This trial is registered with the Clinical trials registry of the US National Library of Medicine at the National Institutes of Health (NIH). It was registered on October 1, 2018. The study presented in this manuscript is funded by NIH National Institute on Minority Health and Health Disparities (NIMHD), Award # R01MD012761-01, Elizabeth Rink (Principal Investigator). The study's ClinicalTrials.gov number is NCT03694418.

Baseline results from NenŨnkUmbi/EdaHiYedo: A randomized clinical trial to improve sexual and reproductive health among American Indian adolescents

We report on baseline findings from NenUnkUmbi/EdaHiYedo, a community based participatory research randomized controlled trial with American Indian adolescents to reduce sexual and reproductive health disparities. American Indian adolescents aged 13-19 years participated in a baseline survey that was administered in five schools. We used zero-inflated negative binomial regression to evaluate how the count of protected sexual acts was associated with independent variables of interest. We stratified models by self-reported gender of adolescents and tested for a two-way interaction effect between gender and the independent variable of interest. Two hundred twenty-three girls and 222 boys (n = 445) were sampled. The average number of lifetime partners was 1.0 (standard deviation = 1.7). Each additional lifetime partner was associated with a 50% increase in the number of protected sexual acts incident rate ratio (IRR = 1.5, 95% confidence interval [CI] 1.1-1.9) and more than a twofold increase in the likelihood of not having protected sexual acts (adjusted odd ratio [aOR] = 2.6, 95% CI 1.3-5.1). Each additional number of substances used in adolescentss' lifetime was associated with an increased likelihood of not having protected sexual acts (aOR = 1.2, 95% CI 1.0-1.5). In boys, each one standard deviation increase in depression severity was associated with a 50% reduction in the number of times a condom was used adjusted IRR (aIRR = 0.5, 95% CI 0.4-0.6, p < .001). Each 1-unit increase in positive prospections of pregnancy was associated with a pronounced decrease likelihood of not having protected sexual acts (aOR = 0.01, 95% CI 0.0-0.1). Findings support the importance of tribally driven tailoring of sexual and reproducive health interventions and services for American Indian adolescents.

The Healthy Native Youth Implementation Toolbox: Using Implementation Mapping to adapt an online decision support system to promote culturally-relevant sexual health education for American Indian and Alaska Native youth

Background

American Indian and Alaska Native (AI/AN) youth experience serious disparities in sexual and reproductive health, including the highest teen birth rate among racial/ethnic groups, and disproportionate rates of sexually transmitted infections (STI), including HIV. A growing number of evidence-based programs (EBPs) that integrate the strengths and cultural teachings of Native communities exist. Yet, multiple factors, including lack of trained personnel, limited resources, and geographic isolation, may hinder their adoption and implementation. Innovative implementation strategies that facilitate the adoption and implementation of sexual health EBPs in Native communities may help reduce these disparities.

Methods

We applied Implementation Mapping, a systematic planning framework that utilizes theory, empirical evidence, and community input, to adapt a theory-based, online decision support system, iCHAMPSS (CHoosing And Maintaining Effective Programs for Sex Education in Schools), to support underlying dissemination and implementation processes unique to Native communities. We used an iterative design process, incorporating input from Native practitioners and academicians, to ensure that the adapted decision support system reflects cultural identification, community values, and experiences.

Results

Grounded in diffusion of innovations, organizational stage theory, and social cognitive theory, the Healthy Native Youth Implementation Toolbox supports Native practitioners through five phases (Gather, Choose, Prepare, Implement, and Grow) to adopt, implement, and maintain a culturally-relevant, age-appropriate sexual health EBP. The Toolbox provides tools, ready-to-use templates, and guidance to plan, implement, and grow a culturally-relevant adolescent health program with their Tribe or community. Hosted within the Healthy Native Youth website (www.healthynativeyouth.org), the Toolbox comprises: (1) a curriculum portal with access to 15 culturally-relevant, age-appropriate evidence-based health promotion programs for AI/AN youth; (2) a "resource library" comprising 20+ support tools, templates, and links to external resources, and (3) "stories from the field" comprising testimonials from experienced Native educators, who have implemented sexual health programs.

Conclusion

There is a continued need to design, test, and evaluate D&I strategies that are relevant to Native communities. The Healthy Native Youth Implementation Toolbox contributes to the dissemination and implementation of evidence-based, culturally-relevant sexual health education programs in diverse Native communities. Implementation Mapping provided a systematic approach to guide the adaptation process and integrate community voice with the ultimate goal of enhancing sexual health equity among AI/AN youth.

Creating a path forward: understanding the context of sexual health and sexually transmitted infections in American Indian/Alaska Native populations &#x2013; a review

This review assessed sexual health and sexually transmitted infection (STI) burden among American Indian/Alaska Native (AI/AN) peoples within the context of current clinical and public health services. We conducted a review of published literature about sexual health and bacterial STIs among AI/AN populations in the United States using Medline (OVID), CINAHL (EbscoHost) and Scopus. Peer-reviewed journals published during 1 January 2005-2 December 2021 were included and supplemented by other publicly available literature. A total of 138 articles from reference lists met inclusion criteria, including 85 peer-review articles and 53 additional references. Results indicate a disproportionate burden of STIs is carried by AI/AN populations compared to non-Hispanic Whites. Risk for STIs in AI/AN people has origins in historical trauma and structural and social determinants of health. STI services are available for AI/AN populations, but many barriers to care exist. Community-based sexual health programming has been successful, but has thus far focused primarily on adolescents and young adults. A myriad of factors contributes to high rates of STIs among AI/AN populations. Longstanding disparities show a clear need to increase the availability of integrated, low-barrier STI prevention and treatment services. Implementation of multi-level (individual, physician, clinic, healthcare organisation, and/or community level), culturally relevant sexual health and STI interventions should be community-based and person-centred, acknowledge social determinants of health, and grounded in deep respect and understanding of AI/AN histories and cultures.

Community-Based Participatory Research (CBPR) to Enhance Participation of Racial/Ethnic Minorities in Clinical Trials: A 10-Year Systematic Review

There has not been a significant improvement in the rate of clinical trial accrual in more than 20 years. Worse, the challenge of inadequate representation among racial and ethnic minorities also persists, deepening disparities in health. Community-Based Participatory Research (CBPR) is a participatory communication method that centers on effective dialogue between researchers and community stakeholders with the goal of creating an equitable partnership for health and social change. The objective of the current study was to provide an update since a systematic review in 2012, on the current status of the empirical research, with a particular focus on the elements of CBPR methods used to improve the rate of accrual of members of racial and ethnic minority communities for clinical trials. Our systematic review found a large increase in the number of CBPR related studies and studies related to racial and ethnic representation in research. More than 85% of studies employing CBPR methods saw statistically positive outcomes. Specifically, the elements of CBPR that are associated with these positive outcomes include community partner participation in (1) a study advisory committee, (2) data collection, (3) the development of interventions, and (4) participant recruitment. However, the results of our study indicate that researchers need to be more transparent about the extent of community participation as well as more thoroughly and accurately describe the nature of the partnership with members of minority communities in order to build upon the scientific literature on community-engaged methods.

Rationale, Design, and Methods for Nen Unkumbi/Edahiyedo ("We Are Here Now"): A Multi-Level Randomized Controlled Trial to Improve Sexual and Reproductive Health Outcomes in a Northern Plains American Indian Reservation Community

American Indian (AI) youth in the United States experience disproportionate sexual and reproductive health (SRH) disparities relative to their non-Indigenous, white counterparts, including increased rates of sexually transmitted infections (STIs), earlier sexual debut, increased rates of teen birth, and reduced access to SRH services. Past research shows that to improve SRH outcomes for AI youth in reservation communities, interventions must address complex factors and multiple levels of community that influence sexual risk behaviors. Here, we describe development of a multi-level, multi-component randomized controlled trial (RCT) to intervene upon SRH outcomes in a Northern Plains American Indian reservation community. Our intervention is rooted in a community based participatory research framework and is evaluated with a stepped wedge design that integrates 5 reservation high schools into a 5-year, cluster-randomized RCT. Ecological Systems Theory was used to design the intervention that includes (1) an individual level component of culturally specific SRH curriculum in school, (2) a parental component of education to improve parent-child communication about SRH and healthy relationships, (3) a community component of cultural mentorship, and (4) a systems-level component to improve delivery of SRH services from reservation healthcare agencies. In this article we present the rationale and details of our research design, instrumentation, data collection protocol, analytical methods, and community participation in the intervention. Our intervention builds upon existing community strengths and integrates traditional Indigenous knowledge and values with current public health knowledge to reduce SRH disparities.

Social vulnerabilities and sexual initiation of 10- to 14-year-old pupils in the city of Rio de Janeiro, Brazil

This study aimed to estimate the prevalence of sexual initiation of pupils aged 10 to 14 who attended the second year of public and private high school in the IX Administrative Region of the city of Rio de Janeiro, Brazil and to identify the most vulnerable subgroups. The sample consisted of 694 pupils who were selected through cluster-based and stratified sampling by considering school type (public or private) and course type (daytime or evening). Information was collected by means of a structured self-administered questionnaire. The chi-square test (χ2) and 95% confidence intervals were used to assess the heterogeneity of proportions among subgroups. The prevalence of the event was 18.4%; it was higher in boys, in subgroups of greater social vulnerability, among those who hooked up/dated up to 14 years of age, in victims of sexual violence in affective-sexual relationships and in pupils showing health risk behaviors. The high rate of sexual initiation in early adolescence, especially in more vulnerable groups, shows that the situation must be understood and addressed by means of intersectoral public policies that take into account a social context of multiple needs rather than reproductive health alone.

The Impact of COVID-19 on the Delivery of Educational Programs in Native American Communities: Qualitative Study

Background

Despite the availability of culturally responsive sexual health educational programs for American Indian and Alaska Native (AI/AN) youth, barriers to their uptake and utilization persist in tribal communities. These challenges were exacerbated by the COVID-19 pandemic, which required flexible program delivery using both in-person and virtual classrooms.

Objective

This exploratory study provides a preliminary understanding of the extent to which pre-existing challenges impact the delivery of culturally responsive sexual health education programs in Native communities and to what extent they were exacerbated by the COVID-19 pandemic. It also highlights the challenges faced by adolescent health advocates when adapting culturally responsive health curricula to online platforms. Finally, this study discloses major socioeconomic, health, and mental challenges experienced by AI/AN youth during the pandemic.

Methods

An exploratory, descriptive, qualitative design approach was adopted to carry out 5 individual and 1 collective in-depth key informant interviews. A total of 8 Native and non-Native sexual health educators served as key informants and shared their personal experiences with the delivery of sexual health education programs for youth during the COVID-19 pandemic. The interviews were conducted virtually from October to November 2020 using Zoom to reach participants dispersed across different regions of the United States. We followed the consolidated criteria for reporting qualitative research (COREQ) as a reference for the study methodology. We also used the Braun and Clarke framework (2006) to conduct a thematic analysis.

Results

Experts’ opinions were structured according to 5 main themes: (1) competing community priorities during COVID-19; (2) moving to web-based programming: skills, training, support; (3) recruiting youth; and (4) challenges for implementation in a household environment; and (5) recommendations to overcome implementation challenges. These themes are complementary, connected, and should be considered holistically for the development, dissemination, and implementation of online sexual health programs for AI/AN youth, specifically during the COVID-19 pandemic. The results raised the following points for discussion: (1) Building partnerships with schools and community organizations facilitates program adaptation and implementation, (2) there is a need to adopt a holistic approach when addressing youth sexual health in AI/AN communities, (3) a systematic and culturally responsive adaptation approach ensures effective virtual program delivery, and (4) community and youth engagement is essential for the success of virtual sexual health programs.

Conclusions

Findings can provide recommendations on actions to be taken by sexual health educators and guidelines to follow to ensure cultural sensitivity, effective adaptation, and successful implementation when setting out to advocate for online sexual health programs for AI/AN youth.

Social vulnerabilities and sexual initiation of 10- to 14-year-old pupils in the city of Rio de Janeiro, Brazil

Abstract This study aimed to estimate the prevalence of sexual initiation of pupils aged 10 to 14 who attended the second year of public and private high school in the IX Administrative Region of the city of Rio de Janeiro, Brazil and to identify the most vulnerable subgroups. The sample consisted of 694 pupils who were selected through cluster-based and stratified sampling by considering school type (public or private) and course type (daytime or evening). Information was collected by means of a structured self-administered questionnaire. The chi-square test (χ2) and 95% confidence intervals were used to assess the heterogeneity of proportions among subgroups. The prevalence of the event was 18.4%; it was higher in boys, in subgroups of greater social vulnerability, among those who hooked up/dated up to 14 years of age, in victims of sexual violence in affective-sexual relationships and in pupils showing health risk behaviors. The high rate of sexual initiation in early adolescence, especially in more vulnerable groups, shows that the situation must be understood and addressed by means of intersectoral public policies that take into account a social context of multiple needs rather than reproductive health alone.

Effectiveness of Native STAND: A Five-Year Study of a Culturally Relevant Sexual Health Intervention

Culturally relevant interventions have the potential to improve adolescent health and protective factors associated with sexual risk taking. We evaluated the impact of the Native STAND curriculum with American Indian and Alaska Native (AI/AN or Native) high school students living across the U.S. using a pre-post evaluation design. Native STAND is a comprehensive sexual health curriculum for Native high school students that focuses on sexually transmitted infections, HIV/AIDS, and teen pregnancy prevention, while also covering drug and alcohol use, suicide, and dating violence. The curriculum was implemented in 48 AI/AN communities from 2014 to 2019. A significantly higher percentage of youth reported at post-test having a serious conversation about sex with their friends (post 36% vs. pre 28%, p < 0.001), thinking about lessons learned (post 24% vs. pre 7%, p < 0.0001), and sharing lessons learned during the conversation (post 21% vs. pre 4%, p < 0.001). A lower percentage of AI/AN youth reported being bullied in the last year (post 31% vs. pre 37%, p < 0.001). Family social support was moderated by dose, with subscale scores of 3.75 at post-with <27 sessions vs. 3.96 at post-with all 27 sessions (p = 0.02). The results demonstrate the effectiveness of Native STAND when delivered in a variety of settings. Efforts are now underway to update Native STAND for medical accuracy, improve alignment with typical class periods, and promote its use and an effective EBI for AI/AN youth.

"There Is a Lot of Practice in Not Thinking about That": Structural, Interpersonal, and Individual-Level Barriers to HIV/STI Prevention among Reservation Based American Indians

American Indians (AI) face significant disparities in HIV/STI morbidity and mortality, and historical, structural, interpersonal, and individual level barriers stymie prevention efforts. The objective of this paper is to examine barriers to HIV/STI prevention among reservation-based AI. We conducted face-to-face qualitative interviews with 17 reservation-based AI community leaders and community members in Southern California on HIV/STI knowledge and attitudes and barriers to prevention. The disruption of traditional coping mechanisms and healing processes were compromised by historical trauma, and this allowed stigmas to exist where they did not exist before. This impacted access to healthcare services and trust in medicine, and is linked to individuals adopting negative coping behaviors that confer risk for HIV/STI transmission (e.g., substance use and sexual behaviors). Most of the participants reported that HIV/STIs were not discussed in their reservation-based communities, and many participants had a misperception of transmission risk. Stigma was also linked to a lack of knowledge and awareness of HIV/STI's. Limited available services, remoteness of communities, perceived lack of privacy, and low cultural competency among providers further hindered the access and use of HIV/STI prevention services. These findings highlight the need to address the historical, structural, and interpersonal factors impacting individual-level behaviors that can increase HIV/STI transmission among reservation-based AIs. Prevention work should build on community strengths to increase HIV/STI knowledge, reduce stigma, and increase access to preventative care while using culturally grounded methodologies.

Sexual and reproductive health self-care: a theory-based intervention

Purpose

This study, a theory-based interventional study, aims to promote self-care behaviors regarding sexual and reproductive health in adolescents (female) in Karaj, Iran.

Design/methodology/approach

This study was conducted on 90 female students of the Alborz University of Medical Sciences in Iran. For selecting subjects, the researchers went to two girls' dormitories on working days and tried to observe the proportion of students with different fields. Initially, 200 eligible female students were identified in the dormitories of Alborz University of Medical Sciences. Based on the sample size estimation, 100 research units were divided into two groups of receiving counseling (intervention group) and not receiving counseling (control group) by four-digit block randomization. Sexual and reproductive health self-care questionnaire was used as a tool for data collection before, after and one month after intervention. Data were analyzed by using X2 and ANOVA tests using SPSS (16).

Findings

Both groups were homogeneous in terms of demographic characteristics before the intervention. The results of the study indicated that after education, sexual and reproductive knowledge (p < 0.001), self-care of sexual health (p < 0.001), self-care of menstrual and genital health (p < 0.001) increased significantly. But, regarding parents' communications (p = 0.11), conversation barriers with parents (p = 0.83), interaction with (p = 0.79) and the perceptions of sexual risk behaviors relationships (p = 0.61) differences are not significant.

Research limitations/implications

Failure of parents to participate in this study and the implementation of this study only on the female sex were main limitations of the present study.

Practical implications

Theory-based education can improve sexual and reproductive health in adolescents' girls.

Originality/value

All Authors declare the manuscript entitled “Sexual and reproductive health self-care: a theory-based intervention” is original work of the author. All data, tables, figures, etc. used in the manuscript are prepared originally by authors; otherwise, the sources are cited and reprint permission is attached.

Predictors of Responsiveness Among American Indian Adolescents to a Community-Based HIV-Risk Reduction Intervention Over 12 Months

This analysis explored predictors of responsiveness to the Respecting the Circle of Life (RCL) intervention, a sexual and reproductive health program for American Indian (AI) youth. Data were collected over 12-month follow-up with 267 AI youth aged 13-19. We used mixed effects regression models to examine: (1) whether trajectory patterns of HIV/AIDS knowledge, condom beliefs, condom use self-efficacy, condom use intention and partner negotiation skills differed by baseline levels categorized into low, medium, and high scorers, and (2) the characteristics of youth who made no improvement over the post-intervention period. Results indicate the RCL intervention had greater longitudinal impact among subgroups with low and medium initial scores. High initial scores in knowledge, beliefs, efficacy, intention and skills predicted unresponsiveness to the RCL intervention. Youth differences in age, gender and school truancy (skipping/suspension) did not predict responsiveness to RCL. Results have important prevention science implications: (1) AI youth at greater risk (i.e., those with low initial levels of knowledge, beliefs, self-efficacy, intention and skills) are likely to respond to RCL and should be the target of replication and dissemination efforts. (2) Responsiveness analyses can guide adaptation of RCL and other sexual and reproductive health programs for AI youth to improve efficacy among unresponsive subgroups (i.e., high initial scorers). (3) RCL is equally likely to impact AI youth across different ages, genders and school status, thus validating population-wide implementation strategies.

Culture, Health, Function, and Participation Among American Indian and Alaska Native Children and Youth With Disabilities: An Exploratory Qualitative Analysis

OBJECTIVE

To investigate the influence of traditional culture on health, disability, and health care services among American Indian and Alaska Native (AI/AN) children and youth with disabilities.

DESIGN

Exploratory descriptive qualitative analysis.

SETTING

Tertiary children's hospital.

PARTICIPANTS

A purposively sampled group (N=17) of AI/AN youth (n=4) with disability lasting at least 6 months age 8-24 years old and parents (n=13) of AI/AN children with disability lasting at least 6 months age 6 months to 17 years old.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participant responses to semistructured interview questions regarding health beliefs, daily activities, participation in cultural activities, and experiences receiving or having their child receive health care and rehabilitation services.

RESULTS

Three themes were identified: (1) participation in cultural activities is important for health as an AI/AN person; (2) experiences participating in cultural activities with functional differences; and (3) lack of recognition of the culturally related functional needs of AI/AN children with disabilities by rehabilitation providers. Children participated in cultural activities primarily through attendance at community-wide events. Barriers to participation in cultural activities included environmental barriers and adaptive mobility devices ill-suited to rough terrain. Participants perceived addressing functional needs related to culture, and cultural activities was not an expected part of rehabilitation services.

CONCLUSIONS

AI/AN children with disabilities experience barriers to participation in cultural activities, making it hard for them to achieve their definition of ideal health. Rehabilitation services have not identified or addressed these unmet culturally related functional needs.

Health-Related Participatory Research in American Indian and Alaska Native Communities: A Scoping Review

A scoping review was conducted to assess the state of the literature on health-related participatory research involving American Indian and Alaska Native communities. Online databases were searched for relevant articles published between 1/1/2000 and 5/31/2017. 10,000+ data points relevant to community-level engagement in and regulation of research, community research capacity and cultural adaptation were extracted from 178 articles. Community engagement varied across study components: 136 (76%) articles reported community participation in research-related meetings and other events and 49 (27%) articles reported community involvement in initiation of research. 156 (88%) articles reported use of community-level tools to guide or regulate research. 93 (52%) articles reported that community members received research-related training. 147 (82%) articles described some type of cultural adaptation. Across all articles, data points on community engagement were not reported in 3061 (40%) out of 7740 cases. Findings suggest a need for increased community engagement in early stages of the research process and for reporting guidelines for participatory research involving American Indian and Alaska Native communities. There is also need to further existing research on the impact of different components of participatory research on process and outcome measures and to develop funding mechanisms that account for the time and resource intensive nature of participatory research.

Frequent residential mobility among American Indians and early indications of sexual risk among young adolescents

American Indian and Alaska Native (AI/AN) youth are more likely to ever have had sex, and to have engaged in sexual activity prior to age 13 compared to all other race groups. It is essential to understand the development of skills to refuse sexual experience in early adolescence in order to reduce disparities associated with early sexual debut among AI/AN youth. Familial, social, and individual factors can act as protective influences on adolescent sexual experience; however, in other settings, research has shown that frequent residential mobility disrupts these protective influences and may increase the likelihood of adolescent sexual activity. AI/AN youth are highly mobile, and, as a result, may be especially vulnerable to increased sexual risk. To date, no prior study has considered the impact of residential mobility on AI/AN youth sexual experience, nor the influence on precursors that reduce initiation of sex. We used data from a longitudinal study of AI/AN youth attending all middle schools from a Northern Plains reservation from 2006-2009 to estimate a structural equation model based on a cultural and age adapted theoretical framework. The tested model included frequent residential mobility as the independent variable and sex refusal self-efficacy as the dependent variable. Mediating variables included factors related to individual risks, psychological well-being, and social supports. Results indicate a direct association between residential mobility and sex refusal self-efficacy (-.29, p = 0.05) and an indirect association mediated by deviant peers (-.08, p = .05). Other mediating variables did not provide insight on the mechanism by which residential mobility influences skills to refuse sexual intercourse among AI/AN youth in early adolescence. Findings provide evidence for an association between residential mobility and precursors to sexual experience suggesting augmenting sexual health interventions for highly mobile youth.

Exploring the Role of Sex and Sexual Experience in Predicting American Indian Adolescent Condom Use Intention Using Protection Motivation Theory

Introduction: American Indian (AI) youth experience poor sexual health outcomes. Research indicates the Protection Motivation Theory (PMT) is a robust model for understanding how sexual risk and protective behaviors are associated with condom use intention (CUI). Studies indicate the constructs of the PMT which influence CUI vary by sex and sexual experience. This analysis explores associations between PMT constructs and CUI by sex and sexual experience among AI youth who participated in the Respecting the Circle of Life (RCL) trial, a sexual and reproductive health intervention. Methods: We analyzed baseline data from the sample of 267 AIs, ages 13-19, who participated in the evaluation. We examined CUI and PMT construct scores by sex and sexual experience utilizing generalized estimated equations and multiple regression models to test which PMT constructs were associated with CUI across sex and sexual experience. Results: Twenty-two percentage of participants were sexually experienced; 56.8% reported CUI at baseline. We found several differences in scores in PMT constructs by sex and sexual experience including self-efficacy, response efficacy, vulnerability, severity, and extrinsic rewards. We also found constructs varied that were associated with CUI varied across sex and sexual experience. No PMT constructs were associated with CUI among sexually experienced youth. Conclusion: Results provide support for developing, selecting and delivering sexual health programs by sex and sexual experience in American Indian communities. Girls programs should focus on internal satisfaction and self-worth while boys should focus on negative impacts of not using condoms. Programs for youth who are not sexually active should focus on negative impacts of not using condoms. Programs for sexually inactive youth should work to change peer norms around condom use and improve knowledge about the efficacy of condom use.

Healthy Native Youth: Improving Access to Effective, Culturally-Relevant Sexual Health Curricula

Tribal health educators across the United States have found it challenging to locate engaging, culturally-relevant sexual health curricula for American Indian and Alaska Native (AI/AN) youth. Healthy Native Youth is a new online resource that provides a "one-stop-shop" for tribal health advocates to access age-appropriate curricula. The site was designed by a team of advisers representing a diverse group of tribal communities, using a collaborative planning process. The website content and navigation was then refined through usability testing with the target audience. The portal allows users to filter and compare curricula on multiple dimensions, including: age, delivery setting, duration, cost, and evidence of effectiveness, to determine best-fit. It includes all materials needed for implementation free-of-charge, including: facilitator training tools, lesson plans, materials to support participant marketing and recruitment, information about each program's cultural relevance, evaluation methods and findings, and references to publications and reports. The website currently includes mCircle of Life, Native It's Your Game, Native STAND, Native VOICES, and Safe in the Village, among others. Since its launch in August 2016, the site has had over 31,000 page views in all 50 States. The Healthy Native Youth portal provides educators in rural communities a promising new tool to support the dissemination and implementation of evidence-based health curricula in geographically-disbursed AI/AN communities. Lessons learned during the design and dissemination of the Healthy Native Youth website may be of value to other Indigenous populations interested in our approach and our findings.

Studies evaluating of health interventions at schools: an integrative literature review

OBJECTIVE

to identify and analyze the available evidence on the strategies used in the studies evaluating health interventions at school.

METHOD

this is an integrative review searching in LILACS, CINAHL, CUIDEN, ScienceDirect, and PubMed. From the pre-defined inclusion and exclusion criteria, there were 121 articles chosen to compose the sample.

RESULTS

english studies (97.5%), with a quantitative approach (80.2%), related to the interventions carried out in the Region of the Americas (54.6%) and the European Region (23.1%) predominated. For the most part, they are interventions as programs (70.2%), interested in evaluating results (73.5%) from the value judgment (83.4%). Prevalence of interventions focused on efficacy, effects or impact, and activities carried out on interventions were focused on physical activity, healthy eating, sexual and reproductive health, mental health, and use of tobacco, alcohol, and other drugs. They are worked through activities of clinical monitoring, health promotion and disease prevention.

CONCLUSION

the evidence indicates that the evaluations of health interventions in the school focus the results produced in programs through the judgment of value. The topics most addressed were healthy eating, physical activity, prevention of alcohol and other drugs, among others.

Advancing Scientific Methods in Community and Cultural Context to Promote Health Equity: Lessons From Intervention Outcomes Research With American Indian and Alaska Native Communities

Evidence-based interventions hold promise for reducing gaps in health equity across diverse populations, but evidence about effectiveness within these populations lags behind the mainstream, often leaving opportunities to fulfill this promise unrealized. Mismatch between standard intervention outcomes research methods and the cultural and community contexts of populations at greatest risk presents additional challenges in designing and implementing rigorous studies; these challenges too often impede efforts to generate needed evidence. We draw on experiences with American Indian and Alaska Native (AIAN) communities to illustrate how consideration of culture and context can constructively shape intervention research and improve the quality of evidence produced. Case examples from a partnership with one AI community highlight opportunities for increasing alignment in intervention development, research design, and study implementation to maximize both validity and feasibility. We suggest that responsively tailoring intervention outcome research to cultural and community contexts is fundamental to supporting health equity.

Beyond Content: Cultural Perspectives on Using the Internet to Deliver a Sexual Health Intervention to American Indian Youth

American Indian and Alaska Native (AIAN) youth are characterized by high rates of pregnancy and risky sexual behavior. Reaching these youth with culturally appropriate interventions is difficult due to geographic dispersion and cultural isolation. Online interventions can provide opportunities for reaching and engaging AIAN youth. However, electronic interventions are also impersonal and this can be culturally incongruous for AIANs and other populations for whom traditional ceremonies, practices and patterns of interpersonal communication are central. This paper describes the application of community based participatory research methods to: (1) identify concerns about the exclusive use of an online sexual health program; (2) address community concerns by developing supplemental class lessons, and (3) evaluate the feasibility and acceptability of the new hybrid intervention. Data derives from qualitative and quantitative sources. During the formative phase of the project, qualitative data from partner interactions was analyzed with participatory inquiry to inform intervention development. To evaluate the intervention, qualitative data (e.g., interviews, surveys) were used to understand and explain quantitative measures such as implementation fidelity and attendance. Implementers were enthusiastic about the hybrid intervention. The lessons were easy to teach and provided opportunities for meaningful discussions, adaptations, and community involvement. The use of online videos was an effective method for providing training. Working with community partners, we resolved cultural concerns arising from the exclusive use of the Internet by creating a hybrid intervention. The additional burden for staff to deliver the class lessons was considered minimal in comparison to the educational and programmatic benefits of the hybrid intervention. ClinicalTrials.gov identifier NCT01698073.

Self-Efficacy About Sexual Risk/Protective Behaviors: Intervention Impact Trajectories Among American Indian Youth

For adolescents, normative development encompasses learning to negotiate challenges of sexual situations; of special importance are skills to prevent early pregnancy, HIV, and other sexually transmitted diseases. Disparities in sexual risk among American Indian youth point to the importance of intervening to attenuate this risk. This study explored the impact of Circle of Life (COL), an HIV prevention intervention based on social cognitive theory, on trajectories of self-efficacy (refusing sex, avoiding sexual situations) among 635 students from 13 middle schools on one American Indian reservation. COL countered a normative decline of refusal self-efficacy among girls receiving the intervention by age 13, while girls participating at age 14 or older, girls in the comparison group, and all boys showed continuing declines.

Effectiveness of a Brief Multi-Component Intervention to HIV Prevention Among Spanish Youth

The greater rate of HIV infection occurs before age 30 in Spain. Our aim was to evaluate the long-term impact of a brief HIV preventive intervention on key sexual risk behavior components in Spanish young population. Participants were 467 young people aged 18-25 years who participated in B-PAPY intervention. They were evaluated at four times: a week, a month, three months and one year after intervention. A self-administered instrument was used. It was found a significant increase from pre-test to follow-ups in HIV knowledge, HIV susceptibility perception, confidence in condom and use of condoms. There were decreases statistically significant in the perceived severity of AIDS. The HIV intervention showed effectiveness over time in the main risk variables for HIV infection. Brief multi-component HIV interventions would be a useful resource to generalize HIV prevention.

NATIVE-It's Your Game: Adapting a Technology-Based Sexual Health Curriculum for American Indian and Alaska Native youth

Sexually transmitted infection (STI) and birth rates among American Indian/Alaska Native (AI/AN) youth indicate a need for effective middle school HIV/STI and pregnancy prevention curricula to delay, or mitigate, the consequences of early sexual activity. While effective curricula exist, there is a dearth of curricula with content salient to AI/AN youth. Further, there is a lack of sexual health curricula that take advantage of the motivational appeal, reach, and fidelity of communication technology for this population, who are sophisticated technology users. We describe the adaptation process used to develop Native It's Your Game, a stand-alone 13-lesson Internet-based sexual health life-skills curriculum adapted from an existing promising sexual health curriculum, It's Your Game-Tech (IYG-Tech). The adaptation included three phases: (1) pre-adaptation needs assessment and IYG-Tech usability testing; (2) adaptation, including design document development, prototype programming, and alpha testing; and (3) post-adaption usability testing. Laboratory- and school-based tests with AI/AN middle school youth demonstrated high ratings on usability parameters. Youth rated the Native IYG lessons favorably in meeting the needs of AI/AN youth (54-86 % agreement across lessons) and in comparison to other learning channels (57-100 %) and rated the lessons as helpful in making better health choices (73-100 %). Tribal stakeholders rated Native IYG favorably, and suggested it was culturally appropriate for AI/AN youth and suitable for implementation in tribal settings. Further efficacy testing is indicated for Native IYG, as a potential strategy to deliver HIV/STI and pregnancy prevention to traditionally underserved AI/AN middle school youth.

The Impact of a Sexual and Reproductive Health Intervention for American Indian Adolescents on Predictors of Condom Use Intention

PURPOSE

American Indian (AI) adolescents experience inequalities in sexual health, in particular, early sexual initiation. Condom use intention is an established predictor of condom use and is an important construct for evaluating interventions among adolescents who are not yet sexually active. This analysis evaluated the impact of Respecting the Circle of Life (RCL), a sexual and reproductive health intervention for AI adolescents, on predictors of condom use intention.

METHODS

We utilized a cluster randomized controlled trial design to evaluate RCL among 267 AIs ages 13-19. We examined baseline psychosocial and theoretical variables associated with condom use intention. Generalized estimating equation regression models determined which baseline variables predictive of condom use intention were impacted.

RESULTS

Mean sample age was 15.1 years (standard deviation 1.7) and 56% were female; 22% had initiated sex. A larger proportion of RCL versus control participants had condom use intention post intervention (relative risk [RR] = 1.39, p = .008), especially younger (ages 13-15; RR = 1.42, p = .007) and sexually inexperienced adolescents (RR = 1.44, p = .01); these differences attenuated at additional follow-up. Baseline predictors of condom use intention included being sexually experienced, having condom use self-efficacy, as well as response efficacy and severity (both theoretical constructs). Of these, the RCL intervention significantly impacted condom use self-efficacy and response efficacy.

CONCLUSIONS

Results demonstrate RCL intervention efficacy impacting variables predictive of condom use intention at baseline, with greater differences among younger, sexually inexperienced adolescents. To sustain intervention impact, future RCL implementation should reinforce education and training in condom use self-efficacy and response efficacy and recruit younger, sexually inexperienced AI adolescents.

Effects of the "Circle of Life" HIV-prevention program on marijuana use among American Indian middle school youths: a group randomized trial in a Northern Plains tribe

BACKGROUND

Early substance use threatens many American Indian/Alaska Native (AI/AN) communities, as it is a risk factor for maladaptive use and adverse health outcomes. Marijuana is among the first substances used by AI/AN youth, and its use becomes widespread during adolescence. Interventions that delay or reduce marijuana use hold the promise of curbing substance disorders and other health risk disparities in AI/AN populations.

OBJECTIVES

We evaluated the effectiveness of the Circle of Life (COL) program in reducing marijuana use among young AI adolescents. COL is a culturally tailored, theory-based human immunodeficiency virus (HIV) and sexually transmitted disease (STD) intervention shown to delay sexual initiation among AI youths.

METHODS

We conducted secondary analyses of data from a school-based group randomized trial conducted between 2006 and 2007 in all 13 middle schools on a rural, Northern Plains reservation (N = 635, 47% female). We used discrete-time survival analysis (DTSA) to assess COL effectiveness on risk of marijuana initiation among AI youths and latent growth curve modeling (LGCM) to evaluate effects on frequency of marijuana use over time.

RESULTS

DTSA models showed that the overall risk of marijuana initiation was 17.3% lower in the COL group compared to the control group. No intervention effect on frequency of marijuana use emerged in LGCM analyses.

CONCLUSION

COL is a multifaceted, culturally tailored, skills-based program effective in preventing marijuana uptake among AI youth.

Factors Associated With Early Sexual Experience Among American Indian and Alaska Native Youth

PURPOSE

American Indian and Alaska Native (AI/AN) youth experience disparities associated with sexual and reproductive health, including early age of sexual initiation. Identifying factors that are most proximally related to early sexual intercourse and that are modifiable through health promotion interventions may help to reduce these disparities. Using a multisystem approach, we assessed individual (biological, psychological, and behavioral), familial, and extrafamilial (peer behavioral) factors associated with lifetime sexual experience among AI/AN early adolescents living in three geographically dispersed U.S. regions.

METHODS

We analyzed cross-sectional data from 537 AI/AN youth aged 12-14 years, recruited from 27 study sites in Alaska, Arizona, and the Pacific Northwest. We used multilevel logistic regression models to estimate associations between independent variables and lifetime sexual intercourse (oral and/or vaginal sex) individually, within discrete systems, and across systems.

RESULTS

The analytical sample was 55.1% female, with a mean age of 13.2 years (standard deviation = 1.06 years); 6.5% were sexually experienced. In the final model, we found that lower next-year intentions to have oral or vaginal sex (psychological factors), avoidance of risky situations, and nonuse of alcohol (behavioral factors) were associated with lower odds of lifetime sexual intercourse (all p ≤ .01). No other variables were significantly associated with lifetime sexual intercourse.

CONCLUSIONS

Interventions that reduce sexual intentions, exposure to risky situations, and alcohol use may help to delay sexual initiation among AI/AN early adolescents.

Programs to improve adolescent sexual and reproductive health in the US: a review of the evidence

BACKGROUND

US adolescents have high rates of teen pregnancy, childbearing, and sexually transmitted infections (STIs), highlighting the need to identify and implement effective programs that will help improve teen sexual and reproductive health.

MATERIALS AND METHODS

This review identified 103 random-assignment evaluations of 85 programs that incorporated intent-to-treat analyses and assessed impacts on pregnancy, childbearing, STIs, and their key determinants - sexual activity, number of sexual partners, condom use, and other contraceptive use - among teens. This review describes the evidence base for five broad program approaches, including abstinence education, comprehensive sex education, clinic-based programs, youth development programs, and parent-youth relationship programs. We also describe programs with impacts on key outcomes, including pregnancy/childbearing, STIs, and those that found impacts on both sexual activity and contraceptive use.

RESULTS

Our review identified 52 effective programs: 38 with consistent impacts on reproductive health outcomes, and 14 with mixed findings (across subpopulations, follow-ups, or multiple measures of a single outcome). We found that a variety of program approaches produced impacts on sexual and reproductive health outcomes. Parent-youth relationship programs and clinic-based program evaluations more frequently showed impacts than other program approaches, although we also identified a number of abstinence-education, comprehensive sex education, and youth-development programs with impacts on sexual and reproductive health outcomes. Overall, we identified nine program evaluations with impacts on teen pregnancies or births, five with impacts on reducing STIs, and 15 with impacts on both delaying/reducing sexual activity and increasing contraceptive use (including condom use).

CONCLUSION

Future efforts should conduct replications of existing program evaluations, identify implementation components linked to impacts, rigorously evaluate programs that appear promising, and expand the evidence base on programs that impact hormonal and long-acting contraceptive method use.

The Respecting the Circle of Life trial for American Indian adolescents: rationale, design, methods, and baseline characteristics

This paper describes the rationale, design, methods, and baseline results of a randomized controlled trial to evaluate the impact of an adapted evidence-based intervention (EBI), "Respecting the Circle of Life" (RCL) to reduce behavioral risks for HIV/AIDS among American Indian (AI) adolescents. A participatory approach shaped intervention adaptation and study design. A total of 267 participants (aged 13-19) were randomized by peer groups of the same sex to receive the RCL intervention or a control condition. Self-report assessments were administered at four intervals. The sample was predominately female (57%), had low HIV knowledge prevention scores, early sexual initiation (mean 14.6 years), and 56% reported intention to use a condom at next sex. Baseline characteristics were evenly distributed between groups with the exception of age and extrinsic reward scores. This is the first rigorous evaluation of an adapted EBI for HIV/AIDS prevention among AI adolescents, an at-risk and understudied population.

Planning for a group-randomized trial with American Indian youth

PURPOSE

To describe lessons learned working with tribal communities in the Northern Plains to plan and implement a group randomized trial of multimedia Circle of Life (mCOL), a sexual risk reduction program designed for American Indian (AI) youth.

METHODS

Project records including emails, travel reports, and meeting minutes were reviewed and synthesized to describe participatory development of the project.

RESULTS

Several challenges were identified including: discussing sexual health interventions for preteens with communities; developing a culturally appropriate research design; managing costs of conducting research in remote and culturally distinct tribal communities; and building research infrastructure of partner organizations. Opportunities for strengthening research partnerships included transparency, openness to bi-directional learning, planning for change, flexibility, and strategic use of technology.

CONCLUSIONS

Findings suggest that meaningful AI community participation in research trials is achievable and a critical step towards generating evidence for interventions in settings where they are most needed. Substantial investments in time, resources, and relationship-building are necessary.