Tribal recommendations for designing culturally appropriate technology-based sexual health interventions targeting Native youth in the Pacific Northwest

Early childbearing, family support, and staying in school in a Northern Plains American Indian reservation

American Indian youth experience teen birth and school dropout at higher rates than other racial and ethnic groups in the United States. Early childbearing is associated with adverse health and socioeconomic outcomes, including attenuated education. However, kinship childrearing norms among Northern Plains tribes can support positive experiences of early childbearing. Using a community based participatory research framework, this mixed methods exploratory study engaged high school students from a Northern Plains reservation community to examine youth perceptions of family support and belief in ability to stay in school should they have a child. We elicited youth observations of facilitators and inhibitors to academic achievement for young parents. This research supports the need for strengths-based, gender specific, and family inclusive sexuality education to support young people in their reproductive choices in reservation settings. We highlight the utility of including youth as co-authors and co-researchers in future studies.

Recruiting and Engaging American Indian and Alaska Native Teens and Young Adults in a SMS Help-Seeking Intervention: Lessons Learned from the BRAVE Study

This paper shares lessons learned recruiting and engaging participants in the BRAVE study, a randomized controlled trial carried out by the Northwest Portland Area Indian Health Board and the mHealth Impact Lab. The team recruited 2330 American Indian/Alaska Native (AI/AN) teens and young adults nationwide (15-24 years old) via social media channels and text message and enrolled 1030 to participate in the 9 month study. Teens and young adults who enrolled in this study received either: 8 weeks of BRAVE text messages designed to improve mental health, help-seeking skills, and promote cultural pride and resilience; or 8 weeks of Science Technology Engineering and Math (STEM) text messages, designed to elevate and re-affirm Native voices in science, technology, engineering, math and medicine; and then received the other set of messages. Results indicate that social media channels like Facebook and Instagram can be used to recruit AI/AN teens and young adults. Retention in this study was high, with 87% of participants completing both the BRAVE and STEM intervention arms. Lessons learned from this process may help teen and young adult-serving organizations, prevention programs, policy makers, researchers, and educators as they support the next generation of AI/AN change makers.

Co-Developed Indigenous Educational Materials for Chronic Kidney Disease: A Scoping Review

BACKGROUND

Canadian Indigenous populations experience significantly more chronic kidney disease (CKD) than the general population. Indigenous people who live in rural and remote areas may also have difficulty accessing both information and care for their CKD. Informed decision making about treatment options for advancing kidney disease may be delayed, which can result in poor health outcomes and decreased quality of life. Moreover, Indigenous people may experience marginalization within Western health care systems.

OBJECTIVE

The objective of this scoping review is to identify culturally appropriate and co-developed Indigenous educational tools that will ultimately support CKD learning and end-stage kidney treatment decision making.

DESIGN

Scoping Review.

SETTING

Databases included Embase, CINAHL, Medline (OVID), ERIC, and the Canadian Agency for Drugs and Technology Gray Matters.

STUDY PARTICIPANTS

Community-based Indigenous patients, families, health care workers, and community members.

METHODS

We systematically reviewed the literature to explore the availability of co-developed Indigenous educational tools and material for CKD treatment options. Titles, abstracts, and full texts were reviewed independently by 2 reviewers with disagreements resolved through a third. All aspects of this project, including searching the databases were done in consultation with an Indigenous Elder.

RESULTS

Only one retrieved article identified a comprehensive CKD tool co-developed by researchers, health care providers, and an Indigenous community. Three themes emerged from the scoping review that may inform characteristics of co-developed tools: cultural appropriateness; appraisal of utility and effectiveness and; content informed by co-development of traditional and Western chronic disease knowledge.

LIMITATIONS

Consistent with scoping review methodology, the methodological quality of included studies was not assessed. In addition, it was difficult to synthesize the findings from the research and gray literature.

CONCLUSION

Little is known about the co-development of Indigenous educational tools for CKD. Further in-depth understanding is required about how to best engage with Indigenous communities, specifically to co-develop contextualized CKD tools that are acceptable to Indigenous people.Trial registration: Not applicable as this review described secondary data.

Self-reported Exposure to Sexual and Reproductive Health Information among American Indian Youth: Implications for Technology Based Intervention

While technology-based interventions show promise in certain populations of American youth, the technology may intrinsically widen intergenerational communication chasms associated with youth's increased access to Smartphone technologies. The authors examined self-reported exposure to sexual and reproductive health information and evaluated its relationship with sexual risk behaviors with American Indian youth. Approximately 296 students, ages of 15-18 years old, were surveyed to examine self-reported exposure and attitudes to information received about sexual intercourse, reproduction, and social media use in relation to sexual risk behaviors. Results indicate that information received regarding sexual intercourse and birth control from intra-familial network members was associated with more engagement in sex, and that increased social media use to talk or learn about sex was associated with not using a condom at the last sexual encounter. We advise that researchers and programmers considering technology-based interventions with AI communities carefully consider the gravity of investing preventive resources into technology-based interventions that may further deepen communication gaps that youth experience within their community networks.

Obesity Education among American Indians: Evaluating a Culturally Appropriate Approach to Health Awareness

This research focused on a key health issue that significantly affects American Indian community - obesity. We sought to understand how American Indians perceive culturally appropriate an ethnic identity education about obesity as compared with the generic education that is not sensitive to the ethnic identity of American Indians. The project utilizes a survey based observational design where a sample of American Indians is measured for their preference of educational flyers showing American Indian imagery versus generic/Caucasian imagery. The perceived obesity among American Indians was compared with actual bodyweight levels. The American Indian community strongly prefers education that is supported by culturally appropriate imagery. This result provides support to the hypothesis that cultural identity plays a vital role in health education among American Indians and can be an effective strategy in future efforts.

Use of sexual health services among American Indian and Alaska Native Women

Because use of sexual health services among American Indian/Alaska Native women is understudied we: (1) examined disparities in use of sexual health services between American Indian/Alaska Native and non-Hispanic white women and (2) identified factors associated with service use among American Indian/Alaska Native women. We used data from the National Survey of Family Growth regarding the use of sexual health services collected between 2006 and 2010 from women aged 15-44 years who self-identified as American Indian/Alaska Native (n = 819) and white (n = 6,196). Weighted logistic regression models estimated the likelihood of reporting the use of sexual health services by race and factors associated with use in the American Indian/Alaska Native sample. Compared to whites, American Indian/Alaska Native women were less likely to use birth control services and more likely to use services for sexually transmitted diseases and HIV. Among American Indian/Alaska Natives, younger women were more likely to use birth control services, and women who had a higher number of sexual partners were more likely to use services for sexually transmitted diseases and HIV. Our results provide a national baseline against which to assess disparities and changes in the use of sexual health services among American Indian/Alaska Native women over time.

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.

Texting 4 Sexual Health: Improving Attitudes, Intention, and Behavior Among American Indian and Alaska Native Youth

PURPOSE

To design and test the effectiveness of a text messaging intervention to promote condom use and STI/HIV testing among American Indian and Alaska Native youth.

METHOD

A total of 408 study participants, 15 to 24 years old, were recruited, consented, surveyed, were sent intervention messages, and were incentivized via text message over a 9-month period. Complete pre- and postsurvey data were collected from 192 participants using SMS short codes. A mixed-effects logistic regression model was used to analyze before-after change in responses assessing sexual health knowledge, attitude, self-efficacy, intention, and behavior.

RESULTS

Participants' condom use attitude, condom use behavior, and STI/HIV testing intention improved after the intervention ( p < .05). Frequent condom use increased from 30% to 42% and was retained by participants at least 3 months postintervention, and the intervention improved participants' intention to get tested for STI/HIV after changing sexual partners, increasing from 46% to 58% postintervention.

CONCLUSIONS

Given the widespread use of cell phones by youth, text-based interventions may offer a feasible and effective tool to promote condom use and STI/HIV testing.

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.

Applying the Theory of Reasoned Action to Understanding Teen Pregnancy with American Indian Communities

Objectives American Indian girls have higher teen pregnancy rates than the national rate. Intervention studies that utilize the Theory of Reasoned Action have found that changing attitudes and subjective norms often leads to subsequent change in a variety of health behaviors in young adults. The current study goal is to better understand sexual decision-making among American Indian youth using the Theory of Reasoned Action model and to introduce ways to utilize attitudes and subjective norms to modify risky behaviors. Methods The project collected qualitative data at a reservation site and an urban site through 16 focus groups with American Indian young people aged 16-24. Results Attitudes towards, perceived impact of, and perception of how others felt about teen pregnancy vary between American Indian parents and non-parents. Particularly, young American Indian parents felt more negatively about teen pregnancy. Participants also perceived a larger impact on female than male teen parents. Conclusions There are differences between American Indian parents and non-parents regarding attitudes towards, the perceived impact of, and how they perceived others felt about teen pregnancy. Teen pregnancy prevention programs for American Indian youth should include youth parents in curriculum creation and curriculum that addresses normative beliefs about teen pregnancy and provides education on the ramifications of teen pregnancy to change attitudes.

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.

Linking online sexual activities to health outcomes among teens

New digital technologies are highly responsive to many of the developmental needs of adolescents, including their need for intimate connection and social identity. This chapter explores adolescents' use of web-based sexual information, texting and "sexting," online dating sites, role-playing games, and sexually explicit media, and presents new data comparing the interpersonal and intrapersonal health outcomes among youth who engage in online sexual activities to those who do not. Despite the media-stoked concerns surrounding adolescents' participation in online sexual activities, the ubiquity of online activities and close overlap between online and offline activities indicate that this type of behavior should not be pathologized or used as a metric of problem behavior. The chapter concludes with implications for parents, educators, researchers, counselors, and health care providers, a call to challenge our deep discomfort around adolescent sexuality and to harness these technologies in ways that help promote growth and positive development.

Teen Pregnancy Prevention Program Recommendations from Urban and Reservation Northern Plains American Indian Community Members

Despite declines over the past few decades, the United States has one of the highest rates of teen pregnancy compared to other industrialized nations. American Indian youth have experienced higher rates of teen pregnancy compared to the overall population for decades. Although it's known that community and cultural adaptation enhance program effectiveness, few teen pregnancy prevention programs have published on recommendations for adapting these programs to address the specific needs of Northern Plains American Indian youth. We employed a mixed-methods analysis of 24 focus groups and 20 interviews with a combined total of 185 urban and reservation-based American Indian youth and elders, local health care providers, and local school personnel to detail recommendations for the cultural adaptation, content, and implementation of a teen pregnancy prevention program specific to this population. Gender differences and urban /reservation site differences in the types of recommendations offered and the potential reasons for these differences are discussed.