NATIVE It's Your Game: Toward Tech-based Sexual Health Education for American Indian and Alaska Native Youth
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Native It's Your Game (N-IYG) is a 13-lesson web-accessible HIV, STI, teen pregnancy prevention curriculum for American Indian and Alaska Native middle school youth designed for access in middle school health or PE lessons, after school, or in summer programs. Lessons include interactive exercises, quizzes, animations, peer video, and fact sheets targeting determinants of sexual risk-taking. N-IYG adaptation to inform surface and deep cultural components involved collaboration between the Inter Tribal Council of Arizona, the Alaska Native Tribal Health Consortium, the Northwest Portland Area Indian Health Board, and the University of Texas. Core content comprises healthy friendships, protecting personal boundaries, puberty and reproduction, healthy dating relationships, consequences of sex (HIV, STI, and pregnancy), refusal skills training, and skills training in condom and contraceptive use. Lessons learned have direct relevance to those interested in cultural adaptation, study design, implementation strategies, and benefits and challenges associated with web-based health promotion programs.
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NATIVE It's Your Game: Toward Tech-based Sexual Health Education for American Indian and Alaska Native Youth
- 1. NATIVE It’s Your Game: Toward Tech- based Sexual Health Education for American Indian and Alaska Native Youth Amanda M Gaston Northwest Portland Area Indian Health Board Native It’s Your Game Project Manager agaston@npaihb.org 503-416-3288 April 26-28, 2015 San Francisco, CA #YTHLive Annual Conference on Youth + Tech + Health
- 4. US Census Bureau. American Indian and Alaska Native Heritage Month, Nov 2012. www.census.gov/newsroom/releases/archives/facts_for_features_special_editions/cb12-ff22.html
- 5. Study Goal To adapt and evaluate the effectiveness of an Internet-based HIV/STI & pregnancy prevention program for middle school- aged youth (12-14 years old) in three geographically dispersed AI/AN communities in Alaska, Arizona & Pacific Northwest.
- 7. Distal Determinants • Problem-solving • Personal Control • Social support • Decision-making • Cultural beliefs • Native identity Proximal Determinants • Knowledge • Beliefs • Perceived Norms • Perceived Risk • Self-efficacy • Refusal • Condom use Proximal Determinants • Healthy Friendships • Healthy Dating Relationships • Sexual Intentions Sexual Behavior Outcomes • Delay sexual debut • Use condoms & contraception • Decrease # of sexual partners • Get tested for HIV/STI and pregnancy , if at risk
- 8. Social Environment • Peer Influence Parental Influence Media Influence • Dating Violence Access to Services Access to Resources • Access to Alcohol & Drugs Mental Health
- 9. Resnicow et al. (1999) Strategies proposed by Kreuter et al. (2003) Examples Surface culture Peripheral Clothing, music, colors, images, fonts, pictures of group members, places Evidential Epidemiological data Linguistic Language(s), terms, literacy level Deep culture Constituent- involving Indigenous staff, lay health workers, involving community in planning & decision-making Sociocultural Cultural values & beliefs; social, historical, environmental and psychological forces that influence target health behavior Resnicow et al. (1999). Cultural sensitivity in public health: Defined and demystified. Ethnicity & Disease, 9:10-21. Kreuter et al. (2003). Achieving cultural appropriateness in health promotion programs: Targeted and tailored approaches. Health Education & Behavior 30:133-146.
- 11. Intro Video
- 18. Adaptation: Youth agreement Usability Parameters Item Response Range (%) Pre-adapta Post-adaptb Likability ‘a lot’ or ‘a little’ 51-98 68-94 Credibility ‘information was correct’ 69-97 77-100 ‘information was trust-worthy’ 67-94 77-100 Motivational appeal ‘would recommend to classmate’ 49-82 37-100 AI/AN appropriate ‘would make changes’ 12-39 NA ‘meets needs of AI/AN youth’ NA 54-86 a Number of youth who rated each lesson ranged from 33 – 69; b Number of youth who rated each lesson ranged from 6 – 27; c Pace and understandability was impacted by unreliable access to internet-based program via internet in one testing location.
- 19. Adaptation: Adult stakeholder agreement IYG-Tech adapted activities % Introduction video featuring Native montage 100 Elder wisdom – advising on life decisions (Datu) 91 Elder voice video introductions (Rene and Kirby) 79 -100 Expert videos – HIV; condom and dental dam demo (Native health educator) 42 - 82 Private wall (Cyber Café journal activity) 83-100
- 20. Evaluation • RCT to test NATIVE-IYG efficacy. • Sites in AK, AZ, and Pacific Northwest (n=25) • American Indian/Alaska Native youth (12-14 y.o.) (n=529) • Follow-up immediately after NATIVE-IYG and at 12 months. • Results pending… Next Steps • Spread the Word - Letters to participants and parents - Community newsletters - Presentations - Publications
Editor's Notes
- If you wouldn’t mind humoring me…please close your eyes. Now imagine your favorite Native American TV character, movie hero, musician, sports figure ... Are you coming up blank? Now imagine what that does to a Native youth’s psyche - not having anybody in the popular media they can relate to - who looks like you, who shares your worldview or life story. Our team is working to change that.
- We are a group of tribal educators and sexual health experts who came together to design Native It’s Your Game; an online sexual health curriculum designed specifically for American Indian/ Alaska Native youth ages 12-14. Some of our team is out there in the audience. We actually meet here at “SexTech” back in 2010 where we first learned about each other’s work and have been meeting here since then.
- To provide context for folks who haven’t worked with Native youth, we experience numerous inequalities associated with sexual and reproductive health. This is evidenced in higher teen birth rates than the national average, along with the highest prevalence of repeat teen births, and the second highest rates of sexually transmitted infections (STIs) compared to non-Hispanic Whites. Before this study there were no interventions tailored to the needs of Native youth.
- Our goal has been to adapt and evaluate the effectiveness of this culturally appropriate intervention for its use in Indian Country. We adopted a community-based participatory research approach to equitably involve tribal communities and maximize their ownership in the development of this program. Through our research in the Pacific Northwest, we found that 76% of Native youth were experienced and comfortable searching online for health information, compared to 55% of 7th-12th graders.
- Phase I of our process involved testing the original curriculum with Native youth and adult stakeholders across Alaska, Arizona, and the Pacific Northwest. Each group ranked the program on a scale of usability measures to identify elements of the program that resonated with their tribal experience, as well as identify elements of the program that did not resonate with Native youth and adult community members.
- Those series of usability sessions gave us the information needed to revise the conceptual framework of the program to better align with the personal values, beliefs, skills, outcome expectations, perceived self-efficacy, environmental factors, and behavioral influences of Native youth. This along with adding cultural beliefs and Native identity altered the distal and proximal determinants of the program, which in turn affects the behavioral outcomes.
- We added activities and resources that reflected the social sexual context that impacts Native youth decision making. Both youth and parents brought up the need for better education on dating violence and healthy relationships. They also brought up topics like sex happening in places where drugs and alcohol were present. And, they also wanted to address mental health which is an ever growing concern, as we have high suicide rates in Indian Country.
- We used Resnicow’s research to prioritize surface and deep cultural adaptations. We also used Intervention Mapping, a stepped framework for developing evidence-based health promotion programs, which guided our adaptation development process. For example, surface cultural changes were made to things like clothing, location, music, and our logo. While deep cultural changes involved changes to cultural values, beliefs, environmental and psychological forces that influence sexual health behaviors.
- The Native It’s Your Game adaptation includes 13 internet-based lessons, each lasting between 30-35 minutes with a mix of videos, interactive activities, quizzes, animation, and journal activities. Lessons cover healthy relationships, puberty and reproduction, HIV/STIs, pregnancy, refusal skills-training, and contraception. Next let me show you a short mix of our intro video.
- In addition to changing the intro video and program name, the animated guide went from a dry, self-depreciating older character to a young, hip Native security guard. The animated youth guides were changed from being chiseled, slender, mid-drift baring animations to more conservative relatable characters. Other small changes were made to character names, images, slang, and locations. All of which are surface changes.
- Examples of deep cultural changes include the addition of videos featuring Native youth, elders, and a health education ‘sexpert’ who reflect tribal and youth perspectives. The elders introduce the curriculum and provide a holistic framework around sexual health that is familiar to tribal communities. They help to desensitize and provide a cultural context to sensitive topics like the anatomy and physiology lesson, which both youth and adults had a hard time with.
- Another important deep cultural value incorporated was a shift towards a more traditional holistic view of sexual health in reference to the Native Wellness Model, which is an integration of physical, social, emotional, mental, and spiritual dimensions of health and wellbeing. The idea is to create a balance of these dimensions to affect the overall health and wellbeing on an individual and its community.
- The original program included a fortune teller activity that framed teen pregnancy outcomes in a way that was not relevant to Native communities, as well as being topic of taboo. The replacement activity is told from the viewpoint of an Alaska Native elder who frames teen pregnancy as a life choice while exploring the pro’s and cons of waiting, and keeping in mind that some participants may be teen parents themselves.
- Wanting Native It’s Your Game to be a holistic curriculum, we needed to include members of the community. These activities include parent and teen newsletters, which give tips on how to talk to your parents or teens about sensitive topics. Homework activities were designed to facilitate dialogue between the parent and child around friendships, dating, and sexual behavior. We also provide fact sheets and resource key chains to all youth.
- After the adaptation phase, we re-tested the new program with youth and adult stakeholders. For the youth feedback portion, you can see here by looking at the columns of feedback from pre-adaptation to post-adaptation that youth reported improvements in likability, credibility, and motivational appeal. The youth ratings after adaption were higher than in the first usability test using the same protocols but with two distinct groups.
- Parents/ Guardians, teachers, health educators, and other community stake holders also reviewed the adaptation and rated its various features based on a satisfaction survey using a four-point Likert scale. Just to highlight as few, adult stakeholders particularly liked the introduction, inclusion of elder guides and the Datu comic book activity, which we saw a clip of earlier. They also liked the ‘sexpert’, and the journal activities.
- Once the two years of adaptation, usability, and pilot testing were complete, the evaluation phase took another two years to complete. This involved a Randomized Control Trial of 529 Native youth, among 25 tribal communities. We collected survey data from youth who completed the program at three different stages; baseline, immediate follow up, and again at 12 months. Currently, data cleaning and analysis is underway. And, our next steps are to spread the word.
- Most importantly, we hope that we have achieved our goal of creating a health resource that reflects and includes the experiences of Native youth and the communities they come from. Making Native It’s Your Game a curriculum that weaves the diverse faces, voices, experiences, and cultural values that can be shared with not only tribal communities, but with other multicultural communities across the US. We want Native youth to know that they belong and are part of the story too.