Substance use and sexual risk behaviors among american Indian and alaska native high school students

'Trauma sits in your body and makes you shut down:' sexual and reproductive health professionals' views of the impact of trauma on the sexual health of Native American older adolescent and young adult women

A history of colonisation and corresponding traumas has resulted in disparate rates of violence and sexual health inequities among many Native American populations. As a result, Native American adolescents and young adults specifically, experience higher rates of STIs, HIV and unintended pregnancy relative to their non-Hispanic White counterparts. To address these inequities, sexual health education programmes should reflect Native American cultural values and traditional teachings to align with community assets and protective factors. The objective of this study was to describe sexual and reproductive health professionals' perspectives on how trauma collectively affects the sexual health of older adolescents and young adult Native American women between the ages of 15-25 years. We purposively sampled sexual and reproductive health professionals who worked with members of this priority population. Individual in-depth interviews were conducted, recorded, and transcribed. Transcripts were analysed using thematic analysis. The themes identified in the interviews include the impact of trauma and colonisation on sexual health, strategies for combatting trauma, promoting sexual health, and supporting the development of culturally congruent sexual health education curricula. Findings point to the need for culturally relevant, trauma-informed sexual health education interventions to help promote sexual and reproductive health equity for Native American adolescent and young adult women.

"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.

Parenting in 2 Worlds: Testing improved parent-adolescent communication about sexuality in Urban American Indian families

Urban American Indian (AI) adolescents are more likely than non-Natives to have early sexual debut, teen pregnancies, sexually transmitted infections, and inadequate sexual health information. A RCT in three Arizona cities, with 585 parents of urban AI adolescents, tested whether a culturally tailored parenting intervention for urban AI families, Parenting in 2 Worlds (P2W), increased parent-adolescent communication about sexuality, compared to an informational family health intervention that was not culturally tailored. P2W produced significantly larger increases on two measures: communication about general sexual health and about sexual decision-making. The desired effects of P2W on the first measure were stronger short-term for cross-gender dyads, while for the second measure, they were stronger long-term for both mothers and fathers of adolescent sons.

Cervical Cancer: Preventable Deaths Among American Indian/Alaska Native Communities

American Indian/Alaska Native (AI/AN) individuals have twice the mortality rate of cervical cancer than the general US population. Participation in prevention programs such as cervical cancer screening and human papillomavirus (HPV) vaccination are under-utilized in this population. There are high rates of established cervical cancer risk factors among this community, with AI/AN people having a higher likelihood of infection with high-risk HPV strains not included in the 9-valent vaccine. There is a need for more robust and urgent prevention and treatment efforts in regard to cervical cancer in the AI/AN community.

Respecting tribal voices in the development of a gestational diabetes risk reduction preconception counseling program for American Indian/Alaska Native adolescent females: a qualitative study

BACKGROUND

American Indians and Alaska Natives (AI/AN) are disproportionately affected by adolescent obesity, adolescent pregnancy and gestational diabetes mellitus (GDM). GDM is associated with increased risk for perinatal death, obesity, and subsequent type 2 diabetes (T2D) for the offspring. Moreover, mothers with GDM are also at increased risk for T2D post-partum. Yet few lifestyle interventions exist to reduce GDM risk prior to pregnancy. We describe the process of adapting an existing validated preconception counseling intervention for AI/AN adolescent girls at-risk for GDM and their mothers. Perspectives and recommendations were gathered from a diverse array of stakeholders to assure the new program called Stopping GDM was culturally responsive and developed with tribal voices and perspectives represented.

METHODS

We conducted focus groups and individual interviews with multiple AI/AN stakeholders (n = 55). Focus groups and interviews were digitally recorded, transcribed verbatim, and analyzed using a thematic content approach to construct cross-cutting themes across the focus groups and interviews.

RESULTS

Four key themes emerged reflecting issues important to planning a reproductive health intervention: 1) Limited awareness, knowledge, and health education resources about GDM; 2) The importance of acknowledging traditional AI/AN values and the diversity of traditions and culture among AI/AN tribes; 3) The need to cultivate healthy decision-making skills and empower girls to make safe and healthy choices; and 4) Lack of communication about reproductive health between AI/AN mothers and daughters and between AI/AN women and health care professionals.

CONCLUSION

Findings have been used to inform the cultural tailoring and adaptation of an existing preconception counseling program, originally designed for non-AI/AN adolescent girls with diabetes, for AI/AN adolescents at-risk for GDM in future pregnancies.

Measurement Invariance and Application of an Alcohol-Related Consequence Scale for American Indian Adolescents

American Indian (AI) adolescents experience disproportionate alcohol-related consequences. The present study evaluated the psychometric properties and application of the American Drug and Alcohol Survey (ADAS™) alcohol-related consequence scale for AI adolescents through a secondary analysis of a large population-based sample of adolescents living on or near AI reservations. We found support for the ADAS alcohol-related consequence scale as a one-factor model, invariant discretely across race, sex assigned at birth, and age, and with good internal consistency. Evidence for construct validity was found through significant positive correlations between frequency of past 12 months of drinking, frequency of past 12 months of intoxication, and lifetime alcohol-related consequences. AI adolescents were significantly more likely to report more alcohol-related consequences than their non-Hispanic White peers. Race significantly interacted with frequency of drinking in predicting alcohol-related consequences such that these associations were stronger for AI adolescents. However, race did not significantly interact with frequency of intoxication in predicting alcohol-related consequences. Results from this study demonstrate the utility of the ADAS alcohol-related consequence scale for use across demographic groups with little risk of measurement bias.

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.

Grounding evidence-based prevention within cultural context: promising effects of substance use prevention adapted for American Indian families

Background: Effective substance use prevention strategies are needed for American Indian (AI) youth, who face disproportionate risk for early substance use and consequently bear a disproportionate burden of health and developmental disparities related to early use. With few exceptions, significant advances in prevention science have largely excluded this population, leaving gaps in the evidence of effective practice. This paper builds on emerging efforts to address this gap, reporting first outcome findings from an evidence-based early substance use prevention program culturally adapted for young adolescents on a Northern Plains reservation. Methods: Using a community-based participatory approach, the Thiwáhe Gluwáš'akapi Program (TG, sacred home in which family is made strong) was developed by embedding cultural kinship teachings within the Strengthening Families Program for Parents and Youth 10-14 and aligning other elements of program content with local culture and context. Results: Results of pre and post comparisons of proximal program outcomes showed that youth reported significant improvements in parental communication about substance use, substance use resistance skills, stress management, family cohesion, and overall well-being. Adults reported improvements in a wide array of parenting behaviors and indicators of family dynamics. Conclusions: These findings provide an initial glimpse into the potential effects of the TG program and suggest that it holds promise for helping AI families address risks for youth substance use through positive impacts on modifiable risk and protective factors documented to influence early substance use.

Prevalence and risk factors associated with psychostimulant use among Black individuals: A meta-analysis and systematic review

BACKGROUND

Psychostimulants (e.g., cocaine, amphetamine) are among the most widely used drugs globally with detrimental short and long-term physical, psychological and social consequences. There is limited data on psychostimulant use for various racial and ethnic groups, including Black people, and the challenges they face living as minorities overcoming historical challenges including increased incarceration associated with drug possession.

METHODS

Peer-reviewed articles were identified in five databases (APA PsycInfo, CINAHL, Cochrane CENTRAL, Embase, MEDLINE). Eligible studies were published in French or English, provided empiral data on psychostimulant use in Black individuals living in a minority context. The PRISMA guideline was used for structuring the review. Random-effects meta-analyses were generated to estimate the pooled prevalence of lifetime and periodic psychostimulant use among Black individuals using STATA 16.

RESULTS

Sixty-three studies published from 1991 to 2022 with a sample size of 139,683 Black individuals were included in the current meta-analysis. Results indicate a pooled prevalence estimate of 11.4% for any form of psychostimulant use among Black individuals. The pooled prevalence estimates were 12.4% (95% CI, 8.4% - 16.4%) for cocaine, 8.3% (95% CI, 0% - 19.1%) for amphetamines, and 11.4% (95% CI, 4.6% - 18.1%) for other stimulants. Prediction intervals for all psychostimulant types were highly heterogenous ranging from 0% to as high as 51.2% for amphetamine suggesting prevalence of use in some studies of Black people could be found to be as low as zero. Subgroup analyses were conducted to examine differences between age groups, gender, reference period, and type of assessment.

CONCLUSIONS

High prevalence rates of psychostimulant use among Black people argues for greater access to evidence-based treatments. However, current psychosocial interventions are suboptimal, warranting further study. Consideration needs to be given to the challenges of the large range of prediction intervals, living in urban areas, racial discrimination experiences, race-based stress, and sociodemographic characteristics, including poverty, education level, age, gender.

Rates of Forced Sexual Experiences Among High School Students From 2001 to 2019

Public awareness of sexual assault and initiatives aimed at preventing sexual assault continue to increase over the years. However, whether rates of sexual assault have diminished because of such cultural shifts remains unclear. The purpose of this study was to assess if rates of sexual assault (i.e., forced sex) have changed over the past 18 years for adolescent girls and boys as well as potential differences across racial/ethnic identities. Using nationally representative data from the Youth Risk Behavioral Surveillance Survey from 2001 to 2019, we conducted logistic regressions to assess rates of experiences of forced sex by sex and by sex and racial/ethnic identity, while accounting for grade level. Participants included 135,837 high school students. From 2001 to 2019, rates of forced sex maintained for girls; however, there was a decrease over time for boys. For girls, there were inconsistent differences in rates of forced sex by racial/ethnic identities. However, boys who identified as Black, Hispanic, Multi-Racial, and Other Race/Ethnicity were at higher risk to report forced sex than their White peers, until 2015; only Other Race/Ethnicity was at higher risk in 2019. As girls and boys aged, the risk of forced sex increased. Despite prevention efforts, rates of forced sex did not decrease from 2001 to 2019 for adolescent girls disregarding race/ethnicity, and for racial/ethnic minority boys. That rates of forced sex continue to be high is problematic as experiencing sexual assault at an earlier age is associated with myriad consequences. Further, results suggest current prevention initiatives may be inadequate at addressing risk factors for forced sex, and more broadly, sexual assault. Moving forward, researchers and educators may want to re-evaluate the strategies used to address and measure sexual assault experiences.

The commercial determinants of Indigenous health and well-being: a systematic scoping review

INTRODUCTION

Health inequity within Indigenous populations is widespread and underpinned by colonialism, dispossession and oppression. Social and cultural determinants of Indigenous health and well-being are well described. Despite emerging literature on the commercial determinants of health, the health and well-being impacts of commercial activities for Indigenous populations is not well understood. We aimed to identify, map and synthesise the available evidence on the commercial determinants of Indigenous health and well-being.

METHODS

Five academic databases (MEDLINE Complete, Global Health APAPsycInfo, Environment Complete and Business Source Complete) and grey literature (Australian Indigenous HealthInfoNet, Google Scholar, Google) were systematically searched for articles describing commercial industry activities that may influence health and well-being for Indigenous peoples in high-income countries. Data were extracted by Indigenous and non-Indigenous researchers and narratively synthesised.

RESULTS

56 articles from the USA, Canada, Australia, New Zealand, Norway and Sweden were included, 11 of which were editorials/commentaries. The activities of the extractive (mining), tobacco, food and beverage, pharmaceutical, alcohol and gambling industries were reported to impact Indigenous populations. Forty-six articles reported health-harming commercial practices, including exploitation of Indigenous land, marketing, lobbying and corporate social responsibility activities. Eight articles reported positive commercial industry activities that may reinforce cultural expression, cultural continuity and Indigenous self-determination. Few articles reported Indigenous involvement across the study design and implementation.

CONCLUSION

Commercial industry activities contribute to health and well-being outcomes of Indigenous populations. Actions to reduce the harmful impacts of commercial activities on Indigenous health and well-being and future empirical research on the commercial determinants of Indigenous health, should be Indigenous led or designed in collaboration with Indigenous peoples.

Creating a path forward: understanding the context of sexual health and sexually transmitted infections in American Indian/Alaska Native populations – 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.

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.

Predictors of Sexual and Reproductive Health Among Girls Involved in the Juvenile Legal System: the Influence of Resources, Race, and Ethnicity

Girls involved in the juvenile legal system are at among the highest risk for sexual and reproductive health (SRH) challenges. Yet, few studies focus on girls or examine multiple predictors of their SRH in tandem. In addition to individual and familial-level risk factors (e.g., trauma, substance use, parental monitoring), this study also examines the influence of structural disadvantage on girls' SRH by assessing the degree to which girls' self-identified resource needs and access challenges across multiple areas (e.g., housing, employment, healthcare) predict SRH risk. Cross-sectional data collected from 269 girls involved in the legal system and their caregivers were analyzed using hierarchical regression analyses. Findings suggest that, over and above individual and familial level predictors, resource access challenges significantly predict girls' SRH, while high resource needs and access challenges predict Black girls' SRH specifically. Implications for programming, policy, and research are delineated.

Barriers, frameworks, and mitigating strategies influencing the dissemination and implementation of health promotion interventions in indigenous communities: a scoping review

BACKGROUND

Many Indigenous communities across the USA and Canada experience a disproportionate burden of health disparities. Effective programs and interventions are essential to build protective skills for different age groups to improve health outcomes. Understanding the relevant barriers and facilitators to the successful dissemination, implementation, and retention of evidence-based interventions and/or evidence-informed programs in Indigenous communities can help guide their dissemination.

PURPOSE

To identify common barriers to dissemination and implementation (D&I) and effective mitigating frameworks and strategies used to successfully disseminate and implement evidence-based interventions and/or evidence-informed programs in American Indian/Alaska Native (AI/AN), Native Hawaiian/Pacific Islander (NH/PI), and Canadian Indigenous communities.

METHODS

A scoping review, informed by the York methodology, comprised five steps: (1) identification of the research questions; (2) searching for relevant studies; (3) selection of studies relevant to the research questions; (4) data charting; and (5) collation, summarization, and reporting of results. The established D&I SISTER strategy taxonomy provided criteria for categorizing reported strategies.

RESULTS

Candidate studies that met inclusion/exclusion criteria were extracted from PubMed (n = 19), Embase (n = 18), and Scopus (n = 1). Seventeen studies were excluded following full review resulting in 21 included studies. The most frequently cited category of barriers was "Social Determinants of Health in Communities." Forty-three percent of barriers were categorized in this community/society-policy level of the SEM and most studies (n = 12, 57%) cited this category. Sixteen studies (76%) used a D&I framework or model (mainly CBPR) to disseminate and implement health promotion evidence-based programs in Indigenous communities. Most highly ranked strategies (80%) corresponded with those previously identified as "important" and "feasible" for D&I The most commonly reported SISTER strategy was "Build partnerships (i.e., coalitions) to support implementation" (86%).

CONCLUSION

D&I frameworks and strategies are increasingly cited as informing the adoption, implementation, and sustainability of evidence-based programs within Indigenous communities. This study contributes towards identifying barriers and effective D&I frameworks and strategies critical to improving reach and sustainability of evidence-based programs in Indigenous communities.

REGISTRATION NUMBER

N/A (scoping review).

Vaginal microbiota of American Indian women and associations with measures of psychosocial stress

Molecular-bacterial vaginosis (BV) is characterized by low levels of vaginal Lactobacillus species and is associated with higher risk of sexually transmitted infections (STI). Perceived psychosocial stress is associated with increased severity and persistence of infections, including STIs. American Indians have the highest rates of stress and high rates of STIs. The prevalence of molecular-BV among American Indian women is unknown. We sought to evaluate measures of psychosocial stress, such as historic loss (a multigenerational factor involving slavery, forced removal from one's land, legally ratified race-based segregation, and contemporary discrimination) and their association with the vaginal microbiota and specific metabolites associated with BV, in 70 Northwestern Plains American Indian women. Demographics, perceived psychosocial stressors, sexual practices, and known BV risk factors were assessed using a modified version of the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project survey. Self-collected mid-vaginal swabs were profiled for bacterial composition by 16S rRNA gene amplicon sequencing and metabolites quantified by targeted liquid-chromatography mass spectrometry. Sixty-six percent of the participants were classified as having molecular-BV, with the rest being either dominated by L. crispatus (10%) or L. iners (24%). High levels of lifetime trauma were associated with higher odds of having molecular-BV (adjusted Odds Ratio (aOR): 2.5, 95% Credible Interval (CrI): 1.1-5.3). Measures of psychosocial stress, including historic loss and historic loss associated symptoms, were significantly associated with lifestyle and behavioral practices. Higher scores of lifetime trauma were associated with increased concentrations of spermine (aFC: 3.3, 95% CrI: 1.2-9.2). Historic loss associated symptoms and biogenic amines were the major correlates of molecular-BV. Historical loss associated symptoms and lifetime trauma are potentially important underlying factors associated with BV.

Are American Indian/Alaska Native Adolescent Health Behaviors Different? A Review of AI/AN Youth Involved in Native STAND Curriculum, 2014-2017 United States

OBJECTIVES

To explore health behavior profiles of AI/AN youth involved in native students together against negative decisions (STAND), a national culture-based curriculum.

METHODS

We analyzed data from 1236 surveys conducted among AI/AN youth at 40 native STAND implementation sites located in 16 states throughout the US from 2014 to 2017. Health profiles included demographics, sexual orientation, sexual activity, STI testing, cigarette use, and suicide attempts in the past 12-months. We used t-tests and chi square tests of independence to compare risk behavior prevalence among the sample.

RESULTS

Health behavior profiles of AI/AN youth indicate that 45.6% of youth did not use condoms the last time they had sex, and 82.7% have never been tested for STIs. Differences in cigarette smoking were observed in questioning youth (questioning: 80.3%, straight/heterosexual: 63.8%, LGBTQ2S + : 49.9%, p = 0.03).

CONCLUSIONS FOR PRACTICE

Health behaviors related to sex, substance, violence and self-harm, are at least as common for AI/AN youth as those observed in other US teens. Future research should consider similarities and differences in health profiles of AI/AN youth when designing interventions that affect them. Further, our findings underscore the need for culturally-relevant curricula like native STAND, not because their health behavior is different, but because their socio-ecologic environment is different.

Impacts of the respecting the circle of life teen pregnancy prevention program on risk and protective factors for early substance use among native American youth

BACKGROUND

Early substance use disproportionately impacts Native American (Native) youth and increases their risk for future abuse and dependence. The literature urges for interventions to move beyond focusing on single risk behaviors (e.g. substance use) and instead have capacity to improve health risk behaviors co-occuring during adolescence, particularly among Native populations for whom few evidence-based interventions (EBI) exist. We evaluated the effectiveness of the Respecting the Circle of Life program (RCL) on risk and protective factors for early substance use. RCL is a culturally tailored EBI shown to improve sexual health outcomes among Native youth.

METHODS

We conducted secondary analyses of data collected through a community-based randomized controlled trial of RCL evaluated among Native youth (ages 11-19) residing on a rural reservation between 2015-2020 (N = 534, 47.4 % male). We used linear regression, controlling for baseline age and sex, to test between study group differences in outcomes at 3-, 9-, and 12-month post-intervention. Models were stratified by sex and age (11-12, 13-14, and 15+ years of age) to examine differences within these subgroups.

RESULTS

Youth receiving RCL reported lower intention to use substances through 12-months follow-up (p = 0.006). Statistically significant improvements were also observed across peer, parent, and sexual partner risk and protective factors to delay substance use initiation, with notable differences among boys and participants ages 13-14.

CONCLUSIONS

RCL is a primary prevention, skills-based program effective in preventing risks for substance use. This evaluation underscores the value in developing programs that influence concurrent adolescent risk behaviors, especially for Native communities who endure multiple health disparities.

Diné (Navajo) female perspectives on mother-daughter communication and cultural assets around the transition to womanhood: a cross-sectional survey

Background

The inclusion of protective factors (“assets”) are increasingly supported in developing culturally grounded interventions for American Indian (AI) populations. This study sought to explore AI women’s cultural assets, perspectives, and teachings to inform the development of a culturally grounded, intergenerational intervention to prevent substance abuse and teenage pregnancy among AI females.

Methods

Adult self-identified AI women (N = 201) who reside on the Navajo Nation completed a cross-sectional survey between May and October 2018. The 21-question survey explored health communication around the transition to womanhood, cultural assets, perceptions of mother–daughter reproductive health communication, and intervention health topics. Univariate descriptive analyses, chi squared, and fisher’s exact tests were conducted.

Results

Respondents ranged in age from 18 to 82 years, with a mean age of 44 ± 15.5 years. Women self-identified as mothers (95; 48%), aunts (59; 30%), older sisters (55; 28%), grandmothers (37; 19%), and/or all of the aforementioned (50; 25%). 66% (N = 95) of women admired their mother/grandmother most during puberty; 29% (N = 58) of women were 10–11 years old when someone first spoke to them about menarche; and 86% (N=172) felt their culture was a source of strength. 70% (N = 139) would have liked to learn more about reproductive health when they were a teenager; 67% (N = 134) felt Diné mothers are able to provide reproductive health education; 51% (N = 101) reported having a rite of passage event, with younger women desiring an event significantly more than older women. Responses also indicate a disruption of cultural practices due to government assimilation policies, as well as the support of male relatives during puberty.

Conclusions

Results informed intervention content and delivery, including target age group, expanded caregiver eligibility criteria, lesson delivery structure and format, and protective cultural teachings. Other implications include the development of a complementary fatherhood and/or family-based intervention to prevent Native girls’ substance use and teen pregnancy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01473-4.

Narrative frames as choice over structure of American Indian sexual and reproductive health consequences of historical trauma

Emerging evidence suggests that the historical trauma associated with settler colonialism affects the sexual and reproductive health (SRH) of American Indian (AI) communities today. This article examines how one AI community narratively frames the influence of historical trauma within the context of community-based participatory research (CBPR) and the implications of this framing for health behaviours, internalized oppression, SRH outcomes, and future CBPR interventions. We found that AIs framed the SRH consequences of historical trauma with renderings that favoured personal choice over structural explanations. Our findings suggest future interventions could: (1) include educational components on historical trauma and the continued role settler colonialism plays in structural violence against AI bodies and communities; and (2) recognize the role that the individualized logic of westernized/white culture may play in the erasure of traditional collectivist AI culture, internalized oppression, and SRH.

Unveiling an 'invisible population': health, substance use, sexual behavior, culture, and discrimination among urban American Indian/Alaska Native adolescents in California

Objectives: There are limited public health data on urban American Indian/Alaska Native (AI/AN) populations, particularly adolescents. The current study attempted to address gaps by providing descriptive information on experiences of urban AI/AN adolescents across northern, central, and southern California.Design: We describe demographics and several behavioral health and cultural domains, including: alcohol and other drug (AOD) use, risky sexual behavior, mental and physical health, discrimination experiences, involvement in traditional practices, and cultural pride and belonging. We recruited 185 urban AI/AN adolescents across northern, central, and southern California from 2014 to 2017 who completed a baseline survey as part of a randomized controlled intervention trial.Results: Average age was 15.6 years; 51% female; 59% of adolescents that indicated AI/AN descent also endorsed another race or ethnicity. Rates of AOD use in this urban AI/AN sample were similar to rates for Monitoring the Future. About one-third of adolescents reported ever having sexual intercourse, with 15% reporting using alcohol or drugs before sex. Most reported good mental and physical health. Most urban AI/AN adolescents participated in traditional practices, such as attending Pow Wows and learning their tribal history. Adolescents also reported discrimination experiences, including being a victim of racial slurs and discrimination by law enforcement.Conclusions: This study describes a select sample of California urban AI/AN adolescents across several behavioral health and cultural domains. Although these adolescents reported numerous discrimination experiences and other stressors, findings suggest that this sample of urban AI/AN teens may be particularly resilient with regard to behavioral health.

Rigorous evaluation of a substance use and teen pregnancy prevention program for American Indian girls and their female caregivers: a study protocol for a randomized controlled trial

Background

Early sexual initiation is associated with higher risk for sexually transmitted infection, teen pregnancy, domestic violence and substance use in later adolescence and early adulthood. Native American adolescents are more likely to have early sexual initiation compared to other racial/ethnic groups. Few programs designed with and for Native adolescents to delay sexual initiation and substance use have been tested through rigorous evaluations. This is the protocol for the randomized controlled trial of the Asdzáán Be’eena’ program, a teen pregnancy and substance use prevention program for young Native girls and their female caregivers.

Methods

N = 410 female adolescents ages 10–14 and their female caregivers will be enrolled in the study and randomized to the intervention or control arm. The intervention consists of the 11-session Asdzáán Be’eena’ program. The control arm consists of mailed non-monetary incentives. All participants will complete evaluations at baseline and 3 follow-up timepoints (immediate, 6 and 12 months post intervention). Evaluations include measures to assess protective factors associated with delayed sexual initiation and substance use.

Discussion

This is one of the first rigorous evaluations of a gender-specific, culturally tailored teen pregnancy and substance use primary prevention program for Native girls and their female caregivers. If proven efficacious, Native communities will have a culturally appropriate program for promoting protective factors associated with delayed substance use and sexual risk taking.

Trial registration

NCT04863729; April 27, 2021.

The intention to prevent sexual risk behaviors among the youth in Yangon, Myanmar

Purpose

The purpose of this paper is to investigate the intention to prevent sexual risk behaviors and associated factors among the youth in Yangon, Myanmar.

Design/methodology/approach

A cross-sectional descriptive research was undertaken among 192 youths. Participants included the youth residing in the study area and participated in the youth development program. Bivariate and multivariate logistic regressions were applied to identify an association.

Findings

The findings indicated that the proportion of a high level of intention to prevent sexual risk behaviors was 53.6%. The factors associated with the intention to prevent sexual risk behaviors were: belief strength on sexual risk behaviors (aOR = 2.84; 95% CI: 1.06–7.26), normative belief on the prevention of sexual risk behaviors (aOR = 2.03; 95% CI: 3.03–6.23), motivation to comply with preventing sexual risk behaviors (aOR = 4.72; 95% CI: 3.11–6.23), decision-making (aOR = 2.46; 95% CI: 2.22–5.41) and negotiation (aOR = 6.3; 95% CI: 2.37–10.23)

Research limitations/implications

The study was a cross-sectional study and cannot establish causal relationships. These results can be a guideline for implementation for the youth but may limit the generalization of results to other age groups in Myanmar.

Practical implications

Findings can be used as a local and national public health guideline for developing interventions to prevent sexual risk behaviors.

Originality/value

Sexual risk behavior is considered taboo and puts Myanmar youths at risk of health and social problems. It is important for prevention efforts to determine factors related to sexual intentions to prevent the consequence of these problems.

Empowering our people: Predictors of retention in an STI risk reduction program among rural Native Americans with binge substance use

PURPOSE

Substance use and sexual risk-taking have been shown to co-occur. Programs focused on sexually transmitted infections (STIs) reduction may benefit substance-using, particularly binge substance-using, adults. This is especially true for rural Native American communities who endure sexual and substance use disparities and have few STI risk reduction programs. This study explores factors predicting retention in an STI risk reduction program among rural Native adults engaged in binge substance use.

METHODS

We analyzed data from 150 Native adults ages 18-55 participating in an evaluation of "EMPWR," a 2-session STI risk reduction program in a rural, reservation-based community. Multivariate logistic regression models were used to estimate associations between independent variables and program completion across demographics, sexual behaviors, substance use behaviors, mental health, recent health care utilization, and perceived enculturation and discrimination.

FINDINGS

The sample was 49.2% (n = 59) female with a mean age of 33.61 years (SD = 8.25). Twenty-six completed only the first EMPWR session, 94 completed both EMPWR sessions, and 30 were randomized but completed 0 sessions. Being married/cohabiting (adjusted odds ratio [AOR] = 6.40, P = .0063) and living with an older generation (AOR = 4.86, P = .0058) were significantly associated with higher odds of completing EMPWR.

CONCLUSIONS

Findings provide insight on factors driving retention of Natives with recent binge substance use in STI risk reduction programming. An important contribution to Native health literature is that living with an older generation positively predicted EMPWR program completion, suggesting that STI risk reduction programs should harness the strength of families to ensure program attendance and optimize impacts in rural reservation contexts.

Dissemination and uptake of HIV/STD preventive interventions in American Indian and Alaska Native communities: a case study

Objectives: HIV and sexually transmitted diseases (STDs) are serious health conditions among American Indian and Alaska Native (AIAN) populations, especially youth. However, few sexual risk reduction evidence-based interventions (EBIs) have been implemented by AIAN-serving organizations. This project sought to identify and assess the parameters facilitating the uptake and use of EBIs in order to strengthen opportunities for sustainability and improved sexual health among AIANs.Design: Guided by Rogers' theory of diffusion of innovation, we conducted a survey with a national sample of stakeholders involved with sexual health and well-being of AIAN youth (N = 142). We collected surveys for nine months beginning September 2010 and analyzed data in 2014 and 2015. We assessed respondents' perceptions of factors that might facilitate or hinder the use of a sexual risk reduction EBI, called RESPECT, in their communities. We regressed the scale of likely program uptake (alpha = 0.88) on each of five measures of perception of diffusion and uptake: trialability (extent new program can be altered), relative advantage (more advantageous than current program), observability (impact of program), complexity (difficulty of implementation), and compatibility (consistent with community values and practices).Results: Trialability (p = .009), observability (p = .003), and compatibility (p = .005) were found to be significantly related to program uptake in the adjusted model. Standardized betas showed that compatibility ranked highest of the three, followed by trialability and observability.Conclusions: For AIAN-serving organizations and AIAN communities, demonstrating trialability, compatibility, and observability of a sexual risk reduction EBI in specific cultural settings may increase likelihood of implementation and sustainability.

"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.

Epidemiology of gonorrhoea: a global perspective

Although understanding the local epidemiology of gonorrhoea is critical for local efforts, understanding the multinational epidemiology may support development of national and international prevention and control policies and strategies. In this paper, current epidemiology of gonorrhoea is reviewed through an international lens and with a focus on selected populations. The World Health Organization (WHO) estimates that ~87 million new gonococcal infections occurred among people aged 15-49 years in 2016. Gonorrhoea rates are rising in many countries. Gay, bisexual and other men who have sex with men, racial or ethnic minorities, Indigenous populations and sex workers appear to bear disproportionate burdens of gonorrhoea. International travel can facilitate spread of gonorrhoea, including resistant strains, across international borders. Critical gaps in epidemiological knowledge are highlighted, including data on gonorrhoea among transgender persons and the burden of extragenital gonorrhoea. Even as further data are gathered, action - informed by currently available data - is needed now to confront this growing international threat.

Sexual risk behaviors and the legacy of colonial violence among Northern plains American Indian youth: A mixed methods exploratory study

INTRODUCTION

In this article, we honor the tribal remembering of two Northern Plains tribes to illustrate how the legacy of colonial violence frames the way in which substance use and mental health affect sexual risk behaviors among American Indian youth on the reservation today.

METHODS

We used a multi-phase, mixed quantitative and qualitative methods design within a community based participatory research framework to illustrate how the legacy of colonial violence frames epidemiological links between substance use, mental health, and sexual risk behavior among American Indian youth. We conducted semistructured interviews with 29 individuals and administered questionnaires to 298 American Indian youth living in a reservation environment.

RESULTS

Our findings explicate how a legacy of colonial violence underlies epidemiological links between mental health and substance use with sexual risk behavior among youth. Salient facets of colonial violence included systematically altered living arrangements, the boarding school era, eroded traditional practices, and the entry of extractive industries onto native lands.

DISCUSSION

The colonial violence enacted against the ancestors of Northern Plains tribal peoples materializes in the health of those living on the reservation today. Community interventions, which seek to address the role of substance use and mental health in sexual risk behavior, could benefit from delineating tribal perceptions regarding the legacy of colonial violence on public health outcomes through the use of a CBPR framework.

Moving the prevention timeline: A scoping review of the literature on precursors to sexual risk in early adolescence among youth of color

INTRODUCTION

Sexual health disparities are leading causes of morbidity among youth of color in the United States. We conducted a scoping review of the literature on precursors to sexual risk-taking among young adolescents of color (ages 10-14) to assess precedents of sexual experience and their utility as measurable proximal constructs and behaviors gauging sexual risk and sexual risk prevention efforts.

METHODS

This study was conducted using the PRISMA extension for scoping reviews (PRISMA-ScR) guidelines. We searched for quantitative studies that assessed the relationships between precursors and subsequent sexual behaviors, incorporated youth of color, and specified young adolescents as the study sample. All articles were in English, however we explored both U.S. and International databases.

RESULTS

The database search yielded 11 studies published between 2000 and 2017. Most literature focused on youth in urban settings, and on Black and Latinx youth, while only two addressed the special circumstances of American Indian and Alaska Native youth. Sex expectancies outcomes for youth of color were likely to predict sexual risk taking and self-efficacy about sex was related to abstinence.

CONCLUSIONS

Etiologic studies that seek to understand precursors to sexual risk taking among youth of color are limited and this paucity truncates the ability to develop sexual risk prevention programs for the age group in which prevention is most needed.

Historical Trauma and American Indian/Alaska Native Youth Mental Health Development and Delinquency

Health disparities in American Indian/Alaska Native (AI/AN) youth are well documented in the literature, as AI/AN youth appear to be more likely to experience trauma and engage in high-risk behavior, such as substance misuse and risky sexual behavior. These youth also appear disproportionally affected by the criminal justice system. Scholars contend that much of these disparities can be traced back to the history of colonization of Indigenous peoples and the transgenerational effects of forced suppression of cultural ideology. This paper reviews the relevant literature on AI/AN youth mental and behavioral health, and this author highlights studies which examine the plausible relation between historical trauma and contemporary AI/AN youth mental health and delinquency. This author proposes that future research should target the high number of AI/AN youths in juvenile justice settings given that these youths appear neglected in current research.

Self-efficacy and response-efficacy: critical components of sexual and reproductive health interventions targeting condom use intention among American Indian adolescents

The Respecting the Circle of Life (RCL) intervention is a comprehensive, skills-based sexual/reproductive health program shown to be effective for reducing sexual risk among American Indian (AI) adolescents (13-19 years of age). This paper seeks to identify critical program components of the RCL intervention for replication of impacts on condom use intention (CUI) when scaling to additional communities. RCL was tested among AI adolescents through a cluster randomized controlled trial (N = 267) embedded in an 8-day basketball camp. Data were collected at baseline, immediately post-camp, at 6 and 12 months post-camp. Previously established predictors of CUI that were statistically significantly impacted by RCL at the post-camp time point were tested as mediators of RCL impact on CUI. Condom use self-efficacy and response efficacy fully mediated the effect of RCL on CUI. The indirect path through condom use self-efficacy had the greatest effect on CUI, explaining 79% of the direct effect. When stratified by gender, there was only evidence of mediation among girls. Results indicate condom use self-efficacy and response efficacy are critical components of the RCL intervention for AI girls, and sexual/reproductive health programs should include practical skills training to improve these constructs to maximize intervention impact on CUI.

Correlates of Nonmedical Prescription Opioid Use Among U.S. Adolescents

INTRODUCTION

The purpose of this study is to assess risk factors, including other substance use, for nonmedical prescription opioid use among U.S. adolescents.

METHODS

A secondary data analysis of the 2017 Youth Risk Behavior Survey was conducted (n=10,175) in 2018. The outcome was nonmedical prescription opioid use. Predictor variables included other substance use, mood, sleep, academic performance, and demographic characteristics. Survey-weighted procedures in SAS, version 9.4 were used, and an adjusted logistic regression model was conducted.

RESULTS

Among the sampled adolescents, 13.8% (95% confidence limit=12.4%, 15.3%) reported nonmedical prescription opioid use. Nonmedical prescription opioid use was more likely among participants aged 15 years (versus 16 years), American Indian/Alaskan Natives, and those who reported being sad or hopeless. All other substance use was significantly associated with increased odds of nonmedical prescription opioid use. Nonmedical prescription opioid use was 1.5 times more likely among electronic vapor users (AOR=1.58, 95% CI=1.34, 1.86), 2 times more likely among cigarette (AOR=2.49, 95% CI=2.16, 2.88) and marijuana users (AOR=2.45, 95% CI=2.05, 2.93), and almost 3 times as likely among alcohol users (AOR=2.98, 95% CI=2.18, 4.07).

CONCLUSIONS

Study findings suggest a need for more interventions for nonmedical prescription opioid use among adolescents in the U.S. Information on nonmedical prescription opioid use should be added to all substance use prevention programs for adolescents. Moreover, future research needs to identify longitudinal predictors of adolescent nonmedical prescription opioid use to inform prevention efforts.

Integrating Community-Engagement and a Multiphase Optimization Strategy Framework: Adapting Substance Use Prevention for American Indian Families

Initiation of substance use often occurs earlier among American Indian (AI) youth than among other youth in the USA, bringing increased risk for a variety of poor health and developmental outcomes. Effective prevention strategies are needed, but the evidence base remains thin for this population. Research makes clear that prevention strategies need to be culturally coherent; programs with an evidence base in one population cannot be assumed to be effective in another. However, guidance on effective adaptation is lacking. This paper reports on cultural adaptation of an evidence-based program utilizing the multiphase optimization strategy (MOST) framework embedded within a community-engaged process to evaluate intervention components. The Strengthening Families Program for Parents and Youth 10-14 was adapted to become the Thiwáhe Gluwáš'akapi Program for American Indian youth and families. Three program components were evaluated for their effectiveness with regard to outcomes (youth substance use, theoretical mediators of program effects on substance use, and program attendance) in a sample of 98 families (122 youth and 137 adults). Consistent with the MOST framework, the value of components was also evaluated with regard to efficiency, economy, and scalability. Expanding on the MOST framework for cultural adaptation, we also considered the results of the MOST findings regarding the acceptability of each component from the perspectives of community members and participants. The promise of a strategic component-based approach to adapting evidence-based interventions is discussed, including the benefits of engaging community to ensure relevance and considering both cultural and scientific rationale for each component to enhance impact.

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.

Community Perceptions of Alcohol Exposed Pregnancy Prevention Program for American Indian and Alaska Native Teens

A community needs assessment during a tribally-led Changing High-Risk Alcohol Use and Increasing Contraception Effectiveness Study (CHOICES) intervention highlighted the need to reduce the risk for alcohol exposed pregnancy (AEP) among American Indian and Alaska Native (AIAN) adolescent girls. The CHOICES for American Indian Teens (CHAT) Program aims to reduce the risk of AEP among AIAN teens in one Northern Plains tribal community. The CHAT team adopted an iterative process to modify the tribally-led CHOICES curriculum for AIAN teens. This paper describes the iterative process as well as the community perception towards AEP prevention among AIAN teens. The CHAT team conducted several levels of formative and qualitative research, including one-on-one interviews (n = 15) with community members, AIAN elders and school counsellors; and three focus groups with AIAN adolescent girls (n = 15). A qualitative data analysis identified several recommendations that centered on making the information regarding alcohol and birth control appealing to teens; ensuring the confidentiality of the participants; making the program culturally relevant; and including boys in the program. This study outlines various components prioritized by community members in creating a culturally-relevant and age-appropriate AEP prevention program and provides community perceptions of AEP prevention for the teens in this community.

Conversation, Condoms, and Contraception: How Does Communication With Sexual Partners Affect Safer Sexual Behaviors Among American Indian Youth?

Communication with sexual partners about protection against sexually transmitted infections (STIs) is associated with safer sexual behaviors among general populations of youth, but little is known about partner communication among American Indian youth. We assessed the prevalence of adolescents’ communication with sexual partners about STI prevention and used multivariable logistic regression to examine associations between communication and safer sexual behaviors (condom use, reliable contraceptive use, and dual method use) among a statewide sample of in-school, American Indian youth in Minnesota in 2013 and 2016 ( n = 739). Half (49.5%) of sexually experienced American Indian youth reported talking about STI prevention at least once with every sexual partner. Communication was associated with all examined safer sexual behaviors among females and only with condom use among males. Study findings highlight the importance of school nurses, health educators, and other clinicians addressing partner communication when counseling adolescent patients.

Emerging Adults' Discussion of Substance Use and Sexual Behavior with Providers

Emerging adulthood (ages 18-25) is a time of increased autonomy and associated with a high rate of risky substance use and sexual behavior. As emerging adults (EA) increasingly have more independence, they have the ability to make health decisions, including whether to see a provider (primary care (PCP) and/or gynecologist (GYN)) and whether to discuss substance use and sexual behavior. The current study aimed to determine: (1) factors associated with PCP and GYN health-care seeking by sexually active EA who use alcohol and/or marijuana; (2) gender differences in substance use and sexual risk topics initiated by providers; (3) whether PCPs compared to GYNs discuss different topics with women. Alcohol and/or marijuana-using, sexually active EA (n = 500) were recruited as part of a health behaviors study. Among participants, 39% did not see a PCP in the previous year. Women, White individuals, and EA with health insurance were most likely to attend a PCP appointment. Even among participants who saw a provider, many participants reported that providers did not initiate a discussion about substance use (approximately half discussed substance use) and sexual behavior (about half discussed STI history, two-thirds discussed condom use, and three-quarters discussed sexual partners). Among women with a PCP and GYN provider, discussions on substance use were more likely to be initiated by a PCP while sexual issues were more likely to be initiated by a GYN. Thus, even among sexually active, substance-using EA, central topics - specifically substance use and sexual behavior - are not routinely brought up by providers.

My Journey: Development and Practice-Based Evidence of a Culturally Attuned Teen Pregnancy Prevention Program for Native Youth

A clear need exists for teen pregnancy prevention programs that are responsive to the specific needs and cultural contexts of Native American communities. Recent data indicates that the birth rate for Native teens is nearly two and a half times the rate for White teens (32.9 versus 13.2). To address this disparity, we conducted formative research with Northern Plains Native American community members, resulting in My Journey, a culturally attuned curriculum for 6⁻8th graders. My Journey is grounded in traditional values and teachings to promote self-efficacy in sexual health decision-making and engagement in prosocial behaviors. We conducted a pilot study with 6⁻8th grade students (n = 45), aged 11⁻14 years (22 females, 23 males). Pilot study findings confirm program feasibility and acceptability. The process evaluation revealed that teachers liked the curriculum, particularly its adaptability of cultural components and ease of student engagement. The outcome evaluation demonstrated that My Journey provided an avenue for NA youth to increase their sex refusal self-efficacy. Application of the culture cube framework revealed My Journey has made a meaningful practice-based evidence contribution as a community-defined, culturally integrated curriculum that is effective. Future directions include broader implementation of My Journey, including adaption for additional populations.

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.

Substance Use Prevention for Urban American Indian Youth: A Efficacy Trial of the Culturally Adapted Living in 2 Worlds Program

This article describes a small efficacy trial of the Living in 2 Worlds (L2W) substance use prevention curriculum, a culturally adapted version of keepin' it REAL (kiR) redesigned for urban American Indian (AI) middle school students. Focused on strengthening resiliency and AI cultural engagement, L2W teaches drug resistance skills, decision making, and culturally grounded prevention messages. Using cluster random assignment, the research team randomized three urban middle schools with enrichment classes for AI students. AI teachers of these classes delivered the L2W curriculum in two schools; the remaining school implemented kiR, unadapted, and became the comparison group. AI students (N = 107) completed a pretest questionnaire before they received the manualized curriculum lessons, and a posttest (85% completion) 1 month after the final lesson. We assessed the adapted L2W intervention, compared to kiR, with paired t tests, baseline adjusted general linear models, and effect size estimates (Cohen's d). Differences between the L2W and kiR groups reached statistically significant thresholds for four outcomes. Youth receiving L2W, compared to kiR, reported less growth in cigarette use from pretest to posttest, less frequent use of the Leave drug resistance strategy, and less loss of connections to AI spirituality and cultural traditions. For other substance use behaviors and antecedents, the direction of the non-significant effects in small sample tests was toward more positive outcomes in L2W and small to medium effect sizes. Results suggest that evidence-based substance use prevention programs that are culturally adapted for urban AI adolescents, like L2W, can be a foundation for prevention approaches to help delay initiation and slow increases in substance use. In addition to study limitations, we discuss implementation challenges in delivering school-based interventions for urban AI populations.

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.

Developmental Assets and Risky Sexual Behaviors among American Indian Youth

This study examined the relationship between developmental assets during early and mid-adolescence and early adult sexual behaviors among American Indians using a subsample from the National Longitudinal Study of Adolescent Health (N = 465). Grounded in an assets framework, the authors explored the protective role of personal, family, school, and community assets as well as cumulative assets for sexual behaviors including early sexual debut, number of sexual partners, and frequency of condom use. The results indicated that certain assets during early and mid-adolescence, such as self-control, family support, and school attachment were protective for various risky sexual behaviors in early adulthood. Furthermore, cumulative assets emerged as an important predictor of sexual behaviors. These findings highlight the utility of applying a developmental asset framework to understand protective factors among American Indian youth.

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.

Indigenous Adolescents' Suicidal Behaviors and Risk Factors: Evidence from the National Youth Risk Behavior Survey

The study sought to examine indigenous adolescents' suicidal behaviors and risk factors in a nationally representative sample and explore potential causes of disparities. The study analyzed the 1991-2013 Youth Risk Behavior Survey National Combined Datasets. Suicidal behavior outcomes included suicide consideration, planning, and attempts during the past 12 months. Logit regressions were used to estimate the effects of potential suicide risk factors on these suicidal behaviors. The results showed that a high percentage of indigenous adolescents exhibited suicidal behaviors (consideration: 24.6 %; planning: 20.7 %; attempts: 16.2 %). After adjusting for risk factors, indigenous adolescents were no more likely than other adolescents to consider or plan for suicide (consideration: OR 1.18, CI 0.96-1.45, p = 0.125; planning: OR 1.16, CI 0.95-1.42, p = 0.156); however, they remained significantly more likely to have made suicide attempts (OR 1.73, CI 1.32-2.26, p < 0.001). Disparities in adolescent suicidal behaviors could be explained by the heterogeneous prevalence of suicidal risk factors across different races/ethnicities.

AMERICAN INDIAN AND ALASKA NATIVE BOYS: EARLY CHILDHOOD RISK AND RESILIENCE AMIDST CONTEXT AND CULTURE

American Indian and Alaska Native (AIAN) adolescent and adult men experience a range of health disparities relative to their non-AIAN counterparts and AIAN women. Given the relatively limited literature on early development in tribal contexts, however, indicators of risk during early childhood specific to AIAN boys are not well-known. The current article reviews sources of strength and challenge within AIAN communities for AIAN children in general, including cultural beliefs and practices that support development, and contextual challenges related to socioeconomic and health disparities and historical trauma affecting the AIAN population as a whole. The research literature on early development is reviewed, highlighting what this literature reveals about early gender differences. The article concludes with calls to action on behalf of AIAN boys that align with each of the five tiers of R. Frieden's (2010) Public Health Pyramid.

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.

Teen pregnancy in Inuit communities - gaps still needed to be filled

Teen pregnancy is depicted around the world as an important cause of health disparities both for the child and the mother. Accordingly, much effort has been invested in its prevention and led to its decline in the northern hemisphere since the mid-1990s. Despite that, high rates are still observed in the circumpolar regions. As Inuit communities have granted better understanding of teenage pregnancy a priority for the coming years, this article comprehensively reviews this multidimensional issue. By depicting current prevalence, likely determinants and possible impacts documented among Inuit of Canada, Alaska and Greenland, and contrasting them to common knowledge that has emerged from other populations over the years, great gaps surface. In some regions, the number of pregnancies per number of Inuit women aged between 15 and 19 years has increased since the turn of the millennium, while statistics from others are either absent or difficult to compare. Only few likely determinants of teenage pregnancy such as low education and some household factors have actually been recognized among Inuit populations. Documented impacts of early pregnancy on Inuit women and their children are also limited compared to those from other populations. As a way to better address early pregnancy in the circumpolar context, the defence for additional scientific efforts and the provision of culturally adapted sexual health prevention programmes appear critical.

Internet-Based Delivery of Evidence-Based Health Promotion Programs Among American Indian and Alaska Native Youth: A Case Study

Background

American Indian and Alaska Native (AI/AN) youth face multiple health challenges compared to other racial/ethnic groups, which could potentially be ameliorated by the dissemination of evidence-based adolescent health promotion programs. Previous studies have indicated that limited trained personnel, cultural barriers, and geographic isolation may hinder the reach and implementation of evidence-based health promotion programs among AI/AN youth. Although Internet access is variable in AI/AN communities across the United States, it is swiftly and steadily improving, and it may provide a viable strategy to disseminate evidence-based health promotion programs to this underserved population.

Objective

We explored the potential of using the Internet to disseminate evidence-based health promotion programs on multiple health topics to AI/AN youth living in diverse communities across 3 geographically dispersed regions of the United States. Specifically, we assessed the Internet’s potential to increase the reach and implementation of evidence-based health promotion programs for AI/AN youth, and to engage AI/AN youth.

Methods

This randomized controlled trial was conducted in 25 participating sites in Alaska, Arizona, and the Pacific Northwest. Predominantly AI/AN youth, aged 12-14 years, accessed 6 evidence-based health promotion programs delivered via the Internet, which focused on sexual health, hearing loss, alcohol use, tobacco use, drug use, and nutrition and physical activity. Adult site coordinators completed computer-based education inventory surveys, connectivity and bandwidth testing to assess parameters related to program reach (computer access, connectivity, and bandwidth), and implementation logs to assess barriers to implementation (program errors and delivery issues). We assessed youths’ perceptions of program engagement via ratings on ease of use, understandability, credibility, likeability, perceived impact, and motivational appeal, using previously established measures.

Results

Sites had sufficient computer access and Internet connectivity to implement the 6 programs with adequate fidelity; however, variable bandwidth (ranging from 0.24 to 93.5 megabits per second; mean 25.6) and technical issues led some sites to access programs via back-up modalities (eg, uploading the programs from a Universal Serial Bus drive). The number of youth providing engagement ratings varied by program (n=40-191; 48-60% female, 85-90% self-identified AI/AN). Across programs, youth rated the programs as easy to use (68-91%), trustworthy (61-89%), likeable (59-87%), and impactful (63-91%). Most youth understood the words in the programs (60-83%), although some needed hints to complete the programs (16-49%). Overall, 37-66% of the participants would recommend the programs to a classmate, and 62-87% found the programs enjoyable when compared to other school lessons.

Conclusions

Findings demonstrate the potential of the Internet to enhance the reach and implementation of evidence-based health promotion programs, and to engage AI/AN youth. Provision of back-up modalities is recommended to address possible connectivity or technical issues. The dissemination of Internet-based health promotion programs may be a promising strategy to address health disparities for this underserved population.

Trial Registration

Clinicaltrials.gov NCT01303575; https://clinicaltrials.gov/ct2/show/NCT01303575 (Archived by WebCite at http://www.webcitation.org/6m7DO4g7c)