Respecting the Circle of Life: Mind, Body & Spirit is an STD/HIV and pregnancy prevention program for Native American youth between the ages 11 and 19 and their parents or other trusted adults. The primary goal of the program is to give youth the knowledge and skills they need to protect themselves from unplanned pregnancy and STDs. The program also covers decision making, values, goal setting, communication, and knowledge about risk behaviors associated with HIV, other STDs, teen pregnancy, violence, and alcohol and drug use. It is available in both print and digital editions, and comes with a self-paced, e-learning training.
Respecting the Circle of Life: Mind, Body & Spirit is an STD/HIV and pregnancy prevention program for Native American youth between the ages 11 and 19 and their parents or other trusted adults. The primary goal of the program is to give youth the knowledge and skills they need to protect themselves from unplanned pregnancy and STDs. The program also covers decision making, values, goal setting, communication, and knowledge about risk behaviors associated with HIV, other STDs, teen pregnancy, violence, and alcohol and drug use. Respecting the Circle of Life is one of the first sexual and reproductive health programs to be developed and rigorously evaluated with Native American youth and families.
Respecting the Circle of Life is adapted from Focus on Youth with ImPACT (FOY), a program originally developed in Baltimore to reduce the risk of HIV among urban African-American youth. The Johns Hopkins Center for American Indian Health worked with Native American community members to adapt the program for use with Native youth and families to include a focus on unintended pregnancy in addition to STD/HIV.
To better address the needs of Native American youth, the following adaptations were made to the FOY curriculum:
The curriculum was designed to be used with small groups of Native American youth ranging from 8 to 12 participants, led by two trained Native American facilitators. In past evaluation, the curriculum was implemented as part of an 8-day summer basketball camp. It can be implemented in various community-based settings. The 1-session youth/parent component is delivered at home or in another private setting within 3 months after the 8 youth peer-group sessions.
Johns Hopkins Center for American Indian Health works in partnership with tribal communities to design public health programs that raise the health status, self-sufficiency, and health leadership of Native people to the highest possible level. As an independent center within the Department of International Health of the Johns Hopkins Bloomberg School of Public Health, the center has satellite offices on tribal lands. With over 35 years of collaboration with Southwestern tribes, the center's programs now reach more than 120 tribal communities in 17 states. These partnerships have achieved landmark public health breakthroughs credited with saving over 60 million children’s lives worldwide.
Bonita Stanton, MD, developer of the original Focus on Youth curriculum, is a nationally recognized expert on pediatric medicine, recently named as the founding dean of the new school of medicine at Seton Hall University and Hackensack University Health Network (HackensackUHN) which is slated to open in fall 2018. She graduated from Wellesley College and Yale University School of Medicine, completed her pediatric residency at Rainbow Babies and Children's Hospital (Case Western Reserve) and her Pediatric Infectious Disease Fellowship training at Yale University School of Medicine. She has served as Vice Dean for Research at Wayne State University School of Medicine. Previously, she served as the Schotanus Professor and Chair of the Department of Pediatrics at Wayne State; Pediatrician-in-Chief at Children's Hospital of Michigan, Detroit Medical Center; and Chair of the Department of Pediatrics, West Virginia University. Earlier in her career, she was a faculty member and Division Chief of General Pediatrics at University of Maryland School of Medicine. For five years, she lived and worked with her family in Bangladesh, where she served as a health consultant to the World Bank and the International Center for Diarrheal Diseases Research, and as director of a community-based research and service program designed to help women and children in the slums of Dhaka.
The curriculum has approximately 18 hours of content divided into 9 sessions. Peer-group participants meet for 8 sessions that each last about 120 minutes. There is also a single 2-hour session conducted with each youth and a parent or other trusted adult after the peer-group sessions.
Core intervention materials include:
Youth Workbooks and a Parent/Trusted Adult Resource Guide are recommended for every participant. Additional workbook/guide sets of 5 and 10 are available.
This curriculum is designed to be taught by two skilled facilitators. Educators interested in implementing this program should be skilled in using interactive teaching methods and guiding group discussions, and should be comfortable with the program content. Ideally, they will be from the same Native community as the youth.
It is highly recommended that educators who plan to teach Respecting the Circle of Life receive research-based professional development to prepare them to effectively implement and replicate the curriculum with fidelity for the intended target group. Training on Respecting the Circle of Life is available through ETR's Professional Learning Services.
RCL is based on Protection Motivation Theory (PMT), a social cognitive theory that emphasizes the balance between pressures to engage in a risk behavior (social and personal rewards), risks involved (severity of the undesired outcome, vulnerability), and considerations of the alternatives (how well the alternatives help avoid undesirable outcomes; ability of the youth to employ the alternative behavior; and social, personal or other costs associated with employing the alternative). It involves an appraisal of threat (e.g., what are the dangers of having unprotected sex?), balanced with an appraisal of coping (e.g., what are the benefits of abstinence or using a condom?). Self-efficacy plays a role in this appraisal process (e.g., do I have the skills and knowledge I need to choose abstinence or use a condom?). PMT recognizes the influence of culture, family and peers in the identification and recognition of risks. If culture, family and peers all consider the threat of unprotected sex significant, chances are the individual youth will as well.
The adapted curriculum promotes concentric circles of support for adolescents’ positive behavior change at individual, peer, family and community levels. Intergenerational intervention has special import to Native American communities as family is generally valued as the nexus of strength for individuals and been shown to yield great influence on adolescents’ behavioral choices. Historical and present-day trauma have eroded traditional family structures (i.e., poverty and overcrowded households, single parent homes, high residential mobility) and contributed to intergenerational cycles of teen pregnancy. Native families experiencing these stressors may rely on a combination of immediate and extended family members as well as close friends for caretaking. Native parents and communities are eager for prevention interventions that strengthen entire family networks; thus, incorporation of parents or trusted adults in the program help make it socially and culturally congruent for youth and families and holds promise for reducing accumulated risk across generations.
The program logic model can be found here:
Logic Model (pdf)
Between 2016 and 2018, a total of 534 Native youth ages 11 to 19 and their parents/trusted adults were enrolled in a randomized controlled trial (RCT) of the 9-session Respecting the Circle of Life (RCL) teen pregnancy prevention program. Participants were randomized to receive RCL or a 9-session control program focused on fitness and nutrition. Youth were enrolled across three annual cohorts (2016, 2017 and 2018); each cohort was followed for 12 months. Each youth selected a parent or other trusted adult participant (e.g., grandparent, aunt/uncle, older cousin, older sibling, etc.) to enroll with them in the study.
Participants were recruited via community outreach including local events, posting flyers in the community and radio announcements. Youth were eligible if ages 11 to 19, of Native American ethnicity (self-identified), an enrolled member or resident of the participating tribal community.
RCL was implemented in an 8-day summer basketball camp, followed by a lesson delivered at home to the youth together with their parent or other trusted adult. Native paraprofessional facilitators from the participating community were selected as facilitators and highly trained in RCL content and classroom management prior to the intervention. The first eight RCL sessions were delivered to peer-groups of youth (e.g., youth of the same age and sex, with 8 to 12 youth per peer group) once per day at camp by two facilitators per group. The ninth youth-parent/trusted adult session was delivered at home within 3 months after camp by one of the facilitators who led the youth’s peer group. Participants completed assessments at baseline, 9 months and 12 months post-intervention.
Results indicate that RCL has strong evidence of effectiveness for the prevention of teen pregnancy in Native American communities.
Compared to the control group, youth who received RCL:
The inclusion of the parent/trusted adult session may be a primary factor for sustaining RCL impact on sexual/reproductive health knowledge, contraceptive use self-efficacy, partner negotiation skills on contraceptive use, and talking with a parent/trusted about sexual/reproductive health. Especially noteworthy are the findings regarding talking with parent/trusted adult about sexual reproductive health: significant improvements were observed at the 12-month follow-up.
Results suggest that RCL implementation with Native youth and families can promote healthy conversations around sex during a critical period of development when youth may begin initiation of sexual activity. These findings mimic those of Stanton and colleagues (developer of FOY + ImPACT), who showed that the intervention impacts of FOY could be enhanced and extended with the addition of a parent/trusted adult component, and are consistent with the literature demonstrating the importance of parents and family in Native youth decision making.
Development of RCL
Chambers, R., Tingey, L., Mullany, B., Parker, S., Lee, A., & Barlow, A. (2016). Exploring sexual risk taking among American Indian adolescents through protection motivation theory. AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV 28 (9): 1089-96, doi: 10.1080/09540121.2016.1164289.
Results from Evaluation of RCL Peer-Group Sessions
Tingey, L., Mullany, B., Strom, R., Hastings, R., Barlow, A., & Rompalo, A. (2015). The Respecting the Circle of Life trial for American Indian adolescents: Rationale, design, methods and baseline characteristics. AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV 27 (7): 885-891. doi:10.1080/09540121.2015.1015481.
Tingey, L., Mullany, B., Chambers, R., Hastings, R., Lee, A., Parker, A., Barlow, A., & Rompalo, A. (2015). Respecting the circle of life: One year outcomes from a randomized controlled comparison of an HIV risk reduction intervention for American Indian adolescents. AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV 27 (9), doi: 10.1080/09540121.2015.1028879.
Tingey, L., Chambers, R., Rosenstock, S., Lee, A., Goklish, N., & Larzelere, F. (2016). The impact of a sexual and reproductive health intervention for American Indian adolescents on predictors of condom use intention. Journal of Adolescent Health 60: 284–291.
Results from High-Impact Evaluation of RCL Peer-Group + Youth/Parent Session
Tingey, L., Chambers, R., Goklish, N., Larzelere, F., Lee, A., Suttle, R., Rosenstock, S., Lake, K., & Barlow, A. (2017). Rigorous evaluation of a pregnancy prevention program for American Indian youth and adolescents: Study protocol for a randomized controlled trial. Trials 18 (1): 89, doi: 10.1186/s13063-017-1842-6.
Tingey, L., Chambers, R., Patel, H., Lee, S., Littlepage, S., Lee, A., Susan, D., Melgar, L., Slimp, A., & Rosenstock, S. (2020). Impacts of the Respecting the Circle of Life teen pregnancy prevention program among Native American youth. Manuscript under review at Journal of Adolescent Health.
Article on the impact of RCL
Core elements of the peer-group sessions:
Key characteristics of the peer-group sessions:
Core elements of the youth/parent-trusted adult session:
Key characteristics of the youth/parent-trusted adult session:
Any modification of key characteristics should be done with great care, and should not compete with or contradict the intent, theory and internal logic of the intervention.
Click the link below to view the Implementation Guide.
For answers to Frequently Asked Questions about program adaptations, please visit our Program Support Help Desk.
Read ETR's Adaptations Policy.
Purchase of the program includes an online, self-paced Training of Educators that gives educators the knowledge and skills to implement the Respecting the Circle of Life curriculum effectively and with a high degree of fidelity. Educators can work through the e-learning modules at their own pace, with plenty of reinforcement and opportunities for review along the way. Subscription access to the training is provided with both the digital and print editions of the program.
As a result of this training, educators will be able to: