Program Success Center

for Sexual & Reproductive Health

Respecting the Circle of Life

Repsecting the Circle of Life Curriculum CoverRespecting 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.

Category Program Features
Setting Community based
Program Length

Curriculum: 18 hours/year | 1 year | 9 sessions total

8 Peer-Group Sessions: 90–120 minutes each
1 Parent/Trusted Adult Session: 90–120 minutes

Age Group Ages 11–19
Look Inside

Table of Contents
Sample Lesson
BUY NOW

Overview | Description | Population | Author

Overview

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.

Description

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:

  1. Content around reproductive anatomy, sexual and reproductive health information, pregnancy prevention strategies and applied skills training was enhanced.
  2. Community- and youth-centered strategies for overcoming access barriers to condom and contraceptive use were included.
  3. Comprehensive substance use prevention components teaching peer refusal and pro-peer relations were built in.
  4. Edits to reflect the importance of social pressure on males and self-esteem and connectedness on females for sexual decision making were added.
  5. All content was modified to reflect the local language, include familiar characters, and add culturally relevant examples and scenarios.
  6. The accompanying DVD was reproduced with local actors and testimonials, including traditional Native storytelling and adding an emphasis on the balance among physical, spiritual and emotional health.

Population Served & Setting

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.

About the Author

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.

 

Length | Elements | Staffing

Length of Program

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.

 

Program Elements

Core intervention materials include:

  • Facilitator Curriculum
  • Youth Workbook (group set of 12)
  • Activity Kit (cards, posters, job aids)
  • Youth and Parent Session Guide
  • Parent/Trusted Adult Resource Guide (group set of 12)
  • Implementation Guide
  • Supplemental Materials Resource Guide
  • Condom Demonstration Tools

Youth Workbooks and a Parent/Trusted Adult Resource Guide are recommended for every participant. Additional workbook/guide sets of 5 and 10 are available.

 

Staffing Requirements

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.

Theory | Logic Model | Evidence Summary | References

Theory

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.

 

Logic Model

The program logic model can be found here:

Logic Model (pdf)

 

Evidence Summary

Research Design

Respecting the Circle of Life (RCL) researchers used a participatory research approach to build trust and increase the likelihood that the intervention would be conceived sensitively and appropriately. A community advisory board and focus groups helped ensure that the intervention was developmentally and culturally grounded.

The study was a peer group randomized controlled comparison of the RCL intervention vs. a control condition delivered over the course of a community-based 8-day summer basketball camp, and evaluated from baseline to 12 months follow-up. The study was conducted in a rural and isolated reservation-based tribal community with a population of approximately 17,000. Participants were eligible if ages 13–19, Native American, and residing in the participating community at time of consent. Participants were recruited through local schools, IHS clinics, public events and word of mouth. The trial only implemented the 8 peer-group sessions and did not include the ninth youth/parent or other trusted adult session.

The study was conducted over two cohorts through summer basketball camps (cohort 1 in summer 2011 and cohort 2 in summer 2012). Each camp consisted of eight consecutive 4-hour weekdays. To reduce the possibility for contamination, researchers utilized two separate school gymnasium facilities (approximately one mile apart). Each day, there was 90 minutes of basketball, a 30-minute lunch, and a 90-minute educational lesson (RCL or control). The study was approved by relevant tribal, Indian Health Service (IHS), and University research review boards. This manuscript was approved by the Tribal Council and Health Advisory Board, the local governing bodies that provide regulatory oversight of all research conducted on the reservation.

Findings

The results of the study showed that 6 months after the intervention was delivered, compared to control participants, youth who received RCL:

  • Had better HIV prevention and transmission knowledge.
  • Had better condom use self-efficacy.
  • Were more likely to believe condoms prevent sexually transmitted infections.
  • Were more likely to talk with an adult about HIV.

Specific findings were as follows:

  • Condom use self-efficacy. RCL participants had significantly improved mean condom use self-efficacy scores compared to controls at post-camp. Condom use self-efficacy was significantly improved among the RCL group out through 12 months. Differences were most significant and sustained among females and older youth (ages 16–19).
  • Knowledge. RCL intervention group participants had higher knowledge scores regarding prevention and transmission of HIV/AIDS than controls at post-camp and 6 months. They were also more likely to believe condoms prevent transmission of HIV and STIs at post-camp and 6 months.
  • Behavioral intent. RCL participants were more likely to have spoken with a family member or adult about HIV/AIDS at post-camp and 6 months. Several other behavioral intent risk variables were significantly improved among RCL participants post-camp. RCL participants reported increased efficacy around partner negotiation skills related to substance use during sex and were more likely to intend to use a condom at next sex.
  • Protection motivation theory. Significant between-group differences were observed at post-camp for all three theoretical constructs comprising the coping-appraisal pathway and none comprising the threat appraisal pathway. Immediately post-camp, RCL participants had higher self-efficacy, response efficacy and response cost. Significantly improved scores among RCL participants were sustained for response efficacy at 6 months.

The study’s overall strong retention rate (90%) and demonstrated knowledge gains among participants support acceptance of the RCL intervention. The significant between-group differences observed on all coping-appraisal theoretical constructs reinforce past research suggesting promotion of protective factors may bear greater importance in Native American populations than a focus on risk. Although some impacts attenuated after 6 months, talking to parents about HIV was statistically significant out through 6 months. Another trial is being conducted with the ninth parent/trusted adult session included which will include longer-term follow-up.

 

References

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., 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.

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.

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.

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.

Core Elements | Implementation Guide | General Adaptation Guidance |FAQs | Policy

Core Elements

Core elements of the peer-group sessions:

  • Core Element 1: Deliver intervention to youth in community-based settings.
  • Core Element 2: Use two skilled facilitators to model communication, negotiation and refusal skills for the youth.
  • Core Element 3: Use “friendship” or venue-based groups (i.e., friends, family members, a basketball team, a scout troop, church group, an existing youth group) to strengthen peer support.
  • Core Element 4: Use culturally appropriate interactive activities proven as effective learning strategies to help youth capture the important constructs in the theory.
  • Core Element 5: Include a “family tree” to contextualize and personalize abstract concepts, such as decision making and risk assessment.
  • Core Element 6: Enable participants to learn and practice a decision-making model such as SPIRIT (Stop and Relax, Problem Identification, Identify Solutions, Review Solutions, I Choose, Try and Treat Yourself).
  • Core Element 7: Train participants in assertive communication and refusal skills specifically related to negotiation of abstinence or safer sex behaviors.
  • Core Element 8: Teach youth proper condom use skills.

Key characteristics of the peer-group sessions:

  • The program is delivered to peer groups of 8 to 12 youth.
  • New members should not join after the third session.
  • Participants meet for at least 90–120 minutes for each session.
  • Culturally and linguistically based activities are embedded for your target population.
  • Groups contain members of the same gender and age group.

Core elements of the youth/parent-trusted adult session:

  • Core Element 1: Deliver session one-on-one to parents/trusted adults and the youth, at their home or a private location selected by the participants, and at a time convenient to them.
  • Core Element 2: Use of a facilitator whom the parents/trusted adults find credible, and who is skilled at building rapport with parents and youth at the beginning of the session.
  • Core Element 3: Deliver session after the youth peer-group sessions.
  • Core Element 4: Enable parent/trusted adults and youth to learn and practice communication skills.
  • Core Element 5: Teach parent/trusted adults and youth proper condom use skills.
  • Core Element 6: Distribute and instruct parent/trusted adults and youth through a Resource Guide that includes the following topics:
    • Basic components of good communication and how to talk to youth
    • Importance of parental monitoring
    • Steps for proper condom use
    • STI and HIV facts, including prevalence data among Native American youth

Key characteristics of the youth/parent-trusted adult session:

  • Use of a video that shows the challenges and importance of parents monitoring and talking to their youth about sex, abstinence, STIs, HIV/AIDS, and condoms.
  • Facilitator must sit down and watch the video with the parent/trusted adult and youth
  • Youth and parent/trusted adult should watch the video together.

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.

 

Implementation Guide

Click the link below to view the Implementation Guide.

Respecting the Circle of Life Implementation Guide (pdf)


For answers to Frequently Asked Questions about program adaptations, please visit our Program Support Help Desk.

Read ETR's Adaptations Policy.

Training & TA

For over 30 years, ETR has been building the capacity of community-based organizations, schools, school districts, and state, county and local agencies in all 50 states and 7 U.S. territories to implement and replicate evidenced-based programs (EBPs) to prevent teen pregnancy, STD/STI and HIV. Our nationally recognized training and research teams work in partnership with clients to customize training and technical assistance (TA) to address the needs of their agencies and funding requirements.

Training

Educators interested in implementing Respecting the Circle of Life should be skilled in using interactive teaching methods and guiding group discussions. 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. Training options include a Training of Educators with follow-up support.

Technical assistance (TA), coaching and ongoing support

ETR provides in-person and web- or phone-based technical assistance before, during and/or after program implementation. TA is tailored to the needs of the site and is designed to support quality assurance, trouble-shoot adaptation issues, and boost implementation.

Enrichment Training

To support a holistic approach to teen pregnancy and HIV prevention programs, ETR offers a number of additional training and technical assistance opportunities, including content-specific workshops, skill-based trainings, organizational development consultation and much more. To learn more about these opportunities, visit our Training & TA pages.

Adaptation

Adaptation support materials, training and/or TA are available to assist educators in meeting the needs of individual communities by implementing EBPs effectively and consistently with core components. All adaptation support is based on ETR's groundbreaking, widely disseminated adaptation guidelines and kits for effective adaptations.

Evaluation

ETR also provides evaluation support for EBP implementation. ETR uses well-established tools for measuring fidelity and outcomes. ETR's evaluation support blends participatory approaches with cutting-edge evaluation science. Services address process and outcome evaluation and include assistance with evaluation planning, instrument design and development, implementation fidelity, data management and analysis, performance measurement, continuous quality improvement (CQI) protocols, and effective tools and strategies for reporting results.

Pricing Packages | Product Budget Calculator

Respecting the Circle of Life Pricing

Basic Set – $569.99 BUY NOW

(contains everything needed to teach with fidelity)

  • Facilitator Curriculum
  • Youth Workbook (group set of 12)
  • Activity Kit (cards, posters, job aids)
  • Youth and Parent Session Guide
  • Parent/Trusted Adult Resource Guide (group set of 12)
  • Implementation Guide
  • Supplemental Materials Resource Guide
  • Condom Demonstration Tools

Additional Youth Workbooks

Additional Parent/Trusted Adult Resource Guides

Workbook & Parent/Trusted Adult Guide Combo Pack