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. It is available in both print and digital editions, and comes with a self-paced, e-learning training.

Category Program Features
Setting Community based
Program Length

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

Peer-Group Sessions: 50, 60, 80 or 120 minutes each (Number of sessions varies depending on length of session.)
1 Parent/Trusted Adult Session: 90–120 minutes

Age Group Ages 11–19
Look Inside

Table of Contents
Alternate Sessions
Sample Lesson

Overview | Description | Population | Author


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:

  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 and in schools. The 1-session youth/parent component is delivered at home or in another private setting within 3 months after the 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 40 years of collaboration with Southwestern tribes, the center's programs now reach more than 150 tribal communities in 23 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 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. Peer-group session outlines are also available for 50-, 60- or 80-minute sessions. The number of peer-group sessions would then vary depending on session length selected.


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


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

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:

  • Had significantly better sexual/reproductive health knowledge at both 9 and 12 months.
  • Had better condom use and contraceptive use self-efficacy at both 9 and 12 months.
  • Had better partner negotiation skills around condom use at 9 months, and around contraceptive use at both 9 and 12 months.
  • Had significantly lower intention to have sex in the next year, and significantly higher intention to use a condom in the next 6 months at 9 months.
  • Reported significantly higher levels of communicating with parents about sexual/reproductive health at both 9 and 12 months.

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., Patel, H., Lee, S., Littlepage, S., Lee, A., Susan, D., Melgar, L., Slimp, A., & Rosenstock, S. (2021). Prevention of sexually transmitted diseases and pregnancy prevention among Native American youth: A randomized controlled trial, 2016–2018. American Journal of Public Health 111 (10): 1874–1884, doi: 10.2105/AJPH.2021.306447. Epub 2021 Sep 16.

Article on the impact of RCL

Teen pregnancy prevention program for Native American youth expands to Minnesota.

Core Elements | Implementation Guide | General Adaptation Guidance | 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 between 50–120 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.

Adjusting the Session Length

The original curriculum schedule may need to be adjusted in some communities so that the program can be implemented in different locations (for example, during or after school) or for shorter amounts of time. Some places may choose to do the full program in sixteen 1-hour long sessions to include all of the content, but others may need further adjustments. To shorten the sessions and maintain fidelity, be sure to keep the core elements in mind when adjusting time. Some activities can be skipped depending on the time available (examples include the knowledge feud and opening and closing rituals), while other activities can be shortened through fewer examples, fewer questions, and/or adding homework to the session.

To assist communities who find the eight 2-hour long youth sessions too long to implement, alternative schedules have been created as examples. They include ten 80-minute sessions, twelve 60-minute sessions, and twelve 50- minute sessions.

View examples of alternate sessions

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.

Self-Paced, E-Learning Training

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: 

  1. Share accurate information related to:
    • Key findings from student outcomes of the Respecting the Circle of Life evaluation
    • STD, HIV and pregnancy facts
    • STD, HIV and pregnancy prevention methods
    • Adolescent risk behaviors for pregnancy, STD and HIV
  2. Increase student proficiency to:
    • Utilize assertive communication and refusal skills
    • Utilize decision-making skills
    • Assess short- and long-term goals
    • Assess personal values
    • Assess and avoid risky situations
    • Avoid sex or say no to unprotected sex
    • Obtain and use condoms and other methods of contraception
  3. Effectively use the following teaching strategies:
    • Group Agreements
    • Brainstorming
    • Roleplay
    • Small-group work
    • Working with guest speakers
    • Large-group discussion
    • Answering student questions accurately and sensitively
  4. Model Respecting the Circle of Life lessons and activities with fidelity.
  5. Identify the impact of personal values on teaching.
  6. Determine acceptable adaptations to the curriculum.
  7. Identify potential barriers and potential solutions for implementing Respecting the Circle of Life.
  8. Create an action plan to implement Respecting the Circle of Life.