One of the first sexual and reproductive health programs to be developed and rigorously evaluated with American Indian adolescents, Respecting the Circle of Life was adapted by Johns Hopkins University Center for American Indian Health from an evidence-based intervention for STI/HIV risk reduction called FOY + ImPACT. Based on Protection Motivation Theory, the FOY + ImPACT program was originally developed in Baltimore and implemented with urban African-American youth.
The Center collaborated with Native American community members to adapt the program for use with Native youth and families, and to include a focus on unintended pregnancy as well as STI/HIV. In addition to focus groups with Native youth and Native parents, the formative research phase also included input and collaboration from tribal stakeholders through a Community Advisory Board comprised of diverse members of Tribal Governance, Indian Health Service, and community-based organizations.
Despite health disparities, including high teen birth rates and repeat teen births, Native communities and ways of life are laden with strength-based practices that promote overall health and well-being. In most Native communities there is strong familial, cultural and community attachment resulting in an inherent support system for youth during adolescence. Key factors protecting against sexual risk specific to Native communities include positive cultural identity, self-esteem, having future aspirations and an absence of internalizing and externalizing behaviors. Research shows programs building on these strengths are both desirable and impactful in Native communities.
In addition to being strength-based, programs aiming to change the sexual behaviors of Native youth and adolescents need to work across key precursor domains of behavior change. These domains, well-established in the literature for both Native and non-Native youth include knowledge, self-efficacy, intention, partner negotiation skills and communication.
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.