We Are Here Now: a Multi-level, Multicomponent Sexual and Reproductive Health Intervention for American Indian Youth

N/E is a community-based participatory research (CBPR) multi-level, multi-component sexual
and reproductive health (SRH) intervention, constructed on Ecological Systems Theory. N/E is
based on Fort Peck tribal members' desire to implement a holistic SRH intervention for AI
youth. N/E includes: 1) A school-based SRH curriculum called Native Stand, designed to
address individual-level factors that lead to sexual risk behaviors; 2) a family-level
curriculum called Native Voices, tailored to increase communication between adult family
members and youth about SRH topics; 3) a cultural mentoring component at the community level
that pairs AI youth with adults and elders to discuss traditional AI beliefs and practices
about SRH; and 4) a mobilizing strategy to activate a multi-sectoral network of
youth-servicing organizations at the systems level in Fort Peck to coordinate SRH services
for AI youth. The overarching aim of this proposal is to refine, tailor, and finalize the
components of N/E and evaluate its efficacy. We will use a cluster-randomized stepped-wedge
design (SWD), in which 5 schools that AI youth from Fort Peck attend are the clusters to be
randomized into the intervention 1 at a time, with all schools eventually being randomized to
the intervention. The 5 schools are located in separate communities, mitigating the potential
for cross-contamination. N/E is a 5-year study involving 456 15- to 18-year-old AI youth.

Our specific aims are:

AIM 1: Refine, tailor, and finalize the components of N/E. Our community advisory board and
the Fort Peck-based and MSU-based research team will design culturally appropriate
adaptations for N/E's 4 levels during the first year of the study, based on the analysis of
our recently completed qualitative and quantitative research (focus groups, interviews, and
surveys), as well as discussions with elders and community stakeholders.

AIM 2: Test the efficacy of N/E for 15- to 18-year-old AI youth. Our hypotheses are:

H1: AI youth who participate in N/E will demonstrate increased condom use at 3, 9, and 12
months. (12 months will be used in the Primary Outcome analysis; 3 and 9 months will be used
in the Secondary Outcomes analysis.) H2: AI youth who participate in N/E will demonstrate
increased use of other birth control at 3, 9, and 12 months. They also will demonstrate a
decrease in sexual risk behaviors as measured by reduced number of sex partners, delayed
onset of sexual intercourse, and decreased substance use during sex, at 3, 9, and 12 months.
(Secondary Outcomes) H3: N/E parents/legal guardians and youth will demonstrate significantly
increased communication about topics related to SRH at 3, 9, and 12 months. AI youth who
participate in the cultural mentoring program will demonstrate significantly increased
understanding of cultural values related to traditional AI beliefs regarding SRH at 3, 9, and
12 months. And AI youth who participate in N/E will report significantly increased use of SRH
services at 3, 9, and 12 months as a result of improved coordination among education, health
care, and social service agencies on the Fort Peck Reservation. (Tertiary Outcomes) AIM 3:
Evaluate the fidelity and acceptability of N/E. N/E's fidelity and acceptability will be
evaluated using qualitative methods, including focus groups, activity logs, and staff field
notes and meetings.

Inclusion Criteria:

- 15 to 18 years old

- a registered member of a federally recognized tribe or an associate tribal member

- a resident of Fort Peck with a parent/legal guardian. Exclusion criteria are minimal
due to the CAB's value of inclusion in the intervention.

- For inclusion in the systems-level component of the intervention, only those staff
members who sit on the Epi Team as representatives of their respective agencies are
eligible.

Exclusion Criteria:

- not meeting the aforementioned inclusion criteria

- having a medically identified physical or cognitive impairment that would impede their
understanding of and participation in the educational content and activities of Native
Stand, Native Voices, and the cultural mentoring program.