8th International Meeting on Indigenous Child Health

March 2019

Jaime Begay, Tuba City Program

Coordinator

Rachel Chambers, Program Manager

Development of the Asdzaan Be’eena’

(Female Pathways) Program

Disclosure Statement

• In the past 12 months Jaime Begay has not had relevant

financial relationships with the manufacturer(s) of

commercial services discussed in this CME activity

• I do not intend to discuss an unapproved/investigative

use of a commercial product/device in my presentation.

• In the past 12 months Rachel Chambers has not had

relevant financial relationships with the manufacturer(s)

of commercial services discussed in this CME activity

• I do not intend to discuss an unapproved/investigative

use of a commercial product/device in my presentation.

Johns Hopkins Center for American Indian Health at the

Bloomberg School of Public Health

Founded in 1991 by Dr.

Mathu Santosham, based on

10 years’ of work with SW

tribes

Mission: To work in

partnership with American

Indian and Alaska Native

communities to raise health

status, self-sufficiency and

health leadership of AI/AN

people to the highest possible

level

The Center’s

work now

serves 125+

tribal

communities

across 20

states.

Center focuses on employing Native staff to do

outreach and health research in their

communities, and Native faculty to assist with

training of AI/AN scholars at JHU

Building local work force capacity

Changing the Future:

Working Across the Lifespan

Birth

Early Childhood

Middle Childhood

Adolescence

Adulthood

“Family Spirit and Family Spirit Nurture” 0-3:

Parenting/Healthy Start

“Arrowhead” Youth

Entrepreneurship

“Together on Diabetes”

Family Health Coach Model

“NativeVision”

Health and Education Promotion

Higher Ed

Scholarships

“Celebrating Life”

Suicide Prevention

“Respecting the Circle of Life”

Teen Pregnancy/STI prevention

Maternal and

Child Immunization

“EMPWR” Risk

Reduction &

Counseling

Pneumonia

Prevention

IPV Prevention “Female Pathways”

Preconception Health Program

What is the Asdzaan Be’eena’

(Female Pathways) Program?

A program for Native girls ages 8-11 and their female

caregiver(s) that is grounded in the strengths of Navajo

culture and community.

We seek to intervene before a child enters their teen years

and provide them with the tools to have a healthy transition

through puberty and into adulthood

Why Mothers or Female Caregivers and their

daughters?

• Navajo is a matrilineal society– Women play a strong role in Navajo society

– The program will reinforce the strength of Navajo women

• The Kinaalda Ceremony– Sacred coming of age ceremony

– Emphasizes the strengths of the Navajo culture and Navajo women

– The program will reinforce some of the concepts that are emphasized during the Kinaalda

• Role of parents/adults in children’s lives– Parents and adult caregivers are essential to

positive development of children

– The program will help to build a strong relationship between girls and their mothers/female caregivers

Asdzaan Be’eena’ Program Goals

• Long-Term Program Outcomes– Prevent teen substance use

– Prevent risky sexual behavior and teen pregnancy

• Short-Term Program Outcomes

– Girls ages 8-11 and female caregivers• Mother-Daughter relationship quality

• Cultural knowledge and connectedness

• Reproductive health knowledge

– Girls ages 8-11• Self esteem, self efficacy & social support

• Attitudes about risky behaviors

• Internalizing and externalizing behaviors

– Caregiver • Parenting self-efficacy

• Depression

• Substance use attitudes and behaviors

Program Development

Finalizing Curriculum

Review of curriculum by project team

Review of curriculum by cultural experts

Review of Findings & Development of Curriculum

Review of findings with community stakeholders

Development of curriculum topics and ideas

Meeting with cultural experts

Draft curriculum modules

Initial Formative Work

Engagement of Community Advisory Board

Qualitative data collection with local communities

Development of themes/iterative analysis

Engaging Community Advisory Boards in Two

Navajo Communities

• Determined how the program should

be delivered to girls ages 8-11 and

female caregivers

• Created a plan for qualitative research

(recruitment, logistics, etc)

• Reviewed and finalized guides for

focus groups and in-depth interviews

• Guided interpretation of findings from

formative research

• Advised on curriculum topics and

themes

Formative Research With Two Navajo Communities

• 11 Focus Groups; 17 In-Depth Interviews– Focus groups and interviews with: girls ages 8-24;

mothers; grandmothers; grandfathers; fathers; and traditional practitioners/cultural experts

• 200 Surveys– Surveys with adult women to assess reproductive health

knowledge and practices related to a girls’ transition to womanhood

Themes from Focus Groups and Interviews

• Cleanliness is emphasized during puberty

• Mothers have little reproductive health knowledge

• Gender roles are important

• Respect for self and others is valued and reflected through

how one dresses

• Knowing clans is important

• A variety of relatives raise young girls

• Historical events are examples of resiliency

• Language is a source of pride

• Education is highly valued

• All milestones in a woman’s life are important and should

be discussed when a child is young

Findings from Surveys

• 54% said their mother is their role model

• 85% of participants said Navajo culture is a strength

• Women first spoke to female caregiver about sexual health

at these ages:– < 9 years old: 30%

– 10-14 years old 44%

– >14 years old: 13%

• 57% felt comfortable talking to their mom about puberty

when they were younger

• 49% had a right of passage ceremony

• 71% wished they learned more about reproductive health

during or before puberty

Engaging Cultural Experts

• Guided curriculum development– Used cultural teachings to inform the curriculum concepts and activities

– Organized curriculum to be consistent with the Navajo Creation Story

– Determined order and format of curriculum

– Discussed specific activities in each lesson and determined what was and

was not appropriate/how activities should be done

– Wrote sections of the curriculum

Program Design, Based on Formative Work

• Enroll participants as “Dyads”

– Girls ages 8-11

– Female Caregiver (18 years or older)

• Program will include a mix of group and individual sessions

– Individual dyad sessions will be delivered in the home

– Group sessions will be delivered in a central place in the community

• Program will consist of 11 lessons delivered weekly

• Implementation will last for 3 months

• Program will be delivered by a Health Coach with cultural

knowledge; cultural experts will assist with group lessons

when possible

Curriculum Topics, Based on Formative WorkBlack World

• Lesson 1 (Dyad): The Clan System and Family

• Lesson 2 (Dyad): Role Models, Respect and Boundaries

Blue World

• Lesson 3 (Group): Mother Daughter Communication

• Lesson 4 (Dyad): Support Networks and Family

Yellow World

• Lesson 5 (Group): Navajo Women’s Strength Through History

• Lesson 6 (Dyad): Positive Thinking and Problem Solving

• Lesson 7 (Group): Communication and Dealing with Bullying

White World

• Lesson 8 (Dyad): Community, Family and Cultural Values

• Lesson 9 (Group): Reproductive Health

• Lesson 10 (Dyad): Self-Esteem and Goal Setting

Glittering World

• Lesson 11 (Group): Holistic Living

Pilot Study and Program Refinement

• Phase 1– Pilot with N=20 Dyads

– Collect outcome data and process/implementation data

– Focus on feasibility and implementation

– After phase 1, refine curriculum and evaluation based on feedback

• Phase 2– Pilot refined program with N=40 dyads

– Collect outcome data and process/implementation data

– Focus on outcome data/preliminary impact of the program

• Phase 3– Refine program based on findings

• Phase 4– Apply for funding and conduct a large Randomized Controlled Trial to assess

program effectiveness

Evaluation Methods for Pilot Study

• Implementation Evaluation

– After each session• Child and Caregiver Session Feedback Forms

• Health Coach Session Feedback Form

– Post-Implementation• Child and Caregiver Program Feedback Form

– Adoption, acceptability, appropriateness, perceived impact & satisfaction

• Outcome Evaluation

– Baseline• Evaluation to assess program impact

– Post-Implementation• Free listing exercise to assess program impact

• Evaluation to assess preliminary program impact

– 3 Month Post-Implementation• Evaluation to assess preliminary program impact

Phase 1 Baseline Evaluation: Child (n=20)

Age m (sd) 9.25 (1.12)

Tribal Affiliation: n (%)

Navajo

Navajo + Another Tribe

16 (80%)

4 (20%)

Participates in Cultural Activities: n (%)

Participates in Church: n (%)

14 (70%)

7 (35%)

Language: n (%)

- Can speak Navajo

- Wants to speak Navajo when older

8 (40%)

20 (100%)

Wants to have a Kinaalda: n (%)

Yes

No

I don’t know

7 (44%)

1 (6%)

7 (44%)

How well do you do in school: n (%)

- Very good

- Good

- Okay

5 (24%)

9 (43%)

6 (29%)

Phase 1 Baseline Evaluation: Child (n=20)

Mean (SD)

Cultural Knowledge (0-1) .55 (.239)

Leach Connectedness Scale (0-4) 3.37 (.307)

Family Cultural (Navajo) Connection (0-2) 1.26 (.283)

Female Caregiver- child relationship (0-2) 1.61 (.327)

Self-Efficacy (0-1) .89 (.152)

Attitudes Toward Risky Behaviors (0-2) 1.13 (.278)

Phase 1 Baseline Evaluation: Caregiver (n=20)

*Reverse coded (lower=better)

Age: mean (sd) 39.1 (10.27)

Relationship to child: n (%)

Mother

Grandmother

18 (90%)

2 (10%)

Employed: n (%) 16 (80%)

Attended some college/graduated from college: n (%) 13 (65%)

Participated in Cultural Activity in past 12 months: n (%)

Participates in Church: n (%)

16 (80%)

7 (35%)

Language: n (%)

- Speaks Navajo

- Understands Navajo

14 (70%)

16 (80%)

Drug and alcohol use: n (%)

- Has ever used alcohol

- Age first drank alcohol (n=16): mean (sd)

- Has used alcohol in past 3 months

- Has ever used illegal drugs

- Age first tried illegal drugs (n=6): mean (sd)

16 (80%)

17.9 (3.32)

6 (30%)

6 (30%)

14.2 (1.8)

Phase 1 Baseline Evaluation: Caregiver (n=20)

Mean (SD)

Cultural Knowledge (0-1) .75 (.089)

Leach Connectedness Scale (0-4) 3.4 (.415)

Family Connection to Navajo (0-3) 1.83 (.782)

Female Caregiver-Child Relationship (0-4*) 1.81 (.556)

Parental Monitoring Scale (0-5) 3.83 (.371)

Parenting Self-Efficacy (0-4*) .47 (.429)

*Reverse coded (lower=better)

Phase 1: Program Feedback: Child

• General Feedback

– Individual dyad sessions (80 completed)

• 98% of girls liked the lesson

• 92.5% liked the delivery method

– Group dyad sessions (56 completed)

• 98% of girls liked the lesson

• 100% liked the delivery method

• Favorite Parts of lessons– Learning about Clans/Navajo history/culture/Kinaalda

– Hands on activities

– Creating a family collage

– Getting an emergency kit

– Learning about communication/active listening

– “seeing mom learning too”

– Time to talk with my mom

Phase 1: Program Feedback: Caregiver

• General Feedback (136 lessons completed)

– Accessibility

• 96% said the lessons were easy to attend

• 97% said the lessons fit into their daily schedule

– Acceptability

• 100% of caregivers liked all lessons

• 99% understood what was taught to them

• 97% said the lesson taught them helpful skills

• 99% said the skills would be relevant to other caregivers

• 99% felt comfortable with their group

– Appropriateness

• 98% said the lesson fit with their values

– Adoption

• 98% said they would recommend the lesson to others

Phase 1: Program Feedback: Caregiver

• Favorite Activities/Aspects of the Lessons

– Helping child define their personal space

– Learning about puberty/reproductive health

– Cultural knowledge

– Communicating with child/communication exercises

– Anti-bullying discussion

– “The bonding experience with my daughter”

– “Realizing that more communication and alone time needs to

happen between my daughter and I”

– “Learning about my daughter”

– The self-reflection that occurs during lessons

– Learning new skills such as problem solving

Suggested Changes to the Program

• Include more hands on activities and hand outs

• Shuffle activities to allow more time for specific activities

and less time for other activities– Lesson 3 was too long, move final activity to another lesson

• Include more activities that start with a discussion between

the mother and daughter– Navajo history lesson should be more of a discussion, less lecture

• Make some language and scenarios more appropriate for

this age group

• Revisit and refine language in some of the lessons

Perceived Impact

Caregiver (n=6) m (sd)

Improve Communication 3 (1.26)

Improve Relationship with

Child

3 (1.26)

Become better parent 3 (.894)

Improve cultural knowledge 2.5 (.837)

Improve connection to culture 2.5 (1.05)

Pride in being Navajo 3.17 (.983)

Feel better about self 3 (1.10)

Increase Support System 1.67 (1.03)

Scale: Not at all (1), A little (2), A moderate amount

(3), A lot (4)

Child (n=6) n (%)

Talk to caregiver more

Yes, a lot

Yes, a little

No

1 (17%)

2 (33%)

3 (50%)

Caregiver Listens More

Yes, a lot

No4 (67%)

2 (33%)

Taught you things about

being Navajo

Yes, a lot

Yes, a little

4 (67%)

2 (33%)

Make you feel happy you

are Navajo

Yes, a lot

6

(100%)

Qualitative Feedback- Perceived Changes (n=6)

• Child– More Active

– Dad expresses self more

– Talk more with mom

– Made a new friend

– Talks with family about Navajo

• Parents– More open with daughter

– Talk with daughter about puberty, kinaalda etc.

– We (daughter and I) have more one-on-one time

– Daughter talks to great grandmother more

– Daughter is more confident about being Navajo (wears Navajo bun and

moccasins more often)

Next Steps

• Refine lessons based on feedback

• Implement and evaluate the refined program with N=40

dyads (Phase 2)

• Analyze implementation findings

• Pilot program with another Tribal community

• Apply for funding for larger trial

Acknowledgements

• Participating Families

• Navajo Tribal Members

• Navajo Nation IRB

• CAIH Faculty and Staff

• RX Foundation

31

THANK YOU

Contact:

bjaime1@jhu.edu

rstrom3@jhu.edu