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
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