Original research article
Pilot testing Fostering Open eXpression
among Youth (FOXY), an arts-based HIV/
STI prevention approach for adolescent
women in the Northwest
Candice L Lys
, Carmen H Logie
and Moses Okumu
Fostering Open eXpression among Youth (FOXY) is an arts-based HIV prevention program developed by Northern
Canadians to address sexual health, HIV, sexually transmitted infections (STIs), sexuality, and healthy relationships among
Northern and Indigenous youth in Canada. We conducted a pilot study with Indigenous and Northern young women
aged 13–17 years from 17 communities in the Northwest Territories to evaluate whether, in comparison to pre-
intervention, FOXY participants demonstrated increased knowledge of STIs, increased safer sex self-efficacy, and
increased resilience. Wilcoxon test results indicated significant increases in STI knowledge scores and safer sex self-
efficacy scores. Findings suggest that FOXY holds promise as an effective method of delivering sexual health information
through peer education, and increasing STI knowledge, safe sex self-efficacy, and resilience.
Arts-based intervention, HIV/STI prevention, Indigenous, Northwest Territories, youth
Date received: 26 January 2018; accepted: 21 March 2018
Sexually transmitted infections (STIs) cause a substan-
tial and immediate threat to the health and wellbeing of
young Canadian Indigenous women. While Indigenous
populations (First Nations, Inuit, and Me
4.3% of the Canadian population, this population
accounted for 10.8% of new HIV infections in 2014.
The Public Health Agency of Canada also points to
higher prevalence of other STIs, such as sevenfold
higher rates of Chlamydia, among Indigenous adults
in comparison with their non-Indigenous counter-
New HIV infections occur disproportionately
among the adolescent and young adult population
(15–29 years), representing 31.6% of HIV-positive
cases compared to other age groups.
Indigenous women, the HIV infection rate is double
that of the non-Indigenous population.
among Canada’s young Indigenous women is inﬂu-
enced by factors such as mental health issues from his-
torical trauma and racism,
alcohol and drug use,
and limited availability of
comprehensive and culturally relevant interventions to
address these structural drivers of HIV.
rupting the transmission of HIV and STIs represents an
urgent public health priority for the Northwest
Territories (NWTs), efﬁcacious strategies for HIV
and STI prevention among Indigenous young women
in Canada remain an understudied area of research
that also needs attention.
University of Toronto Dalla Lana School of Public Health,
Fostering Open eXpression among Youth, Yellowknife, Canada
University of Toronto Factor – Inwentash Faculty of Social Work,
University of Toronto, Women’s College Hospital, Toronto, Canada
Candice Lys, FOXY, 240 Borden Drive, Yellowknife NT X1A 3R4,
International Journal of STD & AIDS
!The Author(s) 2018
Reprints and permissions:
To slow down the spread of HIV and STIs among
young people, public health researchers and service
providers advocate for the development and implemen-
tation of innovative health promotion programs that
better engage young populations.
should encourage the incorporation of information
on social and peer norms while leveraging protective
health behaviors, thus empowering participants with
the skills necessary to make informed sexual health
Speciﬁc to HIV and STI prevention pro-
grams, arts-based interventions are prominent in the
literature as promising methods for reaching and
engaging youth, modifying sexual behavior outcomes
among adolescents, and addressing public health con-
cerns among other marginalized populations.
Current evidence on the public health impact of arts-
based interventions among adolescents documents sev-
eral positive outcomes.
Unlike didactic teaching
methods, arts-based interventions provide an interac-
tive environment while recognizing the knowledge,
experiences, and contributions of program partici-
This environment enables participants
to engage socially and emotionally, while at the
same time inﬂuencing behavior modiﬁcation.
Furthermore, arts-based interventions can address cul-
tural considerations while providing participants with
consistent messaging aimed at skill development tai-
lored to inﬂuence speciﬁc behaviors for change.
The use of peer educators who can easily identify
with the developmental challenges of adolescents is
praised as a strength of these interventions.
based interventions allow for participants to learn in a
fun environment where their personal experiences are
welcomed and utilized to enhance sexual health educa-
Finally, adolescents who participate in
arts-based interventions ﬁnd them informative, inclu-
sive, acceptable, fun, and memorable.
literature indicates that there is a need to include rig-
orous evaluation while developing accessible, engaging,
and culturally appropriate arts-based sexual health
education to increase the replicability and generaliz-
ability of interventions.
Research on the public health impact of arts-based
interventions among adolescents is still emerging.
There is a paucity of evidence regarding rigorously
evaluated interventions utilizing samples of adolescents
from Indigenous populations, where the incidence of
HIV is increasing.
While arts-based interventions
are gaining popularity among adolescent health
researchers and practitioners, the impacts of these
interventions on improving the sexual health of adoles-
cents are less known. Through developing and testing a
peer-led, age-speciﬁc, and culturally relevant arts-based
intervention, the current study will add to the emerging
literature on the effectiveness and generalizability of
arts-based interventions among Indigenous adolescent
women in Canada.
This manuscript describes the implementation of
Fostering Open eXpression among Youth (FOXY),
an arts-based intervention developed by Northern
Canadians for adolescents across the NWTs delivered
by peer educators. Our primary objective was to eval-
uate whether, in comparison to pre-intervention, ado-
lescent women who attended FOXY demonstrated
increased knowledge of STIs. Our secondary objective
was to examine if, in comparison to pre-intervention
scores, participants who received the FOXY interven-
tion would report the following changes in scores at the
post-intervention evaluation: (1) increased safer sex
self-efﬁcacy and (2) increased resilience.
FOXY project staff recruited potential participants
from secondary schools across the NWTs from
September 2015 to May 2016. Active recruitment meth-
ods were utilized to establish contact with potentially
qualifying program participants, including school out-
reach, use of volunteers at high schools, and referrals
from friends of participants. All potential program par-
ticipants were screened to determine eligibility through
the following criteria: individuals self-identifying as
female, residing in the NWTs, willing to attend
FOXY, aged 13–17 years, and capable of providing
The study consists of a multicenter nonrandomized
pragmatic cohort pilot using a pretest/posttest design
approved by the Ethics Review Board at the University
of Toronto and the Aurora Research Institute. Eligible
study participants completed a baseline assessment
before attending a FOXY intervention. Immediately
following completion of the FOXY intervention, par-
ticipants completed a post-intervention evaluation.
Trained facilitators and adolescent peer leaders on
staff cofacilitated these sessions.
FOXY is an interactive arts-based HIV prevention pro-
gram that addresses sexual health, HIV and STIs, sex-
uality, and healthy relationships among Northern and
Indigenous youth in Canada. A unique component of
FOXY is the use of arts-based methods and peer facil-
itation to educate without judgment. The FOXY inter-
vention involves seven workshops lasting between 1
and 2 hours each and conducted over 1–2 days in
2International Journal of STD & AIDS 0(0)
communities across the NWTs (see the study protocol
for further details regarding content of a typical FOXY
Each workshop hosts 8–15 participants
and is led by professional facilitators and trained peer
leaders with expertise in sexual health education and
arts-based HIV prevention.
Cross-sectional surveys were administered directly
before the FOXY workshop and directly following
the workshops. We used venue-based sampling to
recruit participants from Grade 7 to 12 classes at sec-
ondary schools in 17 communities across the NWTs:
Aklavik, Whati, Fort McPherson, N’Dilo, Lutselk’e,
Fort Liard, Fort Simpson, Yellowknife, Ulukhaktok,
Fort Resolution, Behchoko, Inuvik, Tuktoyaktuk, Hay
River, Katlodeeche First Nation, Fort Smith, and
Norman Wells. Self-administered structured surveys
assessed sociodemographics, STI knowledge, safer sex
self-efﬁcacy, and resilience. Participants received remu-
neration valued at $25 (a FOXY branded t-shirt)
for the baseline assessment and post-interven-
Three primary outcome variables were used to assess
the efﬁcacy of the FOXY intervention in increasing STI
knowledge, safer sex self-efﬁcacy, and resilience. Since
these measures were based on self-report, to enhance
the validity of participants’ responses, the researchers
collected posttest assessments immediately following
the intervention to optimize recall of knowledge.
STI knowledge outcomes
Items regarding STI knowledge (Cronbach’s
Alpha ¼0.765, range ¼1–14) were adapted from a pre-
Participants were asked to indicate true
or false to a 14-item scale (score range 1–14).
Safer sex self-efficacy outcomes
This scale measured participants’ current conﬁdence in
using condoms consistently in a variety of situations
with different partners.
The measure consisted of
ﬁve items assessed on a ﬁve-point Likert scale. We
computed a mean score such that higher scores indicat-
ed greater safer sex self-efﬁcacy (Cronbach’s
Alpha ¼0.864, range ¼1–4).
Using the Child and Youth Resilience Measure
(Cronbach’s Alpha ¼.875, range ¼1–12), participants
were asked to rate the availability of individual,
relational, communal, and cultural resources. The mea-
sure consisted of 11 items assessed on a ﬁve-point
Descriptive statistics were used to explore the sociode-
mographic (e.g. age, sexual orientation, parents
attended residential schools, dating relationship) char-
acteristics of the sample. A Kolmogorov–Smirnov test
was used to test for normality on all outcome variables.
Due to the nonnormality of the outcome variables, a
Wilcoxon test was conducted to evaluate whether par-
ticipants had improved their STI knowledge, safer sex
self-efﬁcacy, and resilience before and immediately
after the intervention. The data were analyzed using
IBM SPSS 23.
As shown in Table 1, among participants (n ¼199),
20.5% (n ¼39) identiﬁed as sexual minorities; most
participants 79.4% (n ¼154) identiﬁed as Indigenous.
More than half of the participants reported depressive
symptoms (59.8%; n ¼119), and over one-third of par-
ticipants reported food insecurity (31.7%; n ¼63).
Approximately one-quarter (27%; n ¼53) were in a
dating relationship. About 34.5% (n ¼67) used one
or more substances (e.g. alcohol, weed, coke, speed,
ecstasy) in the three months prior to the survey.
Regarding sexual practices, 12.1% (n ¼24) of adoles-
cent women reported engagement in oral sex, while
17.7% (n ¼35) engaged in vaginal sex. When asked if
they perceived themselves to be at risk for either HIV
or STIs, 14.6% (n ¼29) of participants believed they
were at risk for HIV and 18.6% (n ¼37) believed they
were at risk for STIs.
Pre-intervention outcome measure scores differed by
certain sociodemographic characteristics: depressive
symptoms, Indigenous identity, sexual orientation,
and food security. Participants with depressive symp-
toms reported increased STI knowledge (M ¼4.59,
SD ¼1.54) compared to participants without depres-
sive symptoms (M ¼4.06, SD ¼1.42). Adolescents
who identiﬁed as Indigenous reported lower resilience
scores (M ¼38.57, SD ¼9.51) compared to non-
Indigenous participants (M ¼41.97, SD ¼9.43).
Sexual minorities reported lower STI knowledge
(M ¼3.82, SD ¼1.27) compared to their heterosexual
counterparts (M ¼4.51, SD ¼1.62). Adolescents
experiencing food insecurity reported lower resilience
scores (M ¼36.41, SD ¼9.21) and higher STI
Lys et al. 3
knowledge scores (M ¼4.69, SD ¼1.53) compared to
participants who did not report food insecurity.
Pre- to post-intervention outcome differences
Table 2 reports the signiﬁcant STI knowledge score
median differences before (Mdn ¼4) and after
(Mdn ¼9) the intervention (z ¼9.740, p <0.001,
r¼0.490). STI knowledge scores were signiﬁcantly
higher following the intervention. Safer sex self-
efﬁcacy scores were signiﬁcantly higher following the
intervention (Mdn ¼88) in comparison with pre-inter-
vention scores (Mdn ¼82), z ¼4.110, p <0.001,
r¼0.220. After attending the FOXY intervention,
participants reported slightly higher resilience scores
(Mdn ¼41) compared to pre-intervention (Mdn ¼40),
z¼2.820, p <0.010, r¼0.140.
This study reports on an assessment of the feasibility
and efﬁcacy of FOXY, an arts-based HIV and STI
prevention intervention implemented with young
women in the NWTs, a region with Chlamydia rates
ten-fold that of Canada’s national prevalence.
study provides the ﬁrst statistical support for the feasi-
bility and initial indicators of the FOXY intervention,
demonstrating increases in participants’ STI knowl-
edge, safer sex self-efﬁcacy, and resilience. We had
high study completion (90%), suggesting acceptability
of FOXY among Northern and Indigenous young
women. Though evaluative data on the effectiveness
of arts-based interventions among Indigenous young
people are scant, our study demonstrates that the appli-
cation of interactive approaches appears to hold much
promise for HIV and STI prevention among young
Indigenous and Northern women in Canada.
According to Coyle et al.,
for an HIV or STI pre-
vention program to be efﬁcacious, the intervention
should be interactive, age speciﬁc, and geographically
and culturally relevant in order to increase the uptake
and retention of sexual health information. To our
knowledge, there is a dearth of studies that have eval-
uated the effectiveness of arts-based HIV and STI pre-
vention interventions among Indigenous and Northern
young women, particularly in the Canadian context.
Our pilot ﬁndings suggest that FOXY holds promise
as an effective method of delivering sexual health infor-
mation, and increasing STI knowledge, safer sex self-
Table 1. General characteristics of Northern adolescent
women at baseline (N ¼199).
Age (years of age) 13.85 (1.27)
Sexual orientation (missing¼9)
Heterosexual 151 (79.5)
Sexual minority 39 (20.5)
Yes 154 (79.4)
No 40 (20.6)
Depressive symptoms (missing¼11)
Yes 119 (59.8)
No 69 (34.7)
Food security (missing¼6)
Yes 130 (65.3)
No 63 (31.7)
Relationship status (missing¼1)
Dating 53 (26.8)
Not dating 145 (73.2)
Substance use (missing¼5)
Yes 67 (34.5)
No 127 (65.5)
Oral sex (missing¼2)
Yes 24 (12.1)
No 173 (87.4)
Vaginal sex (missing¼1)
Yes 35 (17.7)
No 163 (82.3)
Perceived HIV risk (missing¼7)
Yes 29 (14.6)
No 163 (81.9)
Perceived STI risk (missing¼4)
Yes 37 (18.6)
No 158 (79.4)
STI: sexually transmitted infection.
Note: The percentages are calculated to exclude missing values.
Table 2. Differences in outcome scores from pre- to post-intervention.
(interquartile range) Effect size r
STI knowledge 4 (1) 9 (5) 4 (5) 0.49***(M)
Safer sex self-efficacy 82 (20) 88 (20) 3.25 (12) 0.22***(M)
Resilience (R) 40 (12) 41 (13) 1 (6) 0.14**(M)
STI: sexually transmitted infection.
*p <.05, **p <.01, ***p <.001 for asymptotic two-tailed Wilcoxon Signed Ranks Test.
(M) ¼moderate effect size with r smaller or equal to 0.3 but larger than 0.5; (L) ¼large effect size with r smaller or equal to 0.5.
Median difference is calculated based on postscores minus prescores.
4International Journal of STD & AIDS 0(0)
efﬁcacy, and resilience.
In addition, our study is con-
sistent with prior research on the importance of peer
educators on providing an encouraging environment
for adolescents to share potentially sensitive informa-
tion about their sexuality and sexual practices.
This study has limitations, and therefore, the results
should be interpreted with caution. First, the nonran-
dom sample and lack of a control group limits the gen-
eralizability of our ﬁndings. The use of a convenience
sample may have biased the evaluation toward overes-
timating the beneﬁts of FOXY. Furthermore, the risk of
measurement error might be high due to reliance on self-
reports, raising the risk of social desirability. However,
our team of trained researchers and peer leaders imple-
mented several measures at the outset of the study to
minimize the limits of self-report, including expert
review of the instruments and pilot testing surveys
with peer leaders. Since this study reports preliminary
ﬁndings of the FOXY intervention, it is too early to
assess whether the effects of the interventions hold
over time. Therefore, there is need for longitudinal stud-
ies to evaluate the long-term outcomes of the FOXY
arts-based HIV and STI prevention intervention.
Furthermore, there were several challenges with
implementing the intervention. Sexual health can be a
sensitive subject for some individuals, so great care was
taken during the development of the intervention to
ensure that it was developmentally and culturally
appropriate for Northern youth. This attention to
detail prolonged the development phase of the inter-
vention. Also, delivery of the intervention occurs in a
dynamic environment with logistical challenges such as
limited airline schedules, weather delays while travel-
ing, and unforeseen complications such as community
events or funerals that may interrupt the delivery of
interventions in the NWTs or require ﬂexibility for
facilitators to accommodate community needs.
Despite these limitations, this study offers strong
preliminary evidence on the feasibility of arts-based
interventions as an HIV and STI prevention approach
and provides foundational details to inform the
improvement and future scale-up of the FOXY inter-
We demonstrated the importance of combin-
ing peer education with arts-based approaches in
advancing HIV and STI prevention with young
Northern women. Our sample’s demographics were
representative of adolescent females in the NWTs,
with rates of depression and sexual practices similar
to national health surveys.
This suggests that the
ﬁndings from this pilot study may be applicable to
other Northern and Indigenous adolescent women
who may face similar experiences in other regions of
Canada outside the NWTs. With limited evaluations of
arts-based interventions in Canada focusing on sexual
health, we compare our ﬁndings to interventions
implemented in the United States, United Kingdom,
South Africa, and Australia that reported similar ﬁnd-
ings regarding increases in STI knowledge, safer sex
In Canada, Indigenous peoples have HIV infection
rates 2.7 times higher than their non-Indigenous coun-
This high rate of HIV infection underscores
the urgency for building an evidence base of efﬁcacious,
innovative, and comprehensive HIV/STI interventions
that are developed and led by Indigenous peo-
Scant published research has evaluated the
effectiveness of arts-based interventions among
Indigenous adolescent women in the Canadian North
and this pilot research adds to the knowledge base of
promising approaches to HIV and STI prevention with
Northern and Indigenous young women.
STI prevention interventions that are tailored for the
unique needs and lived realities of Northern and
Indigenous young women are interactive, engage with
peers in a group-based format, leverage the protective
factors of resilience, and take into consideration the
developmental and cultural context of participants
have potential to promote sexual health and wellbeing
in the NWT.
Declaration of conflicting interests
The author(s) declared no potential conﬂicts of interest with
respect to the research, authorship, and/or publication of
The authors received ﬁnancial support from the Canadian
Institutes of Health Research and the Public Health Agency
of Canada for the research of this article. CM was also sup-
ported by an Ontario Ministry of Research & Innovation
Early Researcher Award.
Candice L Lys http://orcid.org/0000-0003-2621-1095
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