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Pilot testing Fostering Open eXpression among Youth (FOXY), an arts-based HIV/STI prevention approach for adolescent women in the Northwest Territories, Canada

  • FOXY (Fostering Open eXpression among Youth)/SMASH (Strength, Masculinities, & Sexual Health)


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.
Original research article
Pilot testing Fostering Open eXpression
among Youth (FOXY), an arts-based HIV/
STI prevention approach for adolescent
women in the Northwest
Territories, Canada
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
´tis) comprise
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.
For Canada’s
Indigenous women, the HIV infection rate is double
that of the non-Indigenous population.
HIV infection
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,
intergenerational poverty,
and limited availability of
comprehensive and culturally relevant interventions to
address these structural drivers of HIV.
While inter-
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,
Toronto, Canada
Fostering Open eXpression among Youth, Yellowknife, Canada
University of Toronto Factor – Inwentash Faculty of Social Work,
Toronto, Canada
University of Toronto, Women’s College Hospital, Toronto, Canada
Corresponding author:
Candice Lys, FOXY, 240 Borden Drive, Yellowknife NT X1A 3R4,
International Journal of STD & AIDS
0(0) 1–7
!The Author(s) 2018
Reprints and permissions:
DOI: 10.1177/0956462418770873
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.
These programs
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-
tion curricula.
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
informed consent.
Study procedures
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.
Intervention components
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.
Data collection
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-
tion assessment.
Outcome measures
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-
vious study.
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).
Resilience outcomes
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
Likert scale.
Statistical analysis
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
Descriptive characteristics
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,
r¼0.220. After attending the FOXY intervention,
participants reported slightly higher resilience scores
(Mdn ¼41) compared to pre-intervention (Mdn ¼40),
z¼2.820, 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).
Variable n(%)/M(SD)
Age (years of age) 13.85 (1.27)
Sexual orientation (missing¼9)
Heterosexual 151 (79.5)
Sexual minority 39 (20.5)
Indigenous (missing¼5)
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.
Pretest Mdn
Posttest Mdn
Median difference
(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
and resilience.
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.
HIV and
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
this article.
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
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Lys et al. 7
... Adolescence is an important life stage and represents a sociobiological window of opportunity, comprised of social, physical, and brain development transitions [10]. Emergent evidence points to the role of peer programming and arts-and land-based approaches with Northern and Indigenous adolescents in Canada to explore coping strategies [11] and support resilience, personal connectedness, and self-efficacy [12]. Land-based approaches can share teachings of relationality, reciprocity, and holism [13][14][15] to support resilience, address adversity, and improve health and well-being. ...
... Fostering Open eXpression among Youth (FOXY) [12] and Strength, Masculinities, and Sexual Health (SMASH) [34] conduct Peer Leader Retreats as part of an action research programme to promote healthy relationships, sexual health, and resilience among Northern and Indigenous adolescents in the Northwest Territories using a peer model [12]. Retreats were held annually between 2017 and 2019 with adolescents aged 13-17 and included Indigenous teachings, arts-based methods, leadership skill development, and land-based activities. ...
... Fostering Open eXpression among Youth (FOXY) [12] and Strength, Masculinities, and Sexual Health (SMASH) [34] conduct Peer Leader Retreats as part of an action research programme to promote healthy relationships, sexual health, and resilience among Northern and Indigenous adolescents in the Northwest Territories using a peer model [12]. Retreats were held annually between 2017 and 2019 with adolescents aged 13-17 and included Indigenous teachings, arts-based methods, leadership skill development, and land-based activities. ...
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Indigenous adolescents in Canada are among those shouldering the impacts of colonialism and racism. Peer approaches and art-and-land-based programming have demonstrated promise to support empowerment and well-being, yet little is known about their efficacy with Northern and Indigenous adolescents in Canada or of how this group conceptualises empowerment. Fostering Open eXpression among Youth (FOXY) and Strength, Masculinities, and Sexual Health (SMASH) conduct land-and-arts-based Peer Leader Retreats with adolescents from the Northwest Territories, Nunavut and the Yukon Territories. Retreats (2017–2019) included 286 participants (n=196 women [trans-inclusive], n=84 men [trans-inclusive], n=5 non-binary), aged 12–19, the majority of whom (n=235) were Indigenous. Participants completed surveys immediately before and following retreats and 6 months after. Focus group discussions (FGDs) (n=24) were conducted with participants (peer leaders and apprentices) (n=232) following the retreat, and youth staff members (peer facilitators) (aged 14–21, n=7 FGDs). Applying thematic analysis, we explored retreat experiences (FGDs), and Wilcoxon signed-rank tests to examine pre/post retreat changes in leadership, empowerment, and self-confidence (surveys). Quantitatively, there were statistically significant increases in leadership and empowerment in post-retreat scores compared to pre-retreat. Qualitatively, findings demonstrate how Peer Leader Retreats premised on land-and-art-based approaches can support empowerment, confidence, leadership, and social-connectedness.
... In addition to being overrepresented in this pandemic, epidemiological data show that Indigenous people in Canada tend to contract HIV at a younger age than the general population [15]. Indigenous people in Canada, and Indigenous youth in particular, are also overrepresented in rates of other STBBIs [16]. In order to address this disproportionate burden of poor health outcomes faced by Indigenous people in Canada, current health promotion efforts must include the impacts of colonisation as a determinant of health [10]. ...
... They have been recognised as promising approaches for sexual health promotion and HIV prevention with Indigenous youth [17,34,35]. Artsbased approaches are credited with being "fun, participatory, and empowering ways" of engaging Indigenous youth in health promotion and they are compatible with many other wise practices for HIV prevention with Indigenous youth, and can be used as a decolonising strategy within research [16,34,35,36]. ...
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Although Indigenous Elders were traditionally involved in cross-generational health promotion and education, colonisation disrupted this role. Little research examines the role of Elders in contemporary health promotion for Indigenous youth and few strategies have been identified to engage Elders in health promotion or sexual health education. We explored engagement of Elders through participatory filmmaking in a sexual health and HIV education workshop for youth. Eleven youth and five Elders participated in this 3.5-day workshop. During the workshop, Elders indicated they wanted to make a film and attend a sexual health and HIV education session. Four Elders were interviewed about their experiences. Interview transcripts and the Elders’ film were analysed using content analysis. Although Elders initially felt hesitant to engage, the process of participatory filmmaking allowed Elders to co-create an environment for their “comfortable” workshop engagement. Elders’ feelings of comfort were created by having control and sense of ownership over their engagement; the presence of youth; peer-based dialogue; inclusion of traditional items; and an Indigenous sexual health educator. Findings suggest participatory filmmaking is a promising approach for engaging and empowering Elders to reclaim traditional roles in sexual health education and health promotion with Indigenous youth.
... Similarly, the rate of Hepatitis C (HCV) infection is estimated to be approximately 5 times the rate in Indigenous populations than non-Indigenous populations [7,8]. Additionally, Indigenous Peoples in Canada are disproportionately affected by other STBBIs [5,9]. Across Canada, rates of other STBBI, such as syphilis, have increased significantly since 2010, and the overrepresentation of Indigenous Peoples in the STBBI statistics is a trend that is mirrored among Indigenous communities worldwide [10][11][12][13]. ...
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Background Little literature exists on culturally grounded approaches for addressing human immunodeficiency virus (HIV) and sexually transmitted and blood-borne infections (STBBI) among Métis people. The goal of this mixed-methods research was to explore the experiences of Métis community members participating in a dried blood spot testing (DBST) for HIV/STBBI pilot for Métis communities in Alberta, Canada, with the aim of assessing the acceptability of this testing method. Methods Grounded in community-based and Indigenous research approaches and working in partnership with a Métis community-based organization, data collection included a survey and four gathering circles with Métis DBST recipients at one of two community events, and semi-structured interviews with three DBST providers. Results Twenty-six of the 30 DBST recipients completed surveys, and 19 DBST recipients participated in gathering circles. Survey results suggest DBST is a highly acceptable STBBI testing method to Métis community members. Thematic analysis of gathering circle and interview transcripts revealed four broad themes related to the participants’ experiences with DBST related to its acceptability (i. ease of DBST process, ii. overcoming logistical challenges associated with existing STBBI testing, iii. Reducing stigma through health role models and event-based, and iv. Métis-specific services). Conclusions These findings illustrate the potential for DBST to be part of a culturally grounded, Métis-specific response to HIV and STBBI.
The future of Indigenous STBBI (sexually transmitted and blood-borne infections) research must address the unique needs of diverse First Nations, Inuit, and Métis (FNIM) communities across Canada. This requires the expansion of culturally responsive research approaches centred on FNIM ways of being, knowing, and doing. The Feast Centre for Indigenous STBBI Research (Feast Centre) is dedicated to expanding the use of FNIM research methods in response to the unique needs of distinct Indigenous communities and foregrounds the voices of Indigenous Peoples living with or affected by STBBI. Indigenous Peoples in Canada experience higher rates of STBBI compared to other populations, and this is linked to significant health disparities, meaning that conventional public health approaches are not meeting the needs of Indigenous communities. Canada’s colonial health policies sustain health disparities through a lack of culturally responsive approaches to STBBI prevention, treatment, and care. In this article we examine Indigenous STBBI initiatives foundational to the Feast Centre by focusing on the outcomes of a CAAN Communities, Alliances & Networks–led national Indigenous community consultation, the findings of the project’s Indigenous HIV and AIDS scoping review, and vital theoretical insights from Indigenous STBBI literature. We provide key recommendations that emphasize culturally responsive approaches to STBBI research that strive to meet community-identified needs while cultivating the inherent strengths of FNIM communities. We envision these key recommendations within the theoretical framework of Indigenous futurisms in ways that reconceptualize Indigenous STBBI research through cultural strengths and offer guidance for the direction of future research.
Limited research has evaluated sexual health promotion projects with adolescents living in Arctic regions. The study objective was to examine changes in STI knowledge and safer sex efficacy among youth in the Northwest Territories (NWT), Canada who participated in arts-based sexual health workshops. We used a pre/post-test design with a convenience sample of students aged 13-18 years recruited from 17 NWT communities. We conducted summary statistics and comparisons between pre and post-test scores using paired t-tests. Among participants (n = 610), we found statistically significant increases in STI knowledge overall (mean difference = 3.9; p < 0.001) and across gender and age stratifications. There were statistically significant increases in safer sex efficacy overall (mean difference = 0.9, p < 0.001), across genders, and among participants: aged <15 years, in rural communities, reporting food insecurity, reporting dating violence, and Indigenous youth. No statistically significant differences in safer sex efficacy were observed among participants who were aged ≥15, sexually active, reporting consistent condom use, and using drugs/alcohol. Findings signal the promise of youth-targeted, arts-based sexual health workshops for improving STI knowledge and safer sex efficacy among adolescents in the NWT. Further research can explore how safer sex efficacy may be shaped by age, substance use, and sexual experience to inform tailored interventions.
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Background Persons in Arctic regions disproportionately experience depression. Knowledge gaps remain regarding factors associated with depression among adolescents in the Northwest Territories (NWT), Canada, where child and adolescent mental health hospitalizations are nearly 2.5 times the national rate. This study assesses correlates of depression among adolescents in the NWT. Methods We conducted a cross-sectional survey with adolescents aged 13–18 in 17 NWT communities. We assessed associations between socio-demographic characteristics, dating violence, food insecurity and depression, measured with the 9-item Patient Health Questionnaire. We conducted ordered logistic regressions to assess associations with no, mild, or moderate/severe depression scores. Results Participants ( n = 399; mean age: 14.3, s.d. : 1.3) were mostly Indigenous (79%) and 45% reported food insecurity. Nearly half (47%) reported minimal/no depression symptoms, 25% mild symptoms and 28% moderate/severe symptoms. In multivariate analyses, participants who were cisgender women compared to other genders, sexually diverse v . heterosexual, and food insecure had double the odds of more severe depression symptoms. Among those dating, dating violence was associated with double the odds of moderate/severe depression symptoms. Conclusions Findings support tailored interventions to address material (food insecurity), relational (dating violence) and symbolic (gender and sexual orientation norms) contextual factors associated with depression among adolescents in the NWT.
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Background: Rigorously designed longitudinal studies can inform how best to reduce the widening health gap between Indigenous and non-Indigenous children. Methods: A systematic review was performed to identify and present the breadth and depth of longitudinal studies reporting the health and well-being of Indigenous children (aged 0-18 years) globally. Databases were searched up to 23 June 2020. Study characteristics were mapped according to domains of the life course model of health. Risk of bias was assessed using the National Institutes of Health (NIH) Study Quality Assessment Tools. Reported level of Indigenous involvement was also appraised; PROSPERO registration CRD42018089950. Results: From 5545 citations, 380 eligible papers were included for analysis, representing 210 individual studies. Of these, 41% were located in Australia (n = 88), 22.8% in the USA (n = 42), 11.9% in Canada (n = 25) and 10.9% in New Zealand (n = 23). Research tended to focus on either health outcomes (50.9%) or health-risk exposures (43.8%); 55% of studies were graded as 'good' quality; and 89% of studies made at least one reference to the involvement of Indigenous peoples over the course of their research. Conclusions: We identified gaps in the longitudinal assessment of cultural factors influencing Indigenous child health at the macrosocial level, including connection to culture and country, intergenerational trauma, and racism or discrimination. Future longitudinal research needs to be conducted with strong Indigenous leadership and participation including holistic concepts of health. This is critical if we are to better understand the systematic factors driving health inequities experienced by Indigenous children globally.
Historical trauma refers to the collective depredations of the past that continue to affect populations in the present through intergenerational transmission. Indigenous people globally experience poorer health outcomes than non-Indigenous people, but the connections between Indigenous people’s health and experiences of historical trauma are poorly understood. To clarify the scope of research activity on historical trauma related to Indigenous peoples’ health, we conducted a scoping review using Arksey and O’Malley’s method with Levac’s modifications. Seventy-five articles (1996-2020) were selected and analyzed. Key themes included (a) challenges of defining and measuring intergenerational transmission in historical trauma; (b) differentiating historical trauma from contemporary trauma; (c) role of racism, discrimination, and microaggression; (d) questing for resilience through enculturation, acculturation, and assimilation; and (e) addressing historical trauma through interventions and programs. Gaps in the research included work to establish mechanisms of transmission, understand connections to physical health, elucidate present and past trauma, and explore epigenetic mechanisms and effects ascribed to it. Understanding first what constitutes historical trauma and its effects will facilitate development of culturally safe holistic care for Indigenous populations.
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Background Identifying social and structural factors associated with sexually transmitted infections (STI) vulnerability is urgent in the Northwest Territories (NWT), where STI prevalence is 7-fold the Canadian average. The NWT also experiences higher food insecurity and intimate partner violence (IPV) than the national average. Safer sex efficacy (SSE) comprises knowledge, intention, and relationship dynamics for safer sex negotiation. We examined social and structural factors associated with SSE among Northern and Indigenous adolescents in the NWT. Methods With an Indigenous sexual health agency, we conducted a cross-sectional survey with adolescents aged 13–17 in 17 NWT communities. Summary statistics and statistical comparisons were conducted, followed by crude and multivariable regression models, with a canonical link function, to compare factors associated with SSE and within gender stratifications. We conducted post-hoc sensitivity analyses among Indigenous youth. Results There were 610 participants (mean age: 14.2 years [SD: 1.5]; 49.5% cisgender women, 48.9% cisgender men, 1.6% transgender persons); three-quarters (n=447; 73.3%) were Indigenous. One-quarter (n=144; 23,6%) reported food insecurity and nearly one-fifth (n=111; 18.2%) IPV. Among young women, food insecurity (β: -1.89[CI: -2.98, -0.80], p=0.001) and IPV (β: -1.31[CI: -2.53, -0.09], p=0.036) were associated with lower SSE in adjusted analyses, and currently dating was associated with increased SSSE (β: 1.17[CI: 0.15, 2.19], p=0.024). Among young men, food insecurity (β: -2.27[CI: -3.39, -1.15), p=0.014) was associated with reduced SSE. Among sexually active participants (n=115), increased SSE was associated with increased condom use among young women (β: 1.40[0.19, 2.61], p=0.024) and men (β: 2.14[0.14, 4.14], p=0.036). No differences emerged by Indigenous identity across analyses. Conclusion Food insecurity and IPV emerged as syndemic factors associated with lower SSE—a protective factor associated with condom use among Northern and Indigenous adolescents in the NWT. Poverty and violence compromise Indigenous and Northern youth’s sexual agency and in turn contribute to STI vulnerabilities, requiring urgent attention. Disclosure No significant relationships.
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In this article, we describe and evaluate body mapping as (a) an arts-based activity within Fostering Open eXpression Among Youth (FOXY), an educational intervention targeting Northwest Territories (NWT) youth, and (b) a research data collection tool. Data included individual interviews with 41 female participants (aged 13–17 years) who attended FOXY body mapping workshops in six communities in 2013, field notes taken by the researcher during the workshops and interviews, and written reflections from seven FOXY facilitators on the body mapping process (from 2013 to 2016). Thematic analysis explored the utility of body mapping using a developmental evaluation methodology. The results show body mapping is an intervention tool that supports and encourages participant self-reflection, introspection, personal connectedness, and processing difficult emotions. Body mapping is also a data collection catalyst that enables trust and youth voice in research, reduces verbal communication barriers, and facilitates the collection of rich data regarding personal experiences.
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Objectives Sexual and mental health disparities exist in the Northwest Territories (NWT) compared with other Canadian regions. STI rates are 10-fold higher, and youth suicide rates double the Canadian average. Scant research has examined associations between mental and sexual health among youth in the NWT. The study objective was to explore pathways from depression to multiple sex partners (MSP) among young women in the NWT, Canada. Methods We implemented a cross-sectional survey in 2015–2016 with a venue-based recruitment sample of young women aged 13–17 attending secondary schools in 17 NWT communities. We conducted path analysis to test a conceptual model examining associations between depression and a history of MSP, examining substance use and peer support as mediators. Results Participants (n=199; mean age: 13.8, SD: 1.27) mostly identified were Indigenous (n=154; 77.4%) and one-fifth (n=39; 20.5%) were sexually diverse/non-heterosexual. Almost two-thirds (n=119; 63.3%) reported depression symptoms. One-quarter (n=53; 26.6%) were currently dating, and 16.1% (n=32) reported a lifetime history of >1 sex partner (classified as having MSP). There was no direct effect between depression and MSP (β=0.189, p=0.087, 95% CI 0.046 to 0.260). Depression had a direct effect on substance use (β=0.023, p<0.050, 95% CI 0.118 to 0.500), and an indirect effect on MSP through substance use (β=0.498, SE=0.10, p<0.001, 95% CI 0.141 to 0.280). Depression was associated with lower peer support (β=−0.168, p<0.010, 95% CI −0.126 to 0.280); peer support was not associated with MSP (β=−0.158, p=0.130, 95% CI −0.126 to 0.001). Conclusion This research is among the first to identify mental health factors associated with STI vulnerability among young women in the NWT. Findings demonstrate the importance of addressing depression and substance use in sexual health interventions in Northern contexts.
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Background The history of residential schools has been identified as having long lasting and intergenerational effects on the physical and mental well-being of Indigenous populations in Canada. Our objective was to identify the extent and range of research on residential school attendance on specific health outcomes and the populations affected. MethodsA scoping review of the empirical peer-reviewed literature was conducted, following the methodological framework of Arksey and O’Malley (2005). For this review, nine databases were used: Bibliography of Native North Americans, Canadian Health Research Collection, CINAHL, Google Scholar, Indigenous Studies Portal, PubMed, Scopus, Statistics Canada, and Web of Science. Citations that did not focus on health and residential school among a Canadian Indigenous population were excluded. Papers were coded using the following categories: Indigenous identity group, geography, age-sex, residential school attendance, and health status. ResultsSixty-one articles were selected for inclusion in the review. Most focused on the impacts of residential schooling among First Nations, but some included Métis and Inuit. Physical health outcomes linked to residential schooling included poorer general and self-rated health, increased rates of chronic and infectious diseases. Effects on mental and emotional well-being included mental distress, depression, addictive behaviours and substance mis-use, stress, and suicidal behaviours. Conclusion The empirical literature can be seen as further documenting the negative health effects of residential schooling, both among former residential school attendees and subsequent generations. Future empirical research should focus on developing a clearer understanding of the aetiology of these effects, and particularly on identifying the characteristics that lead people and communities to be resilient to them.
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Sexual health education for young people is crucial not only for development of norms but also for protection against vulnerabilities during this stage in life. Although several systematic reviews have examined the effectiveness of peer-led sex education, none have focused on the extent of peer participation. The purpose of this review was to evaluate peer-led sexual health education interventions in more developed countries (MDCs). Electronic and manual searches across five social science, education, and medical databases were conducted. Fifteen articles were selected in total. Most (10 of 15) studies gave low or no responsibility to peers. The majority of articles found improvements in sexual health knowledge (13 of 14) and attitudes (11 of 15) at postintervention stages. Two studies showed improved self-efficacy, and three showed behavioral changes. A preliminary synthesis of effectiveness and level of participation was done. Meta-analysis revealed a large effect on knowledge change (Hedges’ g = 0.84, 95% confidence interval [CI]: 0.43 to 1.25) and a medium effect on attitude change (Hedges’ g = 0.49, 95% CI: 0.19 to 0.80). Peer-led interventions could be a powerful tool. This review shows that this approach is effective in changing knowledge and attitudes but not behaviors. Further research and action are needed to understand optimal implementation.
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Introduction Indigenous youth are disproportionately represented in new HIV infection rates in Canada. Current and historical contexts of colonisation and racism, disconnection from culture and land, as well as intergenerational trauma resulting from the legacy of residential schools are social drivers that elevate exposure to HIV among Indigenous peoples. Peer-education and arts-based interventions are increasingly used for HIV prevention with youth. Yet limited studies have evaluated longitudinal effects of arts-based approaches to HIV prevention with youth. The authors present a rationale and study protocol for an arts-based HIV prevention intervention with Northern and Indigenous youth in the Northwest Territories (NWT), Canada. Methods and analysis This is a multicentre non-randomised cohort pilot study using a pretest/post-test design with a 12-month follow-up. The target population is Northern and Indigenous youth in 18 communities in the NWT. The aim is to recruit 150 youth using venue-based sampling at secondary schools. Participants will be involved in an arts-based intervention, Fostering Open eXpression among Youth (FOXY). Participants will complete a pretest, post-test survey directly following the intervention, and a 12-month follow-up. The primary outcome is new or enhanced HIV knowledge, and secondary outcomes to include: new or enhanced sexually transmitted infections knowledge, and increased self-esteem, resilience, empowerment, safer sex self-efficacy and cultural connectedness. Mixed effects regression analyses will be conducted to evaluate pretest and post-test differences in outcome measurement scores. Ethics and dissemination This study has received approval from the HIV Research Ethics Board at the University of Toronto (REB: 31602). In addition, the project is currently registered in the NWT with the Aurora Research Institute (Licence: 15741). Trial results will be published according to the Transparent Reporting of Evaluations with Nonrandomised Designs statement. Trial registration number NCT02743026; Pre-results.
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Issue addressed Rates of sexually transmissible infections among young people are high, and there is a need for innovative, youth‐focused sexual health promotion programs. This study evaluated the effectiveness of the Sharing Stories youth theatre program, which uses interactive theatre and drama‐based strategies to engage and educate multicultural youth on sexual health issues. The effectiveness of using drama‐based evaluation methods is also discussed. Methods The youth theatre program participants were 18 multicultural youth from South East Asian, African and Middle Eastern backgrounds aged between 14 and 21 years. Four sexual health drama scenarios and a sexual health questionnaire were used to measure changes in knowledge and attitudes. Results Participants reported being confident talking to and supporting their friends with regards to safe sex messages, improved their sexual health knowledge and demonstrated a positive shift in their attitudes towards sexual health. Drama‐based evaluation methods were effective in engaging multicultural youth and worked well across the cultures and age groups. Conclusions Theatre and drama‐based sexual health promotion strategies are an effective method for up‐skilling young people from multicultural backgrounds to be peer educators and good communicators of sexual health information. Dramabased evaluation methods are engaging for young people and an effective way of collecting data from culturally diverse youth. So what? This study recommends incorporating interactive and arts‐based strategies into sexual health promotion programs for multicultural youth. It also provides guidance for health promotion practitioners evaluating an arts‐based health promotion program using arts‐based data collection methods.
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Adolescents are at increased risk of HIV and sexually transmitted infections (STIs) in the Southern states of the USA, where rates among youth are higher than in the rest of the nation. This paper reports on findings from a pilot study of an HIV prevention intervention that uses interactive theatre to educate young people about sexual health. The intervention was developed in Los Angeles and adapted for testing in the Southern USA, with its legacy of abstinence-based approaches to sexual health education. This study assessed intervention effects among a sample of young people in two public high schools in North Carolina. We used a pre-test, post-test quasi-experimental evaluation design to assess changes in 317 ninth-grade participants' knowledge and attitudes about HIV. At post-test, we found statistically significant increases in participants' HIV knowledge (t = 60.14; p = 0.001), as well as changes in attitudes (χ2 = 8.23; p = 0.042) and awareness (χ2 = 4.94; p = 0.026). Focus group data corroborated an increase in HIV knowledge and a reduction in HIV stigma as successful outcomes of intervention participation. The findings make an important contribution to the literature on theatre-based interventions for sexual health education. Furthermore, they highlight the importance of considering sociocultural and political context in implementing HIV prevention interventions in schools.
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br/> This article reports research that aimed to identify and evaluate potential resilience benefits of visual arts interventions for young people with complex needs. The study involved a review of the ‘arts for resilience’ literature and a case study of 10 weekly resilience-building arts workshops for 10 young people experiencing mental health complexities and/or learning difficulties. Findings: We found a significant existing evidence-base linking visual arts practice to individual and community resilience, across disciplinary fields including art therapy, social work, community health, visual arts practice and geographies of health. Visual art activities were utilised to both educate young people about resilience and enhance young people’s overall resilience. Qualitative research material developed from the case study shows that even short-term visual arts interventions can impact on young people’s resilience – crucially, participation was extremely beneficial to young people’s sense of belonging and ability to cope with difficult feelings (topics which arose repeatedly during interview, focus group discussion and observation). Applications: Our review and findings from this small case study provide some initial insights into the resilience benefits of participation in visual arts activities. This, combined with the resilience-based practice framework presented here, could aid the effective targeting of interventions for social workers and others working with young people with complex needs. Alongside this research paper, an arts for resilience practice guide has been produced by the project team (including young people). It contains instructions on how to conduct a range of practical visual arts activities that we identified as being resilience-promoting.
We examined the sexual health change process experienced by 26 college student sexual health educators from three geographic regions of the United States who participated in a multisite arts-based sexual health prevention program. We conducted eight focus groups and used a phenomenological approach to analyze data. We drew from social cognitive theory (SCT) to examine how sexual health knowledge, attitudes, self-efficacy, and communication shifted across the duration of participation. Findings suggest that the college student sexual health educators (a) developed enhanced sexual health awareness and critical consciousness, (b) questioned their own sexual health education and challenged previous beliefs, and (c) demonstrated self-efficacy related to intended behavior change and their perceived role as social justice advocates. We present both similarities and differences regarding the sexual health change process among the college student sexual health educators across the three sites.
Men have a stake in ending gendered violence but this stake has not yet been widely embraced by men. Thus we must think carefully about our future strategic directions. Taking the case of sexual violence, I suggest that these directions involve re-thinking sexuality and sexual health by considering absences in the scholarly and policy literatures. While young people are constantly exhorted in popular media to be sexual and to undertake sex, young men have not been engaged by ‘critical’ analyses of sexuality. The critical literatures—which include writings in Gender/Sexuality studies and Preventive Health—aim to offer alternative understandings of heterosexuality which move beyond the imperatives of the popular media. Yet such critical approaches remain undeveloped, largely negative and/or focussed upon danger rather than considering heterosexuality in positive terms that might offer a substantive alternative and encourage young men in particular to embrace the aim of egalitarian sexual practices, including ending sexual violence. Tensions in Gender/Sexuality scholarship, and Preventive Health sex education materials which draw upon that scholarship, produce significant absences with regard to analysis of heterosexuality and heterosexual subjects. In this context, existing research indicates that recognition of pleasure in sexual health has resulted in increased use of condoms by men and greater involvement of women in the negotiation of sexual practices. Such research is not just relevant to prevention of disease, but has implications for strategies regarding sexual violence. Re-imagining the theoretical framing of Gender/Sexuality studies and Preventative Health to take account of pleasure in sexuality and sexual health is not just a theoretical issue but has some very practical implications.