Building Enabling Environments for Transformative Communication for Sexual Health Promotion with and for Northern and Indigenous Adolescents in the Northwest Territories: Mixed-Methods Findings

Background: Youth are disproportionately affected by sexually transmitted infections (STI) and teen pregnancy in Arctic regions, including the Northwest Territories, Canada. Indigenous peoples comprise just over half (50.7%) of the NWT population and experience health disparities rooted in historical and current contexts of colonization and marginalization. Our mixed-methods study examined Northern and Indigenous adolescent participation in arts- and land-based Peer Leader Retreats in the NWT and associations with sexual health outcomes.

Methods: This community-based research project with an Indigenous sexual health organization involved 9-day Peer Leader Retreats at a NWT fly-in lodge with purposively sampled adolescents aged 13-17 years old from NWT annually between 2016-2021. Retreats addressed HIV and STIs, safer sex, healthy relationships, and gender equity using interactive learning approaches (e.g., role-plays, Elder teachings). Arts-based and Indigenous methods included traditional hand drumming, beading, rattle-making, Northern games, and traditional storytelling. We conducted pre-post retreat surveys measuring socio-demographics and sexual health outcomes (safer sex self-efficacy, HIV/STI knowledge) and post-retreat focus groups. We conducted thematic analysis of focus groups informed by transformative communication frameworks that distinguish between technical (factual knowledge, technical skills) and transformative communication (fostering empowerment by building communication skills [amplifying voice]). We conducted paired sample t-tests, and multivariable linear regression, to assess pre-post retreat changes in safer sex self-efficacy and HIV/STI knowledge scores.

Results: There were 326 participants (mean age: 14.5, standard deviation: 1.3), most were Indigenous (87%) and young women (64%). Qualitative narratives revealed retreats contributed to technical communication (HIV/STI knowledge, condom benefits, correct condom use) and transformative communication (confidence, healthy relationships, sex-positivity, sexual consent). While all participants reported learning about condoms, gender differences emerged when discussing main take-aways. Young woman discussed learning about contraception and STIs, while young men focused on acquiring condom use skills. Paired sample t-tests results revealed statistically significant mean score pre-post test increases in safer sex self-efficacy (M=2.14, Standard Deviation [SD]: 5.2, p<0.001) and HIV/STI knowledge (M=6.13, SD: 0.25, p<0.001). In adjusted linear regression, higher pre-test safer-sex self-efficacy (β=0.59, 95%CI, 0.51, 0.67) and gender (women) (β=1.84, 95%CI=0.77, 2.92) were associated with higher post-test safer sex self-efficacy scores. In adjusted analyses, sexually diverse (vs. heterosexual) (β= -1.14, 95%CI= -2.25, 0.03) and food insecure (vs. food secure) (β= -2.44, 95%CI = -5.05, 0.16) participants had smaller post-test safer sex self-efficacy increases, and Indigenous participants had lower HIV/STI knowledge post-test score increases (β= -1.63, 95%CI = -2.50, -0.77).

Conclusion: Mixed-methods findings revealed that participants reported learning both technical (e.g., knowledge) and transformative communication (e.g., safer sex self-efficacy) skills while participating in Peer Leader Retreats designed to promote healthy relationships, resilience, and connectedness to land. The findings that adolescents who were sexually diverse, food insecure, and young men (vs. women) reported lower safer sex self-efficacy increases, and Indigenous youth reported lower HIV/STI knowledge gains, point to the need to better understand and address social determinants of adolescent sexual health. The integration of arts-based, land-based, and peer-based strategies holds the potential to foster technical and transformative communication to advance sexual health promotion and wellbeing with Northern and Indigenous youth.