Knowledge Translation and Adolescent Girls’ Sexual Health Education in Indigenous Communities 

Research Article

Knowledge Translation and Adolescent Girls’ Sexual Health Education in Indigenous Communities 

Corresponding authorDr. E. Banister, University of Victoria, Canada School of Nursing, Canada.
Tel: Phone: + 1 250 472-4703; Fax: + 1 250 721-6231; Email: ebaniste@uvic.ca

Abstract
Adolescent health issues can have long-term consequences for youth themselves now and as they become adults, and for the community’s social and health systems. While the general adolescent population is already at risk for poor health, the problem is more pronounced in Indigenous communities. This disparity is even more obvious for adolescent sexual–dating health concerns.There is a dire need for health education programs that reach adolescents ‘where they are.’ We argue that such programs would be more effective, especially with Indigenous adolescent girls, if they were founded upon community-based knowledge translation(KT) principles. We describe these principles as contextuality, collaboration, reciprocity, relationality, and reflexivity, all of which are congruent with Indigenous ways of knowing. We maintain that effective communication and other health literacy processes are paramount to the establishment of these principles. Finally, we illustrate the application of the principles in our community-based research project entitled The Adolescent Girls’ Sexual Health and Mentoring Program. Our program was congruent with methods of Indigenous knowledge generation in that it was participatory, relational, communal, and narrative-based.
Keywords: Knowledge Translation; Sexual Health; Adolescent; Indigenous; Health Education Community Based Research; Health Literacy
Introduction

The health of adolescents is of increasing concern around the world (World Health Organization [WHO], 2014). Research has shown that the health status of adolescent girls in North America is challenged by risky sexual behaviour. In the United States, the Centers for Disease Control and Prevention (US CDCP, 2016) identified risky sexual behaviour as being strongly associated with mortality, morbidity, and social problems among youth. Indigenous youth are even more at risk [1,2]. There is a dire need for health education programs that reach adolescents ‘where they are’ [3]. In this article, we argue that such programs would be more effective, especially with Indigenous adolescent girls, if they were founded upon community- based knowledge translation (KT) principles. We suggest these principles are contextuality, collaboration, reciprocity, relationality, and reflexivity, all established through effective communication processes. We then demonstrate how these principles are congruent with Indigenous ways of knowing. Finally, we describe the principles as demonstrated in a community- based research project entitled The Adolescent Girls’ Sexual Health and Mentoring Program [4].

Adolescent Health Issues
Adolescent health issues can have long-term consequences for individuals, the community, and social and health systems [5]. According to the 2015 Youth Risk Behavior Surveillance report (US CDCP, 2016), many young people (aged thirteen to twenty-four) engage in a variety of health-compromising behaviours, such as having sexual intercourse at an earlier age. Early sexual intercourse increases the risk of negative risk behaviours such as having more sexual partners and inconsistent condom use [6] and has been associated with negative mental commuhealth outcomes [7]. In the United States, 30% of high school students (grades 9–12) report being sexually active, and over 11% report having more than four partners. Almost 14% of sexually active adolescents do not use any birth control method and the United States Office of Adolescent Health (2016) reports that “Adolescents ages 15-24 account for nearly half of the 20 million new cases of STD’s each year” (n.p.).

Dating violence in adolescence is also a serious health issue [8]. One-quarter to over two thirds of dating adolescents report physical or psychological abuse including hitting, verbal abuse and sexual coercion in their relationships [9]. Dating violence has been associated with other negative outcomes, such as alcohol and substance use, depression, disordered eating, pregnancy and suicidal ideation [10,11].

While the general adolescent population is already at risk for poor health, the problem is more pronounced in Indigenous communities [12]. This disparity is particularly obvious for adolescent sexual–dating health concerns, including risky alcohol use or sexual activity, risk for fetal alcohol spectrum disorders (FASDs), unplanned pregnancy, and contracting sexually transmitted infections (STIs) such as human immunodeficiency virus (HIV), gonorrhoea, and chlamydia. Indigenous persons are being infected with HIV at a growing rate [13] which is increasing at seven times the rate for the general population. The suicide rate for Indigenous adolescent girls is eight times the national average [14]. Indigenous health is intricately linked to culture and community [15].

Despite these health disparities, little research has focused on the health concerns of Indigenous adolescent women. Even though advancements are being made in health services delivery for Indigenous women in Canada, significant inequities remain in relation to the general population [16].

In sum, research shows that adolescent girls, especially those in Indigenous communities, are at risk for poor sexual health. While all adolescents need developmentally and socially appropriate educational approaches, Indigenous populations need more specialized education that takes into account their cultural realities. Despite considerable funding, however, few intervention programs have shown a substantial influence on postponing sexual initiation or curtailing pregnancy among adolescents. Those studies that focus on changing young people’s knowledge levels, attitudes, or risk behaviours fail to produce long-term sexual health improvements at the population level [17]. Interventions that focus instead on interpersonal, structural and cultural factors can be powerful prevention efforts [18]. Numerous studies have found that health and wellbeing have an intricate connection with culture [18,19]. We suggest that one promising approach to addressing the heightened risk of poor health is through community-based Knowledge Translation processes.

Knowledge Translation

Within the social sciences, researchers are frustrated that research findings have not led to the alleviation of persistent social ills. The gap between research knowledge and practical application is called the know-do gap [20]. Narrowing this gap involves a shift of focus from taking or giving of knowledge – what might be termed knowledge transfer – to the transformational power of knowledge exchange [21] or knowledge translation (KT) [22]. Effective KT involves active participation between the producers and users of knowledge as well as reciprocal interactions between the two [23,24]. We argue that there are five principles of effective KT: contextuality, collaboration, reciprocity, relationality, and reflexivity. We maintain that effective communication and other health literacy processes are paramount to the establishment of these principles.

Contextuality

Knowledge translation is a ‘complex interaction process’ [25] within a specific context. It focuses on real problems within the community and emphasizes participatory research done with the community rather than to the community [26,27]. Researchers
need to understand the context of the user group, including the group’s perceived value of the research and its congruence with their objectives [28]. Understanding these factors can assist researchers in developing and translating knowledge that is accessible and useful [18]. Discovering contextual elements requires careful, long-term, participant observation with communities.

Collaboration

Collaboration is, literally, labouring together. Collaborative research draws upon both local community knowledge and the knowledge of academics, who have traditionally held the power to claim research authority. It is, therefore, important for university researchers to be aware of the power they hold and to engage in power-sharing processes [29]. In collaborativeresearch, investigators do not assert authority by filing the community with knowledge; rather, they engage communitymembers in the research and dissemination processes for mutual knowledge gain [30]. Thus, the principle of collaborationnecessarily involves a power shift.

Reciprocity

The researcher’s awareness in a communal context must be synergistic and reciprocal. Within KT, synergistic relationshipsamong researchers and community members are co-requisite to knowledge exchange and transformation among cultures with dissimilar knowledge bases. Garland, Plemmons, and Koontz (2006) defined partnership synergy as the process through which knowledge and expertise of diverse groups combine in effective ways to achieve goals, plan innovative programs, and enhance relationships with the wider commuhealth nity. To build reciprocity among research partners necessitates ”“sharing benefits and responsibilities” (National Aboriginal Health Organization, n.d.).

Relationality

Literature on KT emphasizes developing and nurturing mutually perceived trust and the strengthening of connectivity [31]. Building relationships can often be an overwhelming, time-intensive challenge for community partners. Personal investments in the research endeavour are based on mutual understanding and goodwill. It is especially important for researchers to recognize “the realities of working in the community, and sensitivity to the burden research can place on communityorganizations. Attention to these issues encourages the development of trusting, durable relationships” [32].

Reflexivity

Reflexivity is the process of becoming more self aware, thus increasing rigour of the research [33]. Reflexivity can only be accomplished through regular efforts to consider one’s thoughts and actions in light of new and often unfamiliar contextual information. Team discussions and reflexive journaling can help researchers to understand their own thoughts and feelings and those of their community partners. All members of the research team need to be conscious of their positions in the research context [29].

Effective Communication

The five principles – contextuality, collaboration, reciprocity, relationality, and reflexivity – are developed through effectivecommunication processes. Health knowledge generated from community sources arises through activities such as storytelling.Community members and university researchers’ work together to build health literacy: the ability to access, comprehend,evaluate, and communicate health information [34]. Communication in various forms (e.g., oral, written, visual, or multimedia combinations) is essential to building and attaining effective knowledge translation and exchange. Communication practices developed over time, in an environment of mutual respect, can open spaces in which those who are voiceless can share their stories [35] and provide opportunities for others to hear those voices.

[36] In their participatory study of the literacies of Indigenous students in the schools found that it was possible and desirableto “appropriate multimodal design in schools in a way that explicitly attends to the dynamic nature of Indigenous practices” (p. 19) including the telling of stories. Similarly, Armstrong (2013) maintains that knowledge generation through research begins with communication through storytelling and that “stories will teach each of us…how we might serve as an agent for change” (p. 61). Indigenous values and wisdom are contained within the stories and result in wisdom. Those holding the wisdom as a result of hearing stories then retell them as a way of disseminating what they know “as a teaching practice” (p. 38).

Indigenous Ways of Knowing

Methods of Indigenous knowledge generation and communication tend to be experiential, participatory, communal, andcongruent with local geography. Contextuality, collaboration, reflexivity, reciprocity, and relationality – all based upon effectivecommunication – resonate with the tenets of Indigenous ways of knowing. Contextuality implies attention to the worldview of Indigenous peoples based, for example, on the importance of the local history, land, or local geography [30]. Collaborationtakes into account the communal, participatory creation of knowledge. Reflexivity in Indigenous communities is shown in their belief in selected stories to teach specific knowledge. Relationality and reciprocity is found in Indigenous ways of bonding individual members to form a strong community group in which the health of the individual is grounded in the health of the collective [37]. Effective communication through stories mediates these processes.

Given the integral connection of culture and community to Indigenous health, [15], we maintain that community-based approaches to KT are important to address the sexual health education concerns of Indigenous adolescent girls. The strengthswithin cultural connection and tradition cannot be underestimated, for example, for counteracting imposed sexualisation and violence [24]. We will now describe a project that demonstrates this approach in practice to KT research in an Indigenouscommunity.

The Adolescent Girls’ Sexual Health and Mentoring Program We conducted a community-based study that focused on adolescent girls’ perceptions of their sexual health and on developing a mentorship program for exploring best practices inadolescent health education [3]. Our study used a respectful, participatory approach based on Indigenous ways of knowing and effective KT principles. We found these approaches to be complementary to each other.

With assistance from a local elder and the administration of a rural Indigenous secondary school in British Columbia, Canada,the researchers became acquainted with ten Indigenous girls, between the ages of fourteen and sixteen. During the first phase of the research, the girls participated in three consecutive focus groups that centred on their sexual health concerns. We designed the focus groups to create a space in which the girls could co-construct the meaning of their sexual health experiences [38]. The girls’ accounts generated rich qualitative data that guided the development of the mentoring and educational program used in phase two. During that phase, we delivered the program weekly to the same girls over a sixteen-week period in approximately ninety-minute group sessions.

The intervention group also included two female Indigenous school staff members (an administrative assistant aged thirty and a learning assistant aged twenty-seven) who were chosen as mentors. Each covered for the other when necessary, for example, when one was unexpectedly required to attend three weeks of traditional ceremonies held at the local band’s Long House. We also included an elder who offered her wisdom, knowledge and ceremonial guidance to help our research process align with Indigenous ways of knowing [24]. Her role as Indigenous knowledge keeper, teacher and translator of knowledge is reflected in her comment: “I can encourage them. It’s an opportunity for me to be able to speak to the girls, to share more. They’re just young kids and they need to keep hearing from the older people.” The program provided culturally appropriate education for the girls, and an opportunity for developing respectful community protocol [24] concerning our instructional approaches.

We believe that the mentoring strategies used and evaluated in the Indigenous girls’ group illustrate principles of effective KT.The community was actively involved in the conceptualization, delivery, application, and evaluation of the program.

The program itself included also feminist strategies designed to facilitate egalitarian relationships in the group, including (a)circling, where each person takes a turn to speak while others in the group listen in situations involving decision-making orconflict, and (b) closing, where participants share a critical reflection about the group’s process at the end of a meeting [38].Aspects of Grasley, Wolfe, and Wekerle’s (1999) youth relationship project that used information, skill-building, and socialaction to empower youth to end relationship violence were also included, to increase learning about unhealthy power imbalances and visits to local community resources to gain information and report back to the group (e.g., the family planningclinic, sexual assault centre). We also adapted a multi-literate approach [36] to enhance participants’ learning [39] through a variety of sign systems (e.g., oral language and visual design) for exploring multiple forms of self-expression. We used activities such as free writing and painting. The KT principles were demonstrated in the data collected during the mentoring program. Illustrative examples for each principle follow.

Contextuality

The community context demanded an experiential, active, and culturally appropriate program through which we could conductour research. Gaining permission to access the community was facilitated in part by the elder [24]. She cared about themaintenance of her culture which future generations would be responsible for, and how the project could positively influenceyouth behaviour in the community context. We encouraged girls’ engagement in learning that was relevant and personallymeaningful and that validated their sexual health experiences. The elder and mentors were invited to collaborate in constructing the sexual health curriculum activities that were culturally and contextually appropriate. We established an environment that helped to empower the girls and provide them with direction and self-efficacy.

For example, each girl identified a personal goal that was revised  throughout each lesson. The entire group linked their goals to successful graduation from school; many recognized that completing their education was central to establishing their own identity and would enhance their ability to give back to their communities. The importance of education was continuallyreinforced and translated to them through the elder’s teachings.

Creating a space of relatedness and connection, both key components of Indigenous worldviews, helped to make possible the girls’ shared goal of obtaining the necessary education to lead productive lives. The presence of the elder and other communitymembers helped to remind all of us about the Indigenous context within which we were working.

Collaboration

Our program provided a safe space for shared learning and reflection. The sexual health education program took place in a school located within the Indigenous community. The girls worked together in a group. Through a variety of activities, they discovered their common concerns; for example, they participated in dialogue with other girls, with mentors, with the elder, and with the researchers. They heard stories. They discussed new information, such as the differences among aggressive, assertive, and passive behaviour. They connected their own experience with this new knowledge and then acted  upon it collectively, deciding, for example, what they could do in specific situations where aggressive behaviours were present. The girls also learned to become mutually supportive. As mentioned earlier, the researchers, mentors, and elder met regularly and worked collaboratively to brainstorm ideas for the sexual health curriculum that helped to make it culturally appropriate and responsive to the girls’ issues as they emerged. Collaboration was a natural way to set and achieve group goals with community members.

Reciprocity

There were two main groupings within the program: the Indigenous community and the university researchers. However, the Indigenous community had sub-communities as well, for example, the adolescent girls and the adults, such as the elder,mentors, and the girls’ parents. The girls became more knowledgeable about abusive relationships and about safe sexualhealth practices. A mentor describes KT processes that contributed to girls’ absorbing this knowledge:

And a lot of [the girls] didn’t know [about safe sex] … We’d take them to the workshop [on sexual health] and they didn’t know about all the STIs and they have no mentor in the community … But to come from the school or someone telling their story… just the activities they did in the program … [t]hey learned … Hopefully … they’ll be able to help one of their own in a badrelationship.
Reciprocity among members of both groups strengthened the effectiveness of the program. Bonds were built among thegroups that reinforced the KT processes.

The knowledge came from the university researchers and from the mentors and elder who shared their stories about sexualhealth issues. Other community adults also became more aware of the problem of dating violence, the need for easily accessible condom machines, and the usefulness of consultants to continue sexual health education. The elder believed, however, that the circles needed to ripple out even wider. As she said,

We spoke at conferences with some of the girls … like we went up to [a conference] last year and did a group up there – butthat’s nothing compared to how much further in our communities this information needs to go. And it needs to reach the Chiefs in Councils … It needs to reach the Child and Family Service Ministries in our Aboriginal Communities.

The reciprocal sharing and generation of knowledge in this project helped create an innovative sexual health program andserved to strengthen relationships with the larger community [40].

Relationality

The ability to enter into and sustain respectful, meaningful relationships is an important skill in Indigenous contexts [41]. The relational aspect of the partnership includes acknowledging that the community has power in determining the research agenda. In this study, adolescent girls wanted information about healthy relationships and ways to negotiate effective communication in their peer relationships.

The project helped to maintain and enhance patterns of relationships in the community and extended benefits beyond that of the girls themselves. The elder commented on developing a relationship with the girls:

Outside of the group they [the girls] would give me hugs … they’d acknowledge me when they see me as part of hearing their stories and maybe a feeling a kind of bond. When you hear a person … you don’t really fully see them until you hear them share … after they’ve shared their experiences of how they feel, who they are, their feelings – once they do that to you, you have a different kind of relationship.

Relationships built on trust are a challenge to build and easy to damage. In this case, the community had a philosophy of livingcommunally and the program we introduced allowed them to discover what was already in place.

Reflexivity

Members of the community commented on their growth in self-awareness because of their participation in the program. We provided opportunities for the girls and mentors to reflect upon their learning in various ways, such as journaling, drawing, and painting activities. While delivering the curriculum, we posed critical questions to facilitate the girls’ and mentors’ reflections on how larger contextual factors influence sexual health experiences. We valued the girls’ knowledge and their processes of translating this both within the group and to others within the Indigenous community. For example, as their daughters talked about their experiences, parents became more aware of some of their daughters’ sexual health issues. The elder reported:

One of the girls [who] fully participated and then was really speaking out, and then she was telling her mum about the group, so her mum was expressing to me how she thought the group really helped her daughter. She said, ‘We need to keep on doing these and whoever’s doing this – it’s a good thing they’re doing it.’ So it’s brought some awareness from the kids to theparents that this is what they’re talking about. [Be] cause ordinarily, I think it’s not something that girls share with either one of their parents.

It also was important for us to engage in reflection about the program. We did not attempt to become experts in Indigenousways of knowing. We tried instead to be open to and, over time, to learn from realities that differed from our own.

Effective Communication

Multi literacy practices, congruent with expressions of Indigenous ways of knowing [36], were used in the program to teach sexual health. Experiential, interactive learning among the girls developed their health literacy. The sharing of stories through listening and speaking, that is, oral literacy, took place in a discussion circle, where a feather was passed from hand to hand to denote the speaker. In keeping with Canadian Indigenous people’s legacy of oral tradition, storytelling serves to translate information among and across generations about their history, origins, and spirituality. For example, the elder shared stories about the imposed ‘Indian Residential Schools’ program, that annihilated the “legitimacy of thought, lifestyles, religions, and languages” [42] of Indigenous peoples and ways this program contributed to intergenerational barriers to opencommunication. She said:

Some of our old people’s parents sent them to residential school and they felt like they weren’t wanted because they were sent away and they didn’t want to go … They learned that their parents had nothing to do with it, but … there was nocommunication … there was no way that the kids came home and said, ‘why did you send me there?’ All of them came homeand didn’t even talk – there was absolutely no communication whatsoever in that whole entire house. And I see it happening in the community … even in my own family, where you can exist in a house and not have any kind of communication – you’rejust there. So when you’re opening up you’re letting people in and that’s what this [program] has done. The girls have sharedtears. They shared their sadness. They shared what happiness they had, which is not too much … I hope for the girls, thatwhen the girls sitting beside them are crying, that they’ll have compassion for that … they had not had really caring feelingstowards others in the group before.

Storytelling was the most frequently reported and observed type of communication. The girls, the elder, and the mentors told stories to each other and to the university researchers. In her role as translator of Indigenous knowledge and use of her skills to provide culturally safe support [24], the elder modelled storytelling, listening, sharing, and ways to take positive action.

The power of communication through writing, creating artefacts, and telling stories invites everyone to participate in whatever way makes them feel comfortable. Then, as they practice new ways of sharing ideas, they empower themselves in a greater variety of situations. Written communication was practised in journal writing. The girls wrote regularly to express their feelings about their sexual health including, for example, their intimate dating relationships. Visual literacy occurred in the creation of symbols such as necklaces that communicated the girls’ authentic voices, membership in the group, and their support for one another. All of these practices developed health literacy over the period of the study. As the elder observed:

They liked the journaling for sure, they liked the arts and the crafts, they liked the circles – after a while they got used to circles … actually what they got was confidence out of that group to speak … they were kind of shy and intimidated and couldn’t … then a change happened in them … they were looking forward to sharing, and looking for the opportunity to hold the feather.

The elder and mentors reported on changes in the girls’ behaviour as their communication abilities developed and on how the study helped the girls reclaim their culture in defining themselves [43].

Discussion and Conclusion
We entered a rural Indigenous community to interview Indigenous teenage girls about the perspectives they had of their own sexual health, and ultimately involved these girls and the community in a sexual health education curriculum. During our program, through synergy among the partners [40], effective KT was developed. Through storytelling in particular, knowledge that was shared helped to create networks that strengthened our relationship with the community.

Through storytelling and reflection, the mentors and elder used their authentic Indigenous voices to share knowledge.Community members, such as the elder, were convinced of the importance of the information sharing for future generations: I think it’s all of the information that’s accumulated from this research and it’s going to be translated into what it was all about … it’s going to be looked at, listened to, heard, and then put down in record for the rest of eternity … and it’s going to be kept as understanding that this is what happened.

Our program was congruent with methods of Indigenous knowledge generation in that it was participatory, relational,communal, and narrative-based. We approached the program with the assumption that culturally appropriate and usefulknowledge is rooted within the community [44]. Involving members of the community in designing and delivering a sexualhealth curriculum that was culturally appropriate facilitated the multilayered KT process.

In summary then, we offer three suggestions for engaging in sexual health education for Indigenous girls within Indigenouscommunities and schools:

1. Non-Indigenous health practitioners need to keep in mind the negative impact of colonialism and the scourge of the “IndianResidential Schools” program (which forced many Indigenous children into boarding schools removing them from theirfamilies). Forbidden their language, these children were no longer able to communicate with their parents. This disrupted ”the cultural continuity that led to the passing on of knowledge and skills from one generation to the next” [45] including information about sexual health. We worked to establish communication between generations by promoting storytelling, atraditional Indigenous way of teaching the next generation.

2. Research in Indigenous communities has too often been ‘on’ community members and not ‘with’ members. Many Indigenouscommunities are reluctant to have researchers on their land. In fact, some Indigenous scholars have made the claim that research is a ‘dirty word’ [46] in many Indigenous communities. We worked with Elder, mentor and the girls to form power sharing situations that contributed to a culturally appropriate sexual health program of benefit to the community. Engaging Elders in research in Indigenous communities is paramount given their role as knowledge keepers and “credible sources of community information” [24].

3. In conducting research with Indigenous communities, researchers need to be aware that community members know what is best for their communities and need to be involved in every step of the research process in order to build relationships based on trust. Extensive time within the community prior to and during the research process is important in helping to establish such trust.

Unresolved and Problematic KT Issues

Sustainability is an important component of effective KT. We realized that, even though the project was congruent with thecommunity’s goal of educating youth about sexual health, the continuation of the program upon completion of the studydepended on a number of factors, including the availability of school staff and financial resources. We returned to the community for two consecutive years to deliver the program as a way of giving back to the community. Our intent was to havethe mentors continue running the groups with assistance from the elder. However, the school had limited resources, and staffshortages meant that the mentors were needed to fulfil their pre-existing organizational roles.

This project was collaboratively designed with input from community members. Even though the girls, mentors, elder, and community members reported on the success of the program, there was no guarantee that this success would transfer to another Indigenous context, given the ‘heterogeneity of over 605 different First Nations in Canada, each with their ownparticular history, language dialect, culture, and social organization’ [42].

Some scholars would argue that as non-Indigenous researchers we were unable to critique sensitively what we observed andrecorded in our research. It could also be argued that we needed to consider whose voice would be valued in our research reports and whether or not we might be guilty of appropriating Indigenous knowledge and experience for our own researchgains. Nevertheless, we believe that we achieved partnership synergy through implementing the five principles describedabove, thus largely avoiding these difficulties. We believe that through the processes of KT in this project we developed araised state of consciousness regarding the sacredness of Indigenous ways of knowing for which we thank our communitypartners. More importantly, we believe that we had a positive influence on the health of the girls in this program. We lookforward to learning more about the use of KT approaches for the purpose of addressing health disparities.

Acknowledgements

The study was supported by a grant from the Canadian Institutes of Health Research.

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