'Trauma sits in your body and makes you shut down:' sexual and reproductive health professionals' views of the impact of trauma on the sexual health of Native American older adolescent and young adult women.

A history of colonisation and corresponding traumas has resulted in disparate rates of violence and sexual health inequities among many Native American populations. As a result, Native American adolescents and young adults specifically, experience higher rates of STIs, HIV and unintended pregnancy relative to their non-Hispanic White counterparts. To address these inequities, sexual health education programmes should reflect Native American cultural values and traditional teachings to align with community assets and protective factors. The objective of this study was to describe sexual and reproductive health professionals' perspectives on how trauma collectively affects the sexual health of older adolescents and young adult Native American women between the ages of 15-25 years. We purposively sampled sexual and reproductive health professionals who worked with members of this priority population. Individual in-depth interviews were conducted, recorded, and transcribed. Transcripts were analysed using thematic analysis. The themes identified in the interviews include the impact of trauma and colonisation on sexual health, strategies for combatting trauma, promoting sexual health, and supporting the development of culturally congruent sexual health education curricula. Findings point to the need for culturally relevant, trauma-informed sexual health education interventions to help promote sexual and reproductive health equity for Native American adolescent and young adult women.

The impact of funding disruptions on large-scale teen pregnancy prevention research projects.

To advance the field of teen pregnancy prevention, new interventions must be developed and tested. The federal Teen Pregnancy Prevention program (TPP) funds the evaluation of promising interventions. We report on a funding disruption to 21 TPP Tier 2B research grantees across the US that was unusual for its ideological causation, sudden timing, severity, and ultimately court decisions compelling the agency to reverse the decision. We address the following question: How did challenges presented by the attempted funding termination impact grantees' ability to continue with their intended research? Results from grantee surveys in 2019 demonstrate the funding disruption negatively impacted participant recruitment, organizational collaboration, program delivery, research rigor, and compromised grantees' ability to complete high-quality evaluations. Results also show most projects could continue, with modified research goals, when funding was reinstated. We conclude administrations should avoid arbitrarily and prematurely terminating research projects. However, there is merit in reinstating funds to projects should a disruption occur. Results from this work are particularly relevant as we anticipate how health research projects may manage other disruptions to funding or timetables, such as those caused by COVID-19. Results are relevant to policy makers, researchers, government and private funders, grantees, and technical assistance teams.

Assessing the Effectiveness of the Respecting the Circle of Life Project on Condom and Contraception Self-efficacy Among American Indian Youth.

Respecting the Circle of Life (RCL) is a teen pregnancy prevention program that was evaluated for effectiveness on sexual health risk behaviors through a two-arm randomized control trial (RCT) with American Indian (AI) youth ages 11-19. The objective of this study is to investigate the effects of RCL compared to a control group on items of condom and contraception self-efficacy. Linear regression analysis was used to compare differences in each item that included condom and contraception self-efficacy scales among the intervention and control participants at baseline, 3 and 9 months post intervention. Youth enrolled in the intervention reported higher levels of condom and contraception self-efficacy across almost all individual items. Exceptions include items related to partner negotiation of condom self-efficacy at 3 months (p = 0.227) and 9 months (p = 0.074) post intervention. Findings indicate RCL is effective at improving overall condom and contraception self-efficacy but did not impact the specific component of partner negotiation for either condom or contraception self-efficacy. This inquiry provides rationale to further explore components of RCL related to partner negotiation.

Implementation Fidelity and Theory-Informed Dose Effects of a Teen Pregnancy Prevention Program for Native American Youth.

In 2019, Native youth had the highest rate of teen pregnancy of all racial/ethnic groups. "Respecting the Circle of Life" (RCL) is one of the first evidence-based teen pregnancy prevention programs for Native teens and there is interest in replicating the program across tribal communities. To inform replication, it is important to consider process data including quality, fidelity, and dosage as these may all moderate impact of the program. Participants were Native youth aged 11-19 and a trusted adult. This study includes participants randomized to the RCL program only (N = 266). Data sources include independent observations, facilitator self-assessments, attendance logs, and self-report assessments completed by enrolled youth at baseline and 3 months post assessment. Data was compiled and summed by cohort. Dosage was number of minutes participating in activities separated by theoretical constructs. Linear regression models were utilized to assess moderation of the effects of the intervention dosage on outcomes of interest. Eighteen facilitators delivered RCL. One hundred eighteen independent observations and 320 facilitator self-assessments were collected and entered. Findings indicate RCL was implemented with high fidelity and quality (4.40 to 4.82 out of a 5-point Likert scale; 96.6% of planned activities completed). Dosage was high with an average completion of 7 out of 9 lessons. There was no association between theoretical construct dosage and outcomes of interest. Overall, this study indicates RCL was delivered with high fidelity, quality, and dosage in this trial. This paper informs future replication of RCL and provides support for hiring paraprofessionals from the local community as facilitators, delivering the RCL to peer groups of the same age and sex, delivering the RCL with short duration and high frequency, and encouraging youth to attend all RCL lessons, but continue to serve youth who have missed one or more lessons.

COVID-19 Messaging on Social Media for American Indian and Alaska Native Communities: Thematic Analysis of Audience Reach and Web Behavior.

Background: During the COVID-19 pandemic, tribal and health organizations used social media to rapidly disseminate public health guidance highlighting protective behaviors such as masking and vaccination to mitigate the pandemic's disproportionate burden on American Indian and Alaska Native (AI/AN) communities. Objective: Seeking to provide guidance for future communication campaigns prioritizing AI/AN audiences, this study aimed to identify Twitter post characteristics associated with higher performance, measured by audience reach (impressions) and web behavior (engagement rate). Methods: We analyzed Twitter posts published by a campaign by the Johns Hopkins Center for Indigenous Health from July 2020 to June 2021. Qualitative analysis was informed by in-depth interviews with members of a Tribal Advisory Board and thematically organized according to the Health Belief Model. A general linearized model was used to analyze associations between Twitter post themes, impressions, and engagement rates. Results: The campaign published 162 Twitter messages, which organically generated 425,834 impressions and 6016 engagements. Iterative analysis of these Twitter posts identified 10 unique themes under theory- and culture-related categories of framing knowledge, cultural messaging, normalizing mitigation strategies, and interactive opportunities, which were corroborated by interviews with Tribal Advisory Board members. Statistical analysis of Twitter impressions and engagement rate by theme demonstrated that posts featuring culturally resonant community role models (P=.02), promoting web-based events (P=.002), and with messaging as part of Twitter Chats (P<.001) were likely to generate higher impressions. In the adjusted analysis controlling for the date of posting, only the promotion of web-based events (P=.003) and Twitter Chat messaging (P=.01) remained significant. Visual, explanatory posts promoting self-efficacy (P=.01; P=.01) and humorous posts (P=.02; P=.01) were the most likely to generate high-engagement rates in both the adjusted and unadjusted analysis. Conclusions: Results from the 1-year Twitter campaign provide lessons to inform organizations designing social media messages to reach and engage AI/AN social media audiences. The use of interactive events, instructional graphics, and Indigenous humor are promising practices to engage community members, potentially opening audiences to receiving important and time-sensitive guidance.

Predictors of STD Screening From the Indigenist Stress-Coping Model Among Native Adults With Binge Substance Use.

Objective: The American Indian/Alaska Native (AI/AN) population in the U.S. is thriving in spite of settler colonialist efforts of erasure. AI/AN people, however, continue to experience persistent health disparities including a disproportionate burden of substance use and sexually transmitted diseases/infections (STDs/STIs), as well as a disproportionate lack of public health STD screening services and STD prevention interventions grounded in AI/AN social contexts, experiences, and epistemologies. The present study explored how stressors and protective factors based on the Indigenist Stress Coping framework predict STD screening outcomes among Native adults. Methods: We analyzed baseline self-report data from 254 Native adults ages 18-55 years with recent binge substance use who were enrolled in an evaluation of "EMPWR," a two-session STD risk reduction program in a rural, reservation-based community in the U.S. Southwest. Logistic regression models with robust variance were used to estimate odds ratios of lifetime STD testing for the theoretical stressors and cultural buffers. Results: A little over half the sample were males (52.5%, n = 136), with a mean age of 33.6 years (SD = 8.8). The majority (76.7%, n = 195) reported having ever been screened for STD in their life. Discrimination score were significantly associated with lifetime STD testing: The higher discrimination was associated with lower odds of STD testing in the fully adjusted model (aOR = 0.40, 95%CI: 0.18, 0.92). The effects of AI/AN-specific cultural buffer such as participation in traditional practices on STD testing outcomes was in the expected positive direction, even though the association was not statistically significant. Household size was significantly associated with STD screening: The higher the number of people lived together in the house, the higher the odds of STD testing in the fully adjusted model (aOR = 1.19, 95%CI: 1.04, 1.38). Conclusion: Our findings suggest that STD prevention programs should take into consideration AI/AN-specific historical traumatic stressors such as lifetime discrimination encounters and how these interact to drive or discourage sexual health services at local clinics. In addition, larger household size may be a protective factor functioning as a form of social support, and the extended family's role should be taken into consideration. Future research should consider improvement in measurements of AI/AN enculturation constructs.

Measuring the effects of the COVID-19 pandemic on Diné and White Mountain Apache school personnel, families, and students: protocol for a prospective longitudinal cohort study.

BACKGROUND: This paper describes the protocol for a longitudinal cohort study, "Project SafeSchools" (PSS), which focuses on measuring the effects of COVID-19 and the return to in-person learning on Diné (Navajo) and White Mountain Apache (Apache) youth, parents, and educators. The early surges of the COVID-19 pandemic led to the closure of most reservation and border town schools serving Diné and Apache communities. This study aims to: (1) understand the barriers and facilitators to school re-opening and in-person school attendance from the perspective of multiple stakeholders in Diné and Apache communities; and (2) evaluate the educational, social, emotional, physical, and mental health impacts of returning to in-person learning for caregivers and youth ages 4-16 who reside or work on the Diné Nation and the White Mountain Apache Tribal lands. METHODS: We aim to recruit up to N = 200 primary caregivers of Diné and Apache youth ages 4-16 and up to N = 120 school personnel. In addition, up to n = 120 of these primary caregivers and their children, ages 11-16, will be selected to participate in qualitative interviews to learn more about the effects of the pandemic on their health and wellbeing. Data from caregiver and school personnel participants will be collected in three waves via self-report surveys that measure COVID-19 related behaviors and attitudes, mental health, educational attitudes, and cultural practices and beliefs for both themselves and their child (caregiver participants only). We hypothesize that an individual's engagement with a variety of cultural activities during school closures and as school re-opened will have a protective effect on adult and youth mental health as they return to in-person learning. DISCUSSION: The results of this study will inform the development or implementation of preventative interventions that may help Diné and Apache youth and their families recover from the negative impact of the COVID-19 pandemic, and positively impact their health and wellness.

Feasibility and Acceptability of Virtual Implementation of a Sexual Reproductive Health Teen Pregnancy Prevention Program for Native Youth.

American Indian/Alaska Native (Native) youth face high rates of substance use, teen pregnancy and sexually transmitted infections. In response to the COVID-19 pandemic, Respecting the Circle of Life (RCL), a sexual reproductive health and teen pregnancy prevention program for Native youth and their trusted adult, was adapted and delivered in a virtual format with Native youth in a rural, reservation-based Native community. This manuscript describes the adaptation process, feasibility, and acceptability of virtual program implementation. The manuscript describes the process of rapidly shifting the RCL program into a virtual format. In addition, a mixed-methods process evaluation of implementation forms, program feedback forms, in-depth interviews with participants, and staff debriefing sessions was completed. Results show virtual implementation of RCL is both feasible and acceptable for Native youth and their trusted adults. A key benefit of virtual implementation is the flexibility in scheduling and ability to have smaller groups of youth, which offers greater privacy for youth participants compared to in-person implementation with larger groups. However, internet connectivity did present a challenge for virtual implementation. Ultimately, sexual and reproductive health programs seeking to reach Native youth and families should consider virtual implementation methods, both during and outside of pandemic situations.

Empowering Our People: Syndemic Moderators and Effects of a Culturally Adapted, Evidence-Based Intervention for Sexual Risk Reduction among Native Americans with Binge Substance Use.

Native American (NA) communities are disproportionately affected by the intersecting, synergistic epidemics of sexually transmitted infections (STIs) and substance use. Targeted approaches to addressing these syndemics are critical given the relative scarcity of mental health and behavioral specialists in NA communities. We conducted a series of moderation analyses using data from a randomized controlled trial of the EMPWR (Educate, Motivate, Protect, Wellness, Respect) intervention for reducing sexual risk behaviors, culturally adapted for NA adults with recent binge substance use living on rural reservations. We considered several potential moderators and substance use and sexual risk outcomes at 6- and 12-months post-baseline. Three hundred and one people participated in the study. Age, marital status, educational attainment, employment, and depressive symptoms were differentially associated with intervention effects. EMPWR could be strengthened with the incorporation of additional skills-building related to condom use negotiation with casual partners. For individuals with lower educational attainment or without employment, additional supports and approaches to intervention may be needed. Importantly, this study did not identify intersecting sexual risk and substance use behaviors as moderators of EMPWR effectiveness, suggesting that NA adults with varying levels of risk behavior may be equally likely to benefit from this intervention.

Improving communication between American Indian youth and caregivers to prevent teenage pregnancy.

American Indian (AI) youth are at increased risk for poor reproductive health outcomes. Parental communication and monitoring are established predictors of sexual risk-taking among adolescents. No program evaluations of sexual risk avoidance programs have focused exclusively on AI youth and parents. This study assesses the impact of the Respecting the Circle of Life (RCL) Teenage Pregnancy Prevention program on parent-youth communication and parental monitoring through a randomized controlled trial with AI youth ages 11-19 and their trusted adults (parents/caregivers) (N = 518). RCL consists of 8-peer group and one parent-youth session. Trusted adult participants completed the Parental Monitoring Scale and the Parent Adolescent Communication Scale at baseline and 3 and 9 months post-intervention via self-report. Intervention impact was evaluated using linear regression models, which included an indicator for study group. At 3 months post, trusted adults in the intervention reported significantly higher levels of sexual health communication (P = 0.042) and spoke to their child more often about how to get condoms (P = 0.001), get birth control (P = 0.014) and protect themselves from human immunodeficiency virus (P = 0.005) compared with trusted adults in the control condition. Program impact varied by age and sex. This study adds to literature and extends findings on RCL impact.

Diné (Navajo) Female Perspectives on Mother-Daughter Cultural Assets Around the Transition to Womanhood: A Qualitative Study.

INTRODUCTION: American Indian (AI) people have protective factors embedded in cultural teachings that buffer against high-risk behaviors. This study applies a qualitative, grounded theory approach to identify cultural assets for a Diné (Navajo) mother-daughter intervention aimed at preventing substance abuse and teen pregnancy. METHOD: Focus groups and in-depth interviews were conducted with 28 AI females' ages 8 years and older from the Navajo Nation. RESULTS: Key themes were (a) preserving the Diné way of life, (b) cultural assets related to being a healthy Diné woman, (c) matrilineal networks as a source of strength/pride, (d) historical trauma as a source of resilience, (e) male influences as protective health factors, (f) Western education as a measure of success, and (g) integrating different belief systems. DISCUSSION: Study findings may be applied as foundational elements for culturally grounded AI substance abuse and teen pregnancy prevention strategies, as well as culturally safe nursing practice.

'Empowering our people' to address depression, violence, and sexual risk among Native Americans with recent binge alcohol use.

Background: This study was launched in response to an American Indian (AI) community's concern regarding the comorbid occurrence of substance use, poor mental health, and other risk factors on sexual health. The purpose of this manuscript was to assess the relationship between alcohol use, violence, depression and STI/HIV risk behaviors on the frequency of unprotected sex acts and number of sexual partners among AI adults.Methods: Specifically, this analysis examines sociodemographic characteristics, experience of sexual and physical violence, binge drinking, depression, and sexual risk taking among n = 281 AI adults ages 18-55. Regression models examine associations between the aforementioned risk factors, number of sex partners and number of unprotected sex acts, by depression status and sex, among participants.Results: Frequent binge drinking predicted frequency of unprotected sex for both males and females; ever experiencing physical violence was a powerful predictor of unprotected sex for females, but not males. Ever experiencing physical violence strongly predicted having multiple sexual partners for females but was related to decreased number of sexual partners for males. Females ever experiencing sexual violence had more sexual partners; this was not observed for males. Binge drinking predicted frequency of unprotected sex acts, regardless of depression status.Discussion: Interventions for AI adults seeking to reduce sexual health risk should reflect past violence victimization in sexual decision making, primarily among women. The significant role of binge alcohol use for modifying sexual decisions should be of prime focus and interventions should be personalized to address individuals' own alcohol use patterns. Additional research should explore how binge alcohol use moderates the relationship between depression and sexual risk.

Empowering our people: Predictors of retention in an STI risk reduction program among rural Native Americans with binge substance use.

PURPOSE: Substance use and sexual risk-taking have been shown to co-occur. Programs focused on sexually transmitted infections (STIs) reduction may benefit substance-using, particularly binge substance-using, adults. This is especially true for rural Native American communities who endure sexual and substance use disparities and have few STI risk reduction programs. This study explores factors predicting retention in an STI risk reduction program among rural Native adults engaged in binge substance use. METHODS: We analyzed data from 150 Native adults ages 18-55 participating in an evaluation of "EMPWR," a 2-session STI risk reduction program in a rural, reservation-based community. Multivariate logistic regression models were used to estimate associations between independent variables and program completion across demographics, sexual behaviors, substance use behaviors, mental health, recent health care utilization, and perceived enculturation and discrimination. FINDINGS: The sample was 49.2% (n = 59) female with a mean age of 33.61 years (SD = 8.25). Twenty-six completed only the first EMPWR session, 94 completed both EMPWR sessions, and 30 were randomized but completed 0 sessions. Being married/cohabiting (adjusted odds ratio [AOR] = 6.40, P = .0063) and living with an older generation (AOR = 4.86, P = .0058) were significantly associated with higher odds of completing EMPWR. CONCLUSIONS: Findings provide insight on factors driving retention of Natives with recent binge substance use in STI risk reduction programming. An important contribution to Native health literature is that living with an older generation positively predicted EMPWR program completion, suggesting that STI risk reduction programs should harness the strength of families to ensure program attendance and optimize impacts in rural reservation contexts.

Mobilizing Established School Partnerships to Reach Underserved Children During a Global Pandemic.

The coronavirus disease 2019 pandemic has led to drastic public health measures, including school closures to slow the spread of severe acute respiratory syndrome coronavirus 2 infection. Reopening educational settings by using diagnostic testing approaches in schools can help accelerate the safe return of students and staff to on-site learning by quickly and accurately identifying cases, limiting the spread of severe acute respiratory syndrome coronavirus 2, and ultimately preventing unnecessary school and work absenteeism. Although the National Institutes of Health has identified community partnerships as the foundation for reducing health disparities, we found limited application of a community-based participatory research (CBPR) approach in school engagement. Guided by the CBPR conceptual model, we provide case studies of 2 established and long-standing school-academic partnerships built on CBPR processes and practices that have served as a research infrastructure to reach underserved children and families during the coronavirus disease 2019 pandemic. The process described in this article can serve as an initial platform to continue to build capacity toward increasing health equity.

Social Network Differences Between American Indian Youth Who have Attempted Suicide and Have Suicide Ideation.

Suicide is a crucial public health concern for American Indian and Alaska native (AIAN) communities. AIANs have the highest suicide rate compared to all other ethnic groups in the United States. Social relations are a salient fixture of AIAN culture. The primary aims of this study were to describe the personal networks of AI youth that have recently had a suicide attempt or suicidal ideation and to identify key network differences between the two groups. This study uses personal networks collected among AIs living on a reservation in the Southwest. Our sample included 46 American Indians that have recently attempted suicide or had suicidal ideation. We explored social network characteristics of the two groups descriptively as well as comparatively (t-tests). Our findings suggest that AI youth that have attempted suicide nominate more friends in their networks that have used alcohol and drugs compared to the networks of AI youth that have recent suicide ideation. Additionally, AI youth that recently attempted suicide have used alcohol and drugs with their network peers at a higher rate than youth that have had recent suicide ideation. Lastly, AI youth that have attempted suicide recently were significantly more likely to have more nominated friends in their networks that they had reached out to when they were struggling with suicide compared to their peers that have experienced recent suicide ideation. These results indicate a promising method moving forward to identify unique intervention strategies that extend beyond the individual.

Community Perspectives on Social Influences on Suicide Within a Native American Reservation.

Relative to the general population, Native Americans (NA) bear a disproportionate burden of suicide-related mortality rates. NA males and females aged 15 to 24 years experience suicide rates nearly 3 times than the U.S. all races rates in this age group. Although efforts have been made to understand and reduce suicide in tribal communities, a large portion has focused on individual characteristics with less attention given to social factors that may also inform suicide. This article aims to build on a local conceptual model of NA youth suicide by examining additional potential social factors through qualitative interviews. Findings from the thematic analysis resulted in the identification of seven perceived social influences: contagion, violence and abuse, discrimination and bullying, negative expectations, spirituality, social support, and cultural strengths. Public health approaches to reduce suicide should consider local social factors that resonate with tribal communities to build resilience.

Impacts of the respecting the circle of life teen pregnancy prevention program on risk and protective factors for early substance use among native American youth.

BACKGROUND: Early substance use disproportionately impacts Native American (Native) youth and increases their risk for future abuse and dependence. The literature urges for interventions to move beyond focusing on single risk behaviors (e.g. substance use) and instead have capacity to improve health risk behaviors co-occuring during adolescence, particularly among Native populations for whom few evidence-based interventions (EBI) exist. We evaluated the effectiveness of the Respecting the Circle of Life program (RCL) on risk and protective factors for early substance use. RCL is a culturally tailored EBI shown to improve sexual health outcomes among Native youth. METHODS: We conducted secondary analyses of data collected through a community-based randomized controlled trial of RCL evaluated among Native youth (ages 11-19) residing on a rural reservation between 2015-2020 (N = 534, 47.4 % male). We used linear regression, controlling for baseline age and sex, to test between study group differences in outcomes at 3-, 9-, and 12-month post-intervention. Models were stratified by sex and age (11-12, 13-14, and 15+ years of age) to examine differences within these subgroups. RESULTS: Youth receiving RCL reported lower intention to use substances through 12-months follow-up (p = 0.006). Statistically significant improvements were also observed across peer, parent, and sexual partner risk and protective factors to delay substance use initiation, with notable differences among boys and participants ages 13-14. CONCLUSIONS: RCL is a primary prevention, skills-based program effective in preventing risks for substance use. This evaluation underscores the value in developing programs that influence concurrent adolescent risk behaviors, especially for Native communities who endure multiple health disparities.

Diné (Navajo) female perspectives on mother-daughter communication and cultural assets around the transition to womanhood: a cross-sectional survey.

BACKGROUND: The inclusion of protective factors ("assets") are increasingly supported in developing culturally grounded interventions for American Indian (AI) populations. This study sought to explore AI women's cultural assets, perspectives, and teachings to inform the development of a culturally grounded, intergenerational intervention to prevent substance abuse and teenage pregnancy among AI females. METHODS: Adult self-identified AI women (N = 201) who reside on the Navajo Nation completed a cross-sectional survey between May and October 2018. The 21-question survey explored health communication around the transition to womanhood, cultural assets, perceptions of mother-daughter reproductive health communication, and intervention health topics. Univariate descriptive analyses, chi squared, and fisher's exact tests were conducted. RESULTS: Respondents ranged in age from 18 to 82 years, with a mean age of 44 ± 15.5 years. Women self-identified as mothers (95; 48%), aunts (59; 30%), older sisters (55; 28%), grandmothers (37; 19%), and/or all of the aforementioned (50; 25%). 66% (N = 95) of women admired their mother/grandmother most during puberty; 29% (N = 58) of women were 10-11 years old when someone first spoke to them about menarche; and 86% (N=172) felt their culture was a source of strength. 70% (N = 139) would have liked to learn more about reproductive health when they were a teenager; 67% (N = 134) felt Diné mothers are able to provide reproductive health education; 51% (N = 101) reported having a rite of passage event, with younger women desiring an event significantly more than older women. Responses also indicate a disruption of cultural practices due to government assimilation policies, as well as the support of male relatives during puberty. CONCLUSIONS: Results informed intervention content and delivery, including target age group, expanded caregiver eligibility criteria, lesson delivery structure and format, and protective cultural teachings. Other implications include the development of a complementary fatherhood and/or family-based intervention to prevent Native girls' substance use and teen pregnancy.

Prevention of Sexually Transmitted Diseases and Pregnancy Prevention Among Native American Youths: A Randomized Controlled Trial, 2016-2018.

Objectives. To evaluate the efficacy of the Respecting the Circle of Life program (RCL) among Native American youths 11 to 19 years of age residing in a rural reservation community in the southwestern United States. Methods. Between 2016 and 2018, we conducted a randomized controlled trial of the RCL program with 534 Native youths. Participants completed assessments at baseline and 9 and 12 months after the intervention. We conducted intention-to-treat analyses based on study group randomization. Results. At 9 months, intervention participants had significantly better condom use self-efficacy (P < .001), higher intentions to use condoms (P = .024) and abstain from sex (P = .008), and better contraceptive use self-efficacy (P < .001) than control participants, as well as better condom use (P = .032) and contraceptive use (P = .002) negotiation skills. At 12 months, intervention participants had significantly better sexual and reproductive health knowledge (P = .021), condom use self-efficacy (P < .001), contraceptive use self-efficacy (P < .001), and contraceptive use negotiation skills (P = .004) than control participants. Intervention participants reported significantly more communication with their parents about sexual and reproductive health than control participants at both 9 and 12 months (P = .042 and P = .001, respectively). Conclusions. The RCL program has a significant impact on key factors associated with pregnancy prevention among Native youths and should be used as an adolescent pregnancy prevention strategy. Trial Registration.  Clinical Trials.gov identifier: NCT02904629. (Am J Public Health. 2021;111(10): 1874-1884. https://doi.org/10.2105/AJPH.2021.306447).