Study design and population
This study incorporates observational and qualitative data from interviews and focus groups into the adaptation and creation of a psychological health intervention using the ADAPT-ITT process within a CBPR framework for Native American Head Start teachers on the Fort Peck Reservation. The TIDieR (Template for Intervention Description and Replication) checklist (36) describes the adaptation process (additional file 1) and the COREQ (Consolidated criteria for reporting qualitative research (37) (additional file 2) describes the process for the interviews and focus groups.
Spanning 180 miles and encompassing 3,200 square miles, the Fort Peck Reservation is home to the Assiniboine and Sioux Tribes—approximately 12,000 tribal members (38). There are six Head Start schools across the Fort Peck reservation serving over 300 children between three to five years old. Those also eligible for services include pregnant women and children from birth to three years of age, and children and families who are homeless, in foster care, or receiving Temporary Assistance for Native Families or Supplemental Security Income (38). Tribal Head Start Administration reports that most children come from single-parent homes, and 80% are below the Federal Poverty Level (Personal communication V. Wood, July10, 2020). There are 21 Head Start teachers and teachers’ assistants; all are women and identify as Native American, with the majority identifying as Assiniboine or Sioux. More than half of these teachers have worked for Head Start for over 20 years. Administration reports that these teachers receive little to no mental health support despite the stresses of their job, personal life, and community (drug addiction, high crime, and suicide rates) (Personal communication V. Wood, July10, 2020).
CBPR framework
The decision to use a selected CBPR framework arose from recognition of the distrust Native American communities have towards academic institutions and researchers, which stems from colonization and experience of unethical research practices with their Peoples (39). Table 1 outlines how CBPR steps and principles were employed throughout the study to enhance the rigor, relevance, and reach of study findings. Team engagement within the community involved 1) access to guidance from a Native American researcher familiar with the community; 2) attending workshops led by Native American Elders and Native academic researchers on how to work with Native populations; and 3) collaboration with other Native and non-Native researchers to conduct a literature review on best practices for culturally safe research with Native American populations (39).
Table 1
Steps of CBPR (54) | Principles of CBPR(32) | Relation to Study Aims | Strengthens the science by… (55) |
Defining, engaging community; identifying community needs and research | Recognition of the community as a unit of identity; recognize tribal sovereignty; building on strengths and resources within community; collaborative partnerships; integration of knowledge and action for mutual benefit of all partners. | Tribal IRB; formation of Tribal Advisory Board (TAB); background research; stakeholder interviews, focus groups; building and maintaining trust; consensus of research goal and development of questions; oversight of research by Native American scholar and TAB. | Ensures Relevance |
Design/Hypothesis testing; responsible conduct of research | Promotion of co-learning and an empowering process that encourages social equality; cyclical and interactive process | Community relevant outcome measures; adapting modules of Wakȟáŋyeža, through iterative work with TAB; Implement with ongoing oversight and problem solving with TAB. | Enhances Rigor |
Analysis; interpretation of results; dissemination; action | Focus on health from strengths-based perspectives; dissemination of findings and knowledge to all partners | Refinement based on new understandings; review and interpretation by all members of team; joint publications; collaborative conference presentations; community presentation | Extends Reach |
ADAPT-ITT methodology
ADAPT-ITT methodology was originally developed to ensure a systematic framework for adapting, implementing, and evaluating evidence-based HIV prevention interventions (34). Using an iterative process and repeated applications Drs. Wingood and DiClemente developed the ADAPT-ITT model considering the need to be cost effective, attentive to cultural context, adhering to core intervention elements, and producing an adapted intervention that is relevant, sustainable, and acceptable for the target population (34). Utilized in domestic and international settings, with diverse populations ADAPT-ITT involves the community and target population throughout the adaption process, uses qualitative data (interviews, focus groups, observation) and quantitative assessments (theater testing, feasibility testing and pretest posttest surveys) to ensure a systematic process to efficiently create an adapted intervention (34). The ADAPT-ITT method consists of eight sequential steps that guide researchers through the adaptation process. For this study we applied each step using the following qualitative and quantitative assessments and tools:
1) Assessment: literature review; focus groups and interviews.
2) Decision: identified and selected an evidence-based intervention to adapt.
3) Adaptation: original intervention reviewed and tested by target audience using theater testing methodology.
4) Production: iterative process with Tribal Advisory Board (TAB) and original intervention designers to develop a draft of the adapted intervention.
5) Topical experts: draft reviewed by TAB, and proposed survey measures piloted with TAB.
6) Integration: feedback from experts incorporated into draft and pretest-posttest survey,
7) Training: a community health worker (CHW) will be trained in recruitment and implementation of adapted intervention and
8) Testing: a feasibility/acceptability study will be conducted in the future.
Figure 1 summarizes processes implemented by the team, which correspond to each step of the ADAPT-ITT model. Of note, the final two steps (7. training and 8. testing) will be reported in a future publication.
Ethics approval
The Fort Peck Head Start administration had interest in exploring and implementing a sustainable intervention to promote their teachers’ well-being, which was solidified in a meeting with the Tribal Executive Board—consisting of Assiniboine and Sioux tribal leaders. We discussed our intent, and a Tribal Resolution (Resolution #30-348-2020-03) authorized this research, which gave permission to apply for funding and conduct a study on the reservation with Fort Peck Head Start teachers. Additionally, the resolution includes a section on the tribe rights to protect intellectual property and Indigenous knowledge including, pictures, songs, or stories and requires that any manuscripts be reviewed by the council prior to publication. Institutional Review Board (IRB) approval was granted by both the XXXX (Blinded for review) and Fort Peck IRBs.
Tribal Advisory Board
With permissions, formal IRB approvals, and training completed a TAB was then established. A TAB is made up of community members who share a common identity, history, symbols, language, and culture (39). They advise researchers on culturally safe research practices with the community and help their communities understand research rationale, impact, and consent processes (39). The TAB for this study consisted of a Head Start supervisor, Head Start teacher, Head Start parent, a cultural advisor, a public-school educator (and Head Start parent), and a Head Start grandparent. TAB members receive an honorarium for attending meetings. Using an iterative process, the researchers worked with the TAB, to develop a logic model that outlines the research process of this study (Fig. 2).
Data Collection
Step 1– Assessment
A comprehensive literature search for studies that have implemented interventions with for Head Start teachers across the U.S. to decrease stress or promote well-being was conducted. We also searched for studies that included Native American Head Start teachers or the use cultural adaptations with the Head Start population.
The next step comprised focus groups and interviews with Head Start teachers, parents, and community members to assess psychological risks such as stress, depression and PTSD, preferences for intervention content, perceived need(s), and an assessment of capacity within the community to help adapt and adopt the chosen intervention. Prior to collecting qualitative data, our TAB reviewed the semi-structured focus group and in-depth interview guides (available upon request). They conveyed culturally appropriate ways of ordering the questions and how to ask difficult questions, and ensured we were taking a strengths-based approach to understanding stressors and coping mechanisms among Fort Peck Head Start teachers. Recruitment was conducted using flyers, email and a presentation describing study purpose at a Head Start staff meeting. Eligibility criteria included being older than 18 years, currently or previously worked for Fort Peck Head Start as a teacher, teachers assistant, supervisor, or ancillary staff, or be parents of children that have or had attended Head Start. Teacher needs, comments and concerns were elicited through interviews with key community members (i.e., cultural leaders, council members, and Head Start administration). Community interest was gauged by noting comments and concerns voiced by Fort Peck administration, Head Start teachers, parents, and ancillary school staff. Teachers’ interest was gauged through individual interviews.
Step 2– Decision
Key feedback from the TAB and qualitative data collection yielded a strong interest in using culture as a solution for stress, a concept which has been largely overlooked in other research studies (40). Based on the results of literature search (detailed in results section), we explored the possibility of adapting an intervention currently being implemented with Head Start parent-child dyads on the Fort Peck Reservation via a randomized control trial (RCT) (ClinicalTrials.gov: NCT04201184).
The RCT, Wakȟáŋyeža, hereafter referred to by its translation - Little Holy One - is an intergenerational intervention designed to reduce parental stress and trauma-related symptoms among parent-child dyads, where the children are 3–5 years of age and attending tribal Head Start (23). The intervention is a strengths-based, 12-module curriculum focused on promoting family wellness across a holistic well-being (i.e., physical [behavioral], emotional, mental [cognitive], and spiritual) spectrum. There are four cultural components in the Little Holy One curriculum, designed to support the psychological health and well-being of parent-child dyads by 1,2) promoting tribal identity and communal mastery (group efficacy), 3) addressing contemporary and historical trauma, and 4) promoting smudging. With support from the Principal Investigator of Little Holy One (TB), our TAB, and Head Start administration—we adapted the four cultural lessons into a stress reduction curriculum for Head Start teachers. Table 2 outlines the lessons taken from the Little Holy One curriculum for adaptation to the tribal Head Start teacher context. The cultural lessons were originally developed in partnership with a Fort Peck-based TAB and community members, and Little Holy One pilot data demonstrate lessons were feasible and acceptable to participants.
Table 2
Lessons for adaptation in original order | Description of lessons | Lesson Activities and time to complete |
Promoting Tribal Identity | Connects one to the Creator, responsibility to live a good life by walking spiritual path | Practice greeting of relatives in Nakoda and Dakota. Traditional naming 1 hour. |
Understanding our Emotions | Understand association among thoughts, feelings, and behavior | Identifying depression, managing anger and stress; working through challenges Visualization activity 1 hour. |
Smudging | Therapeutic healing practice to resolve unsettling feelings and thoughts | Smudging together; smudging as a daily routine 45 mins. |
Strengthening Family and Community | Therapeutic value of connectedness to relatives and community | Knowing our relatives Family tree exercise. My friends and family exercise 1 hour. |
Healing Historical & Contemporary Trauma | Identify imbalances in physical, emotional, mental, and spiritual domains created by historical trauma. | Identifying and coping with effect of historical traumas. Strength and resilience Forgiveness exercise Smudge at end 1 hour. |
Step 3– Adaptation using theater testing methodology
The next step involved gathering community feedback for adapting the cultural lessons. Theater testing is a pre-testing methodology that involves presenting an original product to an audience aligned with the intended target audience (34). The TAB, Head Start teachers, and community members were invited to a presentation of the four cultural components, whereby they could respond and ask questions, allowing the study team an opportunity to gauge their reaction to the product. A CHW trained to deliver the cultural lessons, as they are intended for Little Holy One, implemented the modules to this target audience because of her expertise with the original format and knowledge of local tribal culture. Being the audience encompassed the population of interest, they were able to provide an important assessment of the cultural components and provide direction for the study team to ensure the cultural adaptation would meet their needs.
The research team led a discussion in between presentation of each lesson, which included the following prompts: 1) appropriateness of the lessons for teachers, 2) order in which lessons should be implemented, 3) additional materials and/or activities that might enhance its relevance, and 4) appropriateness of reflection and activity handouts and assignments 5) burden of the intervention. Information extracted from qualitative interviews and focus groups (Step 1) was also introduced during these discussions, which included: teachers often do not realize the degree or impact of their stress, they will not travel to get mental health support, and the need for support mechanisms to be made convenient.
Step 4– Production
After listening to theater session recordings and reading transcripts and field notes, a first draft of the adapted intervention with accompanying handouts was developed. This was then
presented to the designers of the cultural lessons to ensure the adaptation maintained the integrity of their original intervention.
Step 5– Topical experts
With a first draft ready for review we then piloted the pre-posttest survey with the TAB letting them naturally self-administer the survey as intended. Intentional care had been taken to choose measures validated in a Native American context. Discussion with the designers of the original intervention afforded the team access to two measures, cultural identity, and historical trauma, that have been specifically modified for the Assiniboine and Sioux culture. Table 3 details the full list of proposed pre-posttest outcome measures. The TAB is considered an expert group and representative of the target population; thus, their responses were important to assess appropriateness of the chosen outcome measures. The primary outcome of the proposed feasibility study will be to reduce self-perceived stress (measured using the validated self-perceived stress scale (41)). Secondary outcomes are to increase well-being (satisfaction with life (42)) and decrease depression (Center for Epidemiologic Studies Depression Scale- CESD_10 (43)). Longitudinally, we hope to see a decrease in historical loss associated symptoms, and an increase in resilience (Connor Davidson Resilience scale (44)), tribal identity (45), and communal mastery.
Table 3
Proposed Pre- and- Post Test Outcome Measures
Concept | Measure | Number of items and scoring range | Cronbach’s alpha | Time to complete |
Stress | Perceived Stress Scale 10 (PSS-10) (41) | Widely used and has been adapted for Native American populations. 10 items 5-point scale. 0 = Never to 4 = very often | 0.78 | 2 min |
Well-being | Satisfaction with Life Scale (42) | A better measure of subjective well-being in Indigenous populations. 5 items. 7-point scale. 1 = strongly agree to 7 = strongly disagree | 0.87 | 1 min |
Depression | Center for Epidemiologic Studies Depression Scale Revised (CESD-R-10) (43) | Self-Report. Validated among Native American populations. 10 items | 0.86 | 1 min |
Childhood trauma/adversity | Stressful Life Events Questionnaire (SLESQ) (56) | Self-report measure to assess life-time exposure to traumatic events. More accurately captures traumas experienced by Native American population then BFRSS ACE score. 13—item scale | 0.73 | 7 mins |
Group Self Efficacy | Communal Mastery Scale (57) | Developed specifically for Native American contexts. Uses two commonly employed measures of mastery and self-efficacy 10 items 4-point scale. 1 = strongly disagree to 5 = strongly agree | 0.85 | 2.5 min |
Cultural Identity | Tribal Identity (45) | Modified from Orthogonal Cultural Identification Scale specifically for Assiniboine and Sioux identity. 6-items | 0.9 | 1.5 min |
Historical Trauma | Historical Trauma (58) | 3 questions developed specifically for Native American context: yes/no | | 1.5 min |
Historical Trauma | Historical Trauma Checklist | 15 items adapted for Assiniboine/Sioux Tribes. Yes/no don’t know, refuse to answer | | 3.0 min |
Historical Trauma | Historical losses Associated Symptoms Scale (58) | 12 questions. 5-point Scale 0 = Never to 5 = Very often | 0.91 | 1.5 min |
Resilience | Connor-Davidson 10-item Resilience scale (CD-RISC-10) (44) | Is more effective with Native American populations than CD-RISC-25. 10 items. 5-point scale. 0 = Never to 4 = Very often | 0.85 | 1 min |
Childhood resilience | Benevolent Childhood Experiences Scale (BCEs) (59) | Has been used in Native American populations. 10 items yes/no | | 1 min |
Quality of teacher-children relationships | Student Teacher Relationship Scale (short form) (60) | Has been used with Head Start teachers. Items are grouped into two subscales: conflict and closeness. 15 items.5-point scale 1 = definitely does not apply to 5 = definitely applies | conflict 0.73 Closeness 0.72 | 2min |
Childhood Trauma | Adverse Childhood Experience (ACEs) (4) | Validated measure that tallies the different types of abuse, neglect, and other adverse childhood experiences. 10 items – yes/no | .67 | 5 min |
TOTAL TIME | 30 minutes |
TAB members were each given the proposed pre-posttest survey and asked to take notes as they navigated the questions. Following completion, we conducted a focus group-style discussion. TAB members were asked to consider the following questions about the survey: 1) was there any confusion with the survey instructions, 2) do the survey instructions help introduce and guide participants through the survey, 3) was there any variability in your interpretations of the questions, 4) was there any discomfort in answering any of the questions, 5) what did you think of the length of the survey, and 6) what did you think of the order of the measures?
Step 6– Integration
The research team presented the draft of an adapted 5-lesson curriculum for implementation with Fort Peck Head Start teachers to the TAB where it was approved. Finally, we took the feedback from the piloting of the pre-posttest survey and presented the final draft to the TAB once more prior to planned implementation. This iterative process helped ensure no gap between the measures and theoretical constructs and integrated local, cultural perspectives (46)
At the time of data collection, the Fort Peck Reservation experienced a surge in COVID-19 cases, which required a reduction in number of participants for safety, IRB compliance, and adherence to university and tribal protocols. As such, interviews were conducted via Zoom or telephone and focus groups delayed until the tribal government allowed in-person gatherings. The four theater testing sessions were conducted in-person with numbers limited to the TAB members (five in total), one CHW, and one researcher (DW) to comply with tribal government restrictions on how many people could gather.
Data Analysis
All focus groups and interviews were recorded and transcribed verbatim. TAB meetings and theater testing sessions were recorded, and detailed notes taken. Qualitative data was thematically coded using qualitative analysis software F4Analyse by two researchers who met to compare coding and discuss emerging themes. Results were discussed with the research team and brought to the TAB so that findings could be incorporated into intervention adaptation.