Statement of Work.pdf

Proposed Statement of Work For The Contractor in Partnership with the Chinle Service Unit: Health

Promotion Program & Public Health Department 10/1/2020-9/30/2021

1. Scope

a. Background

Respecting the Circle of Life Program (RCL)

Despite alarming rates of sexually transmitted infection (STI) and unintended pregnancy among adolescents and young adults in Navajo communities, there are few evidence-based interventions developed for and with American Indian populations. The Chinle Service Unit: Health Promotion Program, sees a need for holistic interventions that provide youth with essential education and skills training to promote sexual and reproductive health.

The Contractor has a long history of successfully implementing public health programs in partnership with communities across the Navajo Nation. Johns Hopkins is uniquely positioned to address the current need identified by the Navajo Nation Health Department by disseminating the evidence-based program: Respecting the Circle of Life:

Mind, Body and Spirit (RCL).

RCL is an evidence-based, comprehensive sexual and reproductive health program for youth and families delivered through an innovative summer basketball camp and individualized youth-parent component. RCL incorporates culturally appropriate education and activities to increase awareness for prevention of STIs, unintended pregnancy and sexual violence. It was developed in partnership with the White Mountain Apache Tribe, and has been proven effective in improving:

• Sexual health prevention knowledge and attitudes

• Partner negotiation skills related to sex and substance use

• Conversations with parents and family about sexual health

• Condom use intention and condom use self-efficacy

The RCL Program is designed to be delivered by facilitators, Native community health workers, from communities where families are served. Eight sessions are taught during an eight-day summer basketball camp to small groups of peers divided by gender and age. A 9th lesson is taught to the youth by a facilitator together with their parent or another trusted adult in their home. RCL is poised for replication and dissemination through a rigorous process of training and technical assistance provided by The Contractor.

RCL curriculum provides a ready platform for promoting sexual and reproductive health as well as skills training for healthy adolescent development. Curriculum content includes:

1. Communication around sex and substance use

2. Healthy relationships training

3. Sexual violence education

4. Partner negotiation skills

5. Problem-solving skills

6. Sexual health decision-making skills

7. Condom use skills

8. Contraception education

9. Values clarification

10. Goal-setting

11. Parent-adolescent communication

12. Parental monitoring

Arrowhead Business Group (ABG)

Despite high rates of substance use and suicide among adolescents and young adults in Navajo communities, there are few evidence-based interventions developed for and with American Indian populations. The Chinle Service Unit: Health Promotion Program sees a need for holistic interventions that provide youth with essential education and skills training to promote healthy development, problem-solving and decision making;

connection to high school and college matriculation; and opportunities for job training and employment.

The Contractor has a long history of successfully implementing public health programs in partnership with Navajo communities and the Indian Health Service across the Navajo Nation. The Contractor is uniquely positioned to address the current need identified by the Chinle Service Unit: Health Promotion Program by disseminating the program:

Arrowhead Business Group Youth Entrepreneurship Program (ABG).

ABG is a culturally appropriate entrepreneurship intervention targeting youths’ attachment to educational and occupational goals. Curriculum content covers life skills, financial literacy, and business development. ABG incorporates hands-on training for youth to apply curriculum content to launch their own businesses. ABG was developed in partnership with the White Mountain Apache Tribe, and has been show to positively impact:

Marijuana use Suicide Fighting Missing school because felt unsafe Entrepreneurship knowledge Economic empowerment Social connectedness and well-being

The ABG Program is comprised of 16 lessons designed for delivery by Native community health workers from communities where families are served. Ten lessons are taught during a five-day summer overnight camp in an interactive classroom-style setting to groups of youth. Six additional lessons are taught during weekend workshops throughout the school year to provide youth with opportunities for real-world skills application and guidance from community leaders and mentors to launch their own businesses. The ABG program is poised for replication and dissemination through a rigorous process of training and technical assistance provided by Johns Hopkins Center for American Indian Health staff.

ABG curriculum provides a ready platform for substance use and suicide prevention.

Curriculum content includes:

1. Communication

2. Decision making skills training

3. Problem-solving skills training

4. Values clarification

5. Goal setting

6. Incentives to stay in school

7. Mentorship from community leaders and entrepreneurs

Family Spirit Program:

Personal and historical trauma and the inter-generational cycle of these experiences are some of the root causes of health disparities in Indian Country. Among all populations in the United States (US), Native Americans (NAs) report the highest Adverse Childhood Experiences (ACEs) scores. Exposure to ACEs in NA populations, including but not limited to parental substance use, abuse, a history of neglect or domestic violence have been found to be strongly associated with children’s own alcohol and drug abuse, depression, and suicide. Studies have found similar patterns in health outcomes for children whose parents have experienced historical loss, discrimination, exposure to community violence, criminal behavior, bullying, and economic hardship. Without intervention or healing, the intersection of trauma, ACEs and substance use becomes transmitted intergenerationally. Parents who experienced early life traumas have higher risk for substance abuse and domestic violence, that can perpetuate neglect, abuse and/or exposing their own children to traumatic events, which in turn leads to early substance use initiation, formation of unhealthy relationships, and substance abuse problems for their children later in life.

While ACEs are highly prevalent among NA populations, there is a parallel history of tremendous community resilience, cultural protective factors and family strengths that can protect young children’s well-being and break the cycle of inter-generational trauma.

Pregnancy and early childhood are some of the most critical developmental stages of a child’s life and are also sensitive periods for mothers’ behavioral re-direction. Interventions that promote family resilience and strengthen parenting, such as early childhood home visiting programs, have been shown to benefit at-risk families. However, in practice, these interventions may not always be delivered to those families who are hardest reach and at highest risk and may not incorporate content that addresses the most relevant risk factors for these families. Developing tools to assist home visitors in identifying the highest risk families and engaging those families in a home visiting curriculum that is evidence-based, culturally appropriate and addresses their specific risk factors can help ensure the most vulnerable families receive services that build resilience and break cycles of intergenerational despair.

The Chinle Service Unit: Public Health Department has identified a critical need for identifying families with high risks and providing these families with holistic interventions that aim to address trauma and promote resilience while also providing education and support around reducing or preventing mothers’ substance abuse risk. We propose to address these challenges during the critical developmental periods of pregnancy and early childhood when maternal and child health behaviors are dynamic, formative, and associated with life-long impacts.

The Contractor has a long history of successfully implementing public health programs in partnership with Navajo communities and the Indian Health Service (IHS). The Contractor is uniquely positioned to address the current need identified by the Chinle Service Unit:

Public Health Department by developing guidelines for identifying high risk families and additional curricular components for the evidence-based Family Spirit® Program to target: 1) the impacts of mothers’ unresolved historical and lifetime traumas and ACEs; 2) promotion of resilience and family strengthening among mothers and their children; and 3) reducing substance use risk in pregnancy and early childhood parenting to promote well-being among NA families.

The existing Family Spirit Program is a comprehensive maternal and child health home visiting program for mothers from pregnancy through 36 months postpartum. It was developed in partnership with Navajo Nation and the White Mountain Apache and San Carlos Apache Tribes, and, over the past 20 years, has been proven effective in promoting competent parenting, reducing maternal psychosocial risks that could impede positive parenting, and improving child developmental outcomes. Family Spirit is designed to be delivered by NA Family Health Coaches from communities where families are served.

Family Spirit has been replicated in over 130 NA communities across the US, including the Chinle Service Unit: Public Health Department, through a rigorous process of training and technical assistance provided by the Contractor.

The Family Spirit Program and curriculum provides a ready platform to identify at-risk families and address trauma, promote resilience, and reduce or prevent maternal substance abuse risk by enhancing screening and existing curriculum content and activities. The enhanced screening will include prenatal screening of pregnant women for exposure to ACEs, trauma, history of substance use, and other factors related to risks determined through the formative phase of this proposal. The adapted curriculum will expand upon these new focal areas: 1) healing from unresolved trauma and ACEs; 2) promoting resilience and family strengthening among mothers and their children; and 3) reducing maternal substance abuse risk. As with all of Family Spirit, new screening and curriculum materials will be culturally sensitive, incorporate local understanding, cultural assets and traditions, and will be informed by community stakeholder input.

The partnership between The Contractor and Chinle Service Unit: Public Health Department will start with a formative phase. Stakeholder input will explore common ACEs, their consequences on parenting and young children, and pathways to healing specifically among young mothers and their families. Stakeholders will also advise on culturally informed ways to promote resilience among mothers and their children. In addition, the formative phase will gather tribal, community, cultural, family and individual factors that influence maternal substance abuse risk and protective factors in Navajo communities. Findings will inform adaptations to screening instruments and new Family Spirit curricular components that will then be piloted among mothers served by the Chinle Service Unit. At the end of the project year, selected staff member(s) will be trained in the adapted Family Spirit curriculum modules so they can implement them within their current home visiting work in their communities. Staff will also be trained in effective ways to identify and recruit at-risk mothers into the program. The training process will follow the existing Johns Hopkins protocol for providing an in-person training along with pre-training and post-training technical assistance to the Family Health Coaches/home visitor(s). The contract will cover printing of new curricular materials for up to 4 trainees who will become specialists for this specific at-risk population (i.e, mothers with high ACEs, historical and lifecourse traumas) within their service setting.

b. Purpose

RCL & ABG:

Goals: To continue our academic-public health partnership to implement and evaluate the Respecting the Circle of Life and Arrowhead Business Group programs with Navajo youth and families to address risk and protective factors and promote sexual and reproductive health and prevent substance use and suicide. To expand our collaborative partnership to include strategic planning, coordinating of stakeholders at Chinle IHS, coordination with the Chinle Zero Suicide Initiative and training in relevant protocols and suicide prevention programs, replication of the Arrowhead Business Group program in schools on the Navajo Nation, capacity building of Chinle Health Promotion and Disease Prevention staff in evaluation and data management, evaluation of program implementation occurring over the project period, and presentation of results at professional conferences.

Family Spirit:

Goals: 1) To develop modules for the Family Spirit curriculum to address ACEs and historical and modern-day trauma, promote resilience, and reduce or prevent maternal substance abuse; and 2) To train and support Chinle Service Unit home visitor(s) in using the new Family Spirit materials and strategies for effectively identifying, recruiting and engaging high-risk mothers.

2. Requirements:

a. Tasks

To achieve these goals, The Contractor will partner with the Chinle Service Unit: Health Promotion Program to accomplish the following aims during the period of October 1, 2020 to September 30, 2021:

RCL & ABG:

Strategic Planning:

a. Assess each Health Promotion programs/services for how harmful would it be to delay service and what is the safest way to implement the programs/services.

b. Contractor will advise on innovative and interactive virtual implementation of HP program/services that ensures recruitment, retention, and high quality engagement of participants.

c. Hold several strategic planning sessions to complete the Health Promotions Public Health plan for intervention across primary, secondary and tertiary levels

d. Assist with completion of strategic plan documentation (NOTE: this scope of work does not include provision of training/technical assistance on Center programming that is incorporated into the Strategic Plan because that cost will depend on what Center programming is selected as it varies in content/structure).

Stakeholder Coordination:

a. Preparation for and participation in clinical and community stakeholder planning meetings for priority areas to apply for MSPI and DVPI funds (NOTE: this will consist of two meetings in one day)

b. Consult on writing next round of grants for MSPI/DVPI funding Coordinate with Chinle Zero Suicide Initiative:

a. Facilitate meetings between Health Promotion and Zero Suicide teams to identify opportunities to collaborate/partner

b. Train Health Promotions staff in suicide surveillance protocol

c. Train Health Promotions team in suicide prevention interventions (New Hope, Re-

Embracing Life) Arrowhead Business Group:

a. Adapt ABG for delivery at Rough Rock Residential School evening program

b. Adapt ABG for delivery at Chinle High School

c. Adapt ABG for delivery at Pinon Residential School

d. Provide tailored training for facilitators in ABG

Data Management and Analysis (ABG and RCL programs):

e. Conduct all data management activities for data collected through ABG and RCL implementation in Chinle (including adaptation of data collection tools based on mode of delivery, i.e. after school, in school, etc., data entry, data cleaning, data coding and quality assurance)

a. Conduct all data analysis

b. Product summary statistics and graphics with results

Conference Preparation and Presentation:

a. Prepare ABG/RCL results for abstract submissions to conferences in both poster and paper presentation format

b. If accepted, prepare posters and presentations for conferences

c. Present at conferences on behalf of our partnership

Evaluation Capacity Building:

a. Create an evaluation and data management toolkit for Chinle Health Promotions to have as a resource for future evaluation

b. Provide training in evaluation and data management for Chinle Health Promotions staff to administer evaluations independently moving forward Family Spirit:

1. The Contractor will work with the Chinle Service Unit: Public Health Department team to create a Tribal Advisory Board (TAB) that will meet at least quarterly during the year.

The first meeting will be held during Months 1 to 3 to introduce the project and elicit feedback on the project goals, timeline and formative phase process.

2. Formative Development: The Contractor will conduct roundtables and interviews with providers, community members, and parents (potential participants in the program) to understand tribal, community, cultural, family and individual factors related to historic and contemporary trauma, adverse childhood experiences, building resilience, and maternal substance abuse. Discussion guides will be created, and questions will cover topics such as: challenges and opportunities for measuring ACEs and how home visiting might help; common and relevant adverse childhood experiences and traumas and their impact on parenting and children; cultural teachings and practices to heal from trauma;

cultural teachings and practices to build resilience; what resilience should look like;

protective factors against adverse childhood experiences; most commonly used substances; perceived risks for SA among young expectant women and mothers;

community resources; cultural protective factors against SA; cultural teachings around SA prevention; home environment barriers to prevention of SA; etc.

3. Part of the formative phase will also include meetings with key staff from the Pediatrics

Department and Family Spirit home visiting program to discuss how to incorporate ACEs screening into existing services.

4. Based on information gathered during the formative development phase (Months 1 to 3), The Contractor will create new curricular materials to address trauma, build resilience, and target substance abuse risks. The Contractor will also compare the information gathered during this time to existing screening instruments to identify high risk families.

They will liaise with Chinle staff to incorporate ACEs screening into practice.

5. As new curricular materials are created, they will be piloted with local Chinle Service

Unit: Public Health Department staff and, if possible, families already engaged in home visiting services. The curriculum will be refined based on feedback from the piloting.

The screening tool will be piloted with n = 10 parents and home visitors to assess interpretability and acceptability.

6. TAB meetings will be held to elicit feedback on screening tool recommendations, curriculum adaptations and to begin discussing implementation in the community.

7. Chinle Service Unit: Public Health Department and The Contractor will identify existing Family Spirit staff member(s) and supervisor(s) who will be trained in the new Family Spirit materials and screening and recruitment strategies.

8. The Contractor will work with the site staff to further pilot new curricular materials with families already engaged in home visiting services, as well as with TAB members. The curriculum will be further refined based on feedback from the final piloting.

Corresponding instructional materials will also be created as needed to guide the incorporation of new materials and tools into the existing Family Spirit curriculum package.

9. Preliminary training in administering the ACEs measure will be conducted with key staff. The screening tool will be piloted so that policies and procedures may be refined.

10. Regular pre-training meetings with The Contractor’s Program Manager, Program Coordinator, Site Liaison and the site team will occur to plan for the upcoming training and the program implementation.

11. The site team will receive the new screening, recruitment, curriculum lessons and ancillary materials to review prior to the in-person training. This orientation will ensure a solid grounding in the materials prior to the in-person training and will facilitate more focus on implementation and quality service delivery during the training.

12. One in-person training will be conducted to provide in-depth training to the site team in the screening, recruitment, and new curriculum modules designed to focus on promoting resilience to trauma and substance abuse prevention.

13. Following the training, post-training meetings will occur between The Contractor’s

Program Manager, Program Coordinator, Site Liaison and the site team to provide ongoing guidance and technical assistance in implementing the adapted Family Spirit materials.

14. The Contractor will advise the site team and the Chinle Service Unit: Public Health

Department in evaluation measures to track desired process measures and outcomes. The Contractor will provide the team with a proposed evaluation plan for the new program materials, including recommendations with how to identify families that need the new curriculum, based on the desired scope and resources for evaluation.

15. A TAB meeting will be held to focus on program implementation in the community.

NOTE: For all activities and deliverables indicated in Section 2-Requirements, safe social distancing requirements due to COVID-19 will be adhered to and/or the Contractor will perform tasks virtually (e.g. via Zoom or some other online platform).

3. Qualifications and Experience of The Contractor:

The Contractor is uniquely poised to conduct the propose scope of work. The Contractor has a 30+ year continuous track record of conducting high quality community-based service and research with Native communities. This includes proving the efficacy of oral rehydration therapy for infant diarrhea and four pediatric vaccines for Haemophilus influenza, type-b meningitis, rotavirus and pneumococcal disease1. These five public health services are now part of standardized global pediatric care. Together they prevent 3-5 million child deaths a year around the world.

Stigmatization and a lack of trust of the outside community, particularly around sensitive topic areas including suicide, substance use and sexual health, are barriers to conducting this type of service delivery and performance measurement in Native communities. The Contractor has decades of past service provision and the necessary knowledge, experience and expertise working to develop, deliver and evaluate family-focused human service provision programming, described in detail below:

RCL was developed by the Contractor in partnership with the White Mountain Apache in 2010. The Contractor has conducted two rigorous trials of RCL with Native youth and parents (NIH Grant#:

U26IHS300286; DHHS-OPA Grant# TP2AH000041-01-00). Results trial demonstrate how the parent lesson enhances and extends RCL impacts on partner negotiation about condom and contraceptive use and communication between youth and parents.2 Additionally, the RCL program was implemented with high quality (interaction: 4.6 out of 5, participant engagement: 4.4 out of 5, facilitator knowledge: 83.1 out of 100) and fidelity (96.3% of lesson content was delivered as intended). We also had high retention rates (average 85% of lessons). The Contractor has been replicating and evaluating RCL through a previous contract to deliver RCL as a service to Navajo youth and parents through the Chinle Service Unit’s Health Promotion and Disease Prevention program’s Domestic Violence Prevention Initiative.

In 2013 the Contractor took a positive development approach to design and evaluate ABG, a cultural-assets based curriculum focused on known risk and protective factors to promote economic mobility in Native communities. The Contractor conducted a trial of ABG with N=393 youth (NIH grant #: U261IHS0080-01-00) and found positive impacts on entrepreneurship knowledge, economic confidence, security, abilities, agency and participation and future planning3. Results also indicate ABG significantly reduced marijuana use, physical fighting and weapon carrying. The Contractor has been replicating and evaluating ABG through a previous contract to deliver ABG as a service to Navajo youth and parents through the Chinle Service Unit’s Health Promotion and Disease Prevention program’s Methamphetamine and Suicide Prevention Initiative.

In 1996 the Contractor partnered with the Navajo Nation to design an early childhood home-visiting intervention for expectant teen mothers. Family Spirit (FS) is a structured 63-lesson curriculum, 1 Santosham, Mathuram et al. "Oral rehydration therapy of infantile diarrhea: a controlled study of well-nourished children hospitalized in the United States and Panama." NE journal of medicine 306, no. 18 (1982): 1070-1076.;

1 Santosham, Mathuram et al.. "Safety and immunogenicity of a Haemophilus influenzae type b conjugate vaccine in a high risk American Indian population." The Pediatric infectious disease journal 10, no. 2 (1991): 113-116.;

1 O'Brien, Katherine L. et al. "Efficacy and safety of seven-valent conjugate pneumococcal vaccine in American Indian children: group randomised trial." The Lancet 362, no. 9381 (2003): 355-361.;

1 Santosham, Mathuram et al. "Efficacy and safety of high-dose rhesus-human reassortant rotavirus vaccine in Native American populations." The Journal of pediatrics 131, no. 4 (1997): 632-638.

1 O'Brien, et al. "Efficacy and safety of seven-valent conjugate pneumococcal vaccine in American Indian children:

group randomised trial." The Lancet 362, no. 9381 (2003): 355-361.

2 Tingey, Lauren, Rachel Chambers, et al. "Rigorous evaluation of a pregnancy prevention program for American Indian youth and adolescents: study protocol for a randomized controlled trial." Trials 18, no. 1 (2017): 1-8.

3 Tingey, Lauren et al. "Entrepreneurial, Economic, and Social Well-Being Outcomes from an RCT of a Youth Entrepreneurship Education Intervention among Native American Adolescents." International journal of environmental research and public health 17, no. 7 (2020): 2383.

delivered by Native paraprofessionals from pregnancy to 3 years post-partum. FS has been evaluated through three successive trials. Results includes FS significantly improves parental knowledge, self-efficacy, maternal involvement, decreased stress, decreased maternal substance use, depression and risk-taking behaviors, and improved child social, emotional and behavioral outcomes from birth to three years postpartum4. Based on this evidence, FS has been accepted into the National Registry of Evidence-Based Practices and Programs, receiving a perfect 4.0/4.0 for “dissemination readiness” and achieved the highest federal rating for a home-visiting program. FS is the only evidence-based early childhood home visiting intervention designed for Native communities. The Contractor has service provision contracts to deliver FS as a direct service to over 140 tribal communities across 17 states.

4. Reporting Requirements:

1. Work will begin upon acceptance of this contract by all parties; to be completed no later than September 30, 2021.

2. All new educational materials will be reviewed with Dr. Jill Moses, Director of Public Health, for approval prior to completion.

5. Allocation of Rights. The Government shall have:

i. (i) Unlimited rights in all data delivered under this contract, and in all data first produced in the performance of this contract, except as provided in paragraph (c) of this clause for copyright.

ii. (ii) The right to limit assertion of copyright in data first produced in the performance of this contract, and to obtain assignment of copyright in that data, in accordance with paragraph (c)(1) of this clause.

iii. (iii) The right to limit the release and use of certain data in accordance with paragraph (d) of this clause.

iv. (i) The Contractor shall not assert or authorize others to assert any claim to copyright subsisting in any data first produced in the performance of this contract without prior written permission of the Contracting Officer. When copyright is asserted, the Contractor shall affix the appropriate copyright notice of 17 U.S.C. 401 or 402 and acknowledgment of Government sponsorship (including contract number) to the data when delivered to the Government, as well as when the data are published or deposited for registration as a published work in the U.S. Copyright Office. The Contractor grants to the Government, and others acting on its behalf, a paid-up, nonexclusive, irrevocable, worldwide license for all delivered data to reproduce, prepare derivative works, distribute copies to the public, and perform publicly and display publicly, by or on behalf of the Government.

v. (ii) If the Government desires to obtain copyright in data first produced in the performance of this contract and permission has not been granted as set forth in paragraph (c)(1)(i) of this clause, the Contracting Officer shall direct the

4 Barlow, Allison, Britta Mullany, Nicole Neault et al. "Paraprofessional-delivered home-visiting intervention for American Indian teen mothers and children: 3-year outcomes from a randomized controlled trial." American Journal of Psychiatry 172, no. 2 (2015): 154-162.

Contractor to assign (with or without registration), or obtain the assignment of, the copyright to the Government or its designated assignee.

vi. (2) Data not first produced in the performance of this contract. The Contractor shall not, without prior written permission of the Contracting Officer, incorporate in data delivered under this contract any data not first produced in the performance of this contract and which contain the copyright notice of 17 U.S.C. 401 or 402, unless the Contractor identifies such data and grants to the Government, or acquires on its behalf, a license of the same scope as set forth in subparagraph (c)(1) of this clause.

vii. (d) Release and use restrictions. Except as otherwise specifically provided for in this contract, the Contractor shall not use, release, reproduce, distribute, or publish any data first produced in the performance of this contract, nor authorize others to do so, without written permission of the Contracting Officer.

viii. (e) Indemnity. The Contractor shall indemnify the Government and its officers, agents, and employees acting for the Government against any liability, including costs and expenses, incurred as the result of the violation of trade secrets, copyrights, or right of privacy or publicity, arising out of the creation, delivery, publication, or use of any data furnished under this contract; or any libelous or other unlawful matter contained in such data. The provisions of this paragraph do not apply unless the Government provides notice to the Contractor as soon as practicable of any claim or suit, affords the Contractor an opportunity under applicable laws, rules, or regulations to participate in the defense of the claim or suit, and obtains the Contractor’s consent to the settlement of any claim or suit other than as required by final decree of a court of competent jurisdiction; and these provisions do not apply to material furnished to the Contractor by the Government and incorporated in data to which this clause applies.