Native FACETS

Compared with the general U.S. population, American Indians experience different patterns of cancer mortality. While American Indian and Alaska Natives tend to have lower cancer rates, their rates have been increasing in the past 20 years. Rates of mortality from certain cancers, such as those of the cervix, liver, stomach, and gallbladder, are also dramatically higher among American Indians than other racial groups in the United States. Cancer is now the second leading cause of death among American Indians and Alaska Natives, who continue to have a poorer survival rate from all cancers combined than any other racial group. One contributing factor is the prevalence of cigarette smoking, which is higher for almost all American Indian tribes in comparison to the general population. Cigarette smoking alone is directly responsible for approximately 30% of all cancer deaths annually in the United States. It causes 87% of lung cancer deaths and is responsible for most cancers of the larynx, oral cavity and pharynx, esophagus, and bladder.  Cancer prevention and control programs should be designed specifically for this minority population. Skill interventions, derived from social learning theory, hold special promise for intervention strategies to prevent cancer among American Indian youth. Skill interventions designed for adolescents help them recognize and avoid risk-taking behaviors and promote their health through problem-solving, coping, and communication skills. 

The program name, Native FACETS, stands for Family/Friends, Active healthy choices, Cancer prevention, Eating wisely, Thankfulness, and Survival as a Native American. The program was designed to lower cancer risk among American Indians through youth tobacco prevention and dietary modification. The diet curriculum was based on federally recommended dietary guidelines and culturally specific food practices of the indigenous peoples of the Northeast, as described in interviews with American Indians. The tobacco use prevention curriculum was based on reviews of the relevant literature and tailored to the study sites by collaborative community representatives. To further increase the intervention's cultural sensitivity, American Indians were recruited and trained to deliver the intervention.

The intervention teaches facts about tobacco and nutrition using films, storytelling, lectures, activities, and demonstrations, as well as media literacy exercises and problem-solving role plays. Group leaders build subjects' knowledge of ancestral tobacco use and its modern-day abuse, and the meaning and significance of ancestral food and traditional respect for the body. Leaders also stress the importance of family and the survival of American Indian culture as a way of combating negative peer pressures and other social influences. Throughout the curriculum, youth learn and practice resistance skills, decision making, problem-solving, and self-reward skills.

The program is delivered in 15 weekly group sessions, 90 minutes each in length, after the school day or on Saturdays at participating community centers.

The intended audience for this intervention is American Indian youth in the Northeastern United States, aged 8-13 years.

The program can be administered in a community center setting.

Required resources include the following:

• Three Native FACETS curricula in tobacco prevention, diet and nutrition modification, and combined tobacco prevention and diet modification
• Anthology of Native American Tobacco Traditions, a collection of stories and facts about traditional Native American tobacco
• The Tobacco Chronicles, a resource chronicle about tobacco in the United States, and more specifically about its relationship to American Indians and Alaska Natives

Necessary materials for each session are listed in the Native FACETS curriculum guide, and required handouts are included.

Either volunteers or paid staff are required to act as group leaders to run the weekly group sessions. Training is not required since the curriculum provides enough detail to enable leading the sessions. Group leaders should be knowledgeable about basic teaching methods and group work skills.

 The Native FACETS program was evaluated using a randomized clinical trial to assess patterns of tobacco use, behavioral intentions, knowledge, attitudes, and perceptions relative to tobacco use and dietary habits among American Indian youths.  Participants were recruited from eight different sites located in the Northeastern portion of the United States, with representation from 50 different tribal affiliations. Sites were randomly assigned to four conditions: dietary intervention only, tobacco intervention only, combined tobacco and diet intervention, and control (received a 2-day health and nutrition intervention 8 months after the conclusion of the intervention period). The sample was composed of 135 youth participants (57.7% female), aged 8-13 years at pretest, approximately evenly distributed across conditions except for the combined tobacco and diet group, which had fewer youths. All participants identified themselves as American Indian or Native American. 

The outcome measures were gathered via self-report procedures at pretest, posttest (at the completion of the intervention), and follow-up (6 months after posttest). Participants responded to multiple-choice questions regarding the prevalence and number of cigarettes smoked, smokeless tobacco used, knowledge and attitudes about tobacco and their diets, self-esteem, communication skills, problem-solving skills, and other psychosocial determinants of tobacco use and diet.

Results from the study include the following:

Effects of the Native FACETS Intervention on Tobacco
-- At 6-month follow-up, compared to youths in all other study arms (tobacco only: 26%; diet only: 40%; control: 43%), a significantly lower percentage of youths who received the combined tobacco and dietary intervention reported ever having tried smoking cigarettes (18%; p<.05).

--At 6-month follow-up, none of the youths who received either the tobacco-only intervention or the combined tobacco and dietary intervention reported smoking cigarettes now, whereas 30% of the youths who received the diet-only intervention (p<.05) and 25% of the youths in the control group reported smoking cigarettes now (p<.05). Similarly, none of the youths who received either the tobacco-only intervention or the combined tobacco and dietary intervention reported they would join older kids smoking, whereas 20% of the youths who received the diet-only intervention (p<.05) and 21% of youths in the control group (p<.05) reported they would join older kids smoking.

--At 6-month follow-up, all of the youths who received either the tobacco-only intervention or the combined tobacco and dietary intervention responded they would like to quit smoking. This is most likely an indication of their approval of quitting, rather than their need to quit. In contrast, 40% of youths who received the diet-only intervention (p<.05) and 25% of youths in the control group (p<.05) responded they would like to quit smoking.

--At 6-month follow-up, significantly fewer youths who received either the tobacco-only intervention (0%; p<.05), the diet-only intervention (10%; p<.05), or the combined tobacco and dietary intervention (0%; p<.05) reported smoking cigarettes in the last 24 hours, compared to youths in the control group (33%). 

Effects of the Native FACETS Intervention on Knowledge and Attitudes Relative to Tobacco Use
--Compared to youths in the control group who did not receive any intervention, those who received either the combined tobacco and dietary intervention or the tobacco-only intervention had significantly higher gain scores from pretest to 6-month follow-up on all measures of knowledge and attitudes relative to tobacco use. These include (1) knowledge of ceremonial (traditional) tobacco use among American Indians (p<.05), (2) knowledge of the harmful effects of tobacco use (p<.05), (3) greater awareness of the motives of tobacco advertising (p<.05), and (4) greater ability to resist peer pressure to use tobacco (p<.05).

Effects of the Native FACETS Intervention on Knowledge and Attitudes Relative to Dietary Habits
--Compared to youths in the control group who did not receive any intervention, those who received the combined tobacco and dietary intervention had significantly higher gain scores from pretest to 6-month follow-up on all measures of knowledge and attitudes relative to dietary habits. These include knowledge of American Indian dietary traditions (p<.05), and knowledge of cancer risks related to the consumption of fat (p<.05), fiber (p<.05), and fruits and vegetables (p<.05).