title: Internet-Based Delivery of Evidence-Based Health Promotion Programs Among American Indian and Alaska Native Youth: A Case Study.
abstract: BACKGROUND
  American Indian and Alaska Native (AI/AN) youth face multiple health challenges compared to other racial/ethnic groups, which could potentially be ameliorated by the dissemination of evidence-based adolescent health promotion programs. Previous studies have indicated that limited trained personnel, cultural barriers, and geographic isolation may hinder the reach and implementation of evidence-based health promotion programs among AI/AN youth. Although Internet access is variable in AI/AN communities across the United States, it is swiftly and steadily improving, and it may provide a viable strategy to disseminate evidence-based health promotion programs to this underserved population.
  
  
  OBJECTIVE
  We explored the potential of using the Internet to disseminate evidence-based health promotion programs on multiple health topics to AI/AN youth living in diverse communities across 3 geographically dispersed regions of the United States. Specifically, we assessed the Internet's potential to increase the reach and implementation of evidence-based health promotion programs for AI/AN youth, and to engage AI/AN youth.
  
  
  METHODS
  This randomized controlled trial was conducted in 25 participating sites in Alaska, Arizona, and the Pacific Northwest. Predominantly AI/AN youth, aged 12-14 years, accessed 6 evidence-based health promotion programs delivered via the Internet, which focused on sexual health, hearing loss, alcohol use, tobacco use, drug use, and nutrition and physical activity. Adult site coordinators completed computer-based education inventory surveys, connectivity and bandwidth testing to assess parameters related to program reach (computer access, connectivity, and bandwidth), and implementation logs to assess barriers to implementation (program errors and delivery issues). We assessed youths' perceptions of program engagement via ratings on ease of use, understandability, credibility, likeability, perceived impact, and motivational appeal, using previously established measures.
  
  
  RESULTS
  Sites had sufficient computer access and Internet connectivity to implement the 6 programs with adequate fidelity; however, variable bandwidth (ranging from 0.24 to 93.5 megabits per second; mean 25.6) and technical issues led some sites to access programs via back-up modalities (eg, uploading the programs from a Universal Serial Bus drive). The number of youth providing engagement ratings varied by program (n=40-191; 48-60% female, 85-90% self-identified AI/AN). Across programs, youth rated the programs as easy to use (68-91%), trustworthy (61-89%), likeable (59-87%), and impactful (63-91%). Most youth understood the words in the programs (60-83%), although some needed hints to complete the programs (16-49%). Overall, 37-66% of the participants would recommend the programs to a classmate, and 62-87% found the programs enjoyable when compared to other school lessons.
  
  
  CONCLUSIONS
  Findings demonstrate the potential of the Internet to enhance the reach and implementation of evidence-based health promotion programs, and to engage AI/AN youth. Provision of back-up modalities is recommended to address possible connectivity or technical issues. The dissemination of Internet-based health promotion programs may be a promising strategy to address health disparities for this underserved population.
  
  
  BACKGROUND
  Clinicaltrials.gov NCT01303575; https://clinicaltrials.gov/ct2/show/NCT01303575 (Archived by WebCite at http://www.webcitation.org/6m7DO4g7c).
authors.affiliation: Department of Health Promotion and Behavioral Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, United States.
authors.forename: Christine M
authors.identifier: http://orcid.org/0000-0003-0587-894X
authors.initials: CM
authors.lastname: Markham
authors.affiliation: Northwest Portland Area Indian Health Board, Portland, OR, United States.
authors.forename: Stephanie
authors.identifier: http://orcid.org/0000-0001-6800-4647
authors.initials: S
authors.lastname: Craig Rushing
authors.affiliation: Alaska Native Tribal Health Consortium, Anchorage, AK, United States.
authors.forename: Cornelia
authors.identifier: http://orcid.org/0000-0001-8249-1939
authors.initials: C
authors.lastname: Jessen
authors.affiliation: Inter Tribal Council of Arizona, Inc., Phoenix, AZ, United States.
authors.forename: Gwenda
authors.identifier: http://orcid.org/0000-0002-1522-212X
authors.initials: G
authors.lastname: Gorman
authors.affiliation: Department of Health Promotion and Behavioral Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, United States.
authors.forename: Jennifer
authors.identifier: http://orcid.org/0000-0002-9210-010X
authors.initials: J
authors.lastname: Torres
authors.affiliation: Oregon Health & Science University, Portland, OR, United States.
authors.forename: William E
authors.identifier: http://orcid.org/0000-0003-3833-7154
authors.initials: WE
authors.lastname: Lambert
authors.affiliation: The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
authors.forename: Alexander V
authors.identifier: http://orcid.org/0000-0003-3329-2292
authors.initials: AV
authors.lastname: Prokhorov
authors.affiliation: Rice University, Houston, TX, United States.
authors.forename: Leslie
authors.identifier: http://orcid.org/0000-0003-2433-7890
authors.initials: L
authors.lastname: Miller
authors.affiliation: The Cooper Institute, Dallas, TX, United States.
authors.forename: Kelly
authors.identifier: http://orcid.org/0000-0002-1449-1213
authors.initials: K
authors.lastname: Allums-Featherston
authors.affiliation: Department of Health Promotion and Behavioral Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, United States.
authors.forename: Robert C
authors.identifier: http://orcid.org/0000-0002-8690-497X
authors.initials: RC
authors.lastname: Addy
authors.affiliation: Department of Health Promotion and Behavioral Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, United States.
authors.forename: Melissa F
authors.identifier: http://orcid.org/0000-0003-0771-9336
authors.initials: MF
authors.lastname: Peskin
authors.affiliation: Department of Health Promotion and Behavioral Sciences, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, United States.
authors.forename: Ross
authors.identifier: http://orcid.org/0000-0003-2750-0817
authors.initials: R
authors.lastname: Shegog
keywords: Alaska Native; American Indian; Internet; adolescents; health promotion