Wakaya: Rising Up for Choctaw Youth Health

Study participants will be recruited in staggered cohorts with those in each recruitment wave receiving individual-level random assignment to either immediate intervention or waitlist control (3 months wait to intervention) for a total of 176 Choctaw youth (ages 12-19 years) participating over 5 years.

Recruitment strategies:

The following Recruitment strategies will be used: posting flyers, posters and brochures in stores, community centers, and other locations identified by our community advisors; and posting flyers in the tribal newspaper, school newsletters, tribal gathering areas, tribal health fairs, pow wows, local boys and girls clubs, youth centers, other local news outlets, and on a study webpage.

Screening:

* Participants will mainly be screened in-person, some may be screened over phone using the same talking points. * Youth who are screened out will be given a community resource list. * If a person is eligible, but declines to participate, they will be given a brief one-item exit question regarding general reason for non-participation. * Eligible youth who agree to participate will be asked to schedule their baseline assessment.

After consent or assent and parental permission are obtained, CNO study staff will set up the study laptop and headphones that the participant will use to enter their responses to the baseline computer-assisted questionnaire.

Assessments:

The baseline assessment consists of a brief physical health assessment and a computer-assisted behavioral health survey administered by study staff. Youth participants are required to take a non-invasive physical health assessment (BMI with portable digital weight scale and height measure), identify the age they began puberty (girls \< 12 years old began menstruation; boys \<14 when voice changed "a lot" will be classified as early puberty) and to use an accelerometer for 7 days after the baseline assessment. They will also be asked to run or walk for 12 minutes. The computer-assisted behavioral health survey will ask a series of questions and take under 45 minutes to complete.

The assessments will be conducted via Audio-Computer Assisted Self-Interviews (ACASI) programmed into study computers. Participants will complete 4 surveys: baseline, immediately after Trail of Tears Walk, a three-month follow up,and a six-month follow-up.

Intervention Schedule:

Month 1-3: Up to 20 group sessions on Choctaw history, traditions, cultural systems and health beliefs. Experiential, outdoor activities are incorporated to promote group cohesion, improve relational worldviews, and connectedness to nature and the environment. Examples include activities on an outdoor ropes course or increasing physical activity by walking or gardening. Fitbits will be given to participants and peers can choose to support each other to meet goals on a social media platform. Up to 3 individual Motivational Interviewing sessions to identify personal change goals and community leadership.

Month 2-3: Attend an Overnight Culture Camp to strengthen group cohesion and synthesize goals.

Month 3: Walk on the Choctaw Trail of Tears and visit ancient sites. Upon completion, make a commitment to conduct a community-wide event based on personal and leadership goals and Trail experience.

Months 4-12: Up to 6 group meetings to plan community leadership events related to obesity prevention, includes an individual MI booster session to revise their personal \& community leadership goals, digital storytelling training, and a community Traditional Games Olympiad. Participants may create a story related to healthful food habits, obesity prevention and alcohol, tobacco and other drug use (ATOD).

Month 9: Share digital stories, community events, and participate in a leadership ceremony.

Post-intervention: Ripple Effect Mapping focus groups among 64 individuals. A random selection of 12 youth per region and 4 nonparticipant community stakeholders i.e., elders, leaders in the community.

• Body Mass Index (BMI) change [Time frame: Baseline; Immediate post-intervention (month 3); 3 months post (month 6); 6 months post-intervention (month 9)]
• Weight change assessed via digital scale [Time frame: Baseline; Immediate post-intervention (month 3); 3 months post (month 6); 6 months post-intervention (month 9)]
• Change in food addiction [Time frame: Baseline; Immediate post-intervention (month 3); 3 months post (month 6); 6 months post-intervention (month 9)]
• Change in tobacco use frequency (non-ceremonial use) assessed by self-report [Time frame: Baseline; Immediate post-intervention (month 3); 3 months post (month 6); 6 months post-intervention (month 9)]
• Change in alcohol use over time [Time frame: Baseline; Immediate post-intervention (month 3); 3 months post (month 6); 6 months post-intervention (month 9)]
• Change in marijuana use over time [Time frame: Baseline; Immediate post-intervention (month 3); 3 months post (month 6); 6 months post-intervention (month 9)]
• Change in drug and alcohol refusal self-efficacy [Time frame: Baseline; Immediate post-intervention (month 3) 3 months post (month 6); 6 months post-intervention (month 9)]