Fostering Open eXpression among Youth (FOXY)

Northwest Territories, Canada

Indigenous peoples in Canada experience social and health disparities due to the ongoing effects of racism, colonization, and intergenerational trauma from forced family separation by the residential school system. HIV is an example of one of these health disparities; HIV in Canada disproportionately affects Indigenous people,1 and more specifically Indigenous women and youth (15–29 years old).2 While these social and health disparities persist, there are also strengths and protective factors among Indigenous peoples, including cultural connectedness and resiliency. Fostering Open eXpression among Youth (FOXY) is an arts-based intervention for the prevention of HIV and sexually transmitted infection (STI) that was designed by and for Northern and Indigenous youth in the Northwest Territories (NWT). The FOXY intervention uses trained facilitators and peer leaders to deliver workshops on sexual health, sexuality, and healthy relationships to young women and girls aged 13-17 years. An observational pilot study funded by the Canadian Institutes of Health Research found that participants’ STI knowledge and safer sex self-efficacy were significantly improved after the intervention.

Program description3,4

FOXY is an HIV and STI prevention program developed by and for Northern and Indigenous Canadian youth in the NWT to foster more open expression and communication regarding sexuality and sexual health. FOXY was developed over two years with the help of adolescent peer leaders and was focus tested with youth. FOXY integrated local knowledge and local context into its development and uses an arts-based approach (e.g., drama activities to facilitate discussion and learning), which can help participants to develop self-reflection and decision-making skills. Through the use of an arts-based approach, which is associated with increased empowerment, FOXY provides judgment free-education on sexual health, HIV and STIs, sexuality, and healthy relationships.

The intervention includes seven workshops of between one and two hours each, which are conducted over one or two days. Workshops are led by trained facilitators and peer leaders with expertise in sexual health and arts-based education. There are eight to 15 participants per workshop.

Participants in this pilot study were recruited from 17 communities across the NWT from September 2015 to May 2016. Participants self-identified as women or girls, resided in the NWT, and were 13–17 years old.


The study compared pre- and post-intervention scores of participants related to STI knowledge, safer sex self-efficacy (i.e., confidence in using condoms consistently), and resilience using the Child and Youth Resilience Measure.* Information was collected immediately before and after the program was delivered, using three self-reported surveys each time.

The majority (79%) of the 199 participants identified as Indigenous and 21% identified as sexual minorities. In terms of sexual practice, 18% of participants self-reported that they had engaged in vaginal sex, 19% believed that they were at risk for STIs, and 15% believed that they were at risk of HIV. The comparison of pre- and post-intervention scores indicated:

  • significantly higher STI knowledge scores (median score of 4 pre- and 9 post-intervention [out of 14]);
  • significantly higher safer sex self-efficacy scores; and
  • slightly higher resilience scores.3

The current study (published in 2018) does not consider the long-term outcomes of the program, but there are plans to follow program participants for a 12-month period.4

What does this mean for service providers?

The FOXY intervention, an educational and arts-based intervention that uses peer leaders and trained facilitators, has produced favourable results. The intervention demonstrates the importance of culturally appropriate health education programming for Northern youth that is developed by Northern youth, while contributing to the evidence base for arts-based HIV and STI prevention programs. Indigenous peoples face social and structural barriers that contribute to the disproportionate effect of HIV in Canada among Indigenous women and youth, and this intervention provides a novel and tailored approach to engage young women. Long-term results will be useful in determining the longevity of the positive outcomes and further utility of the program in HIV prevention efforts.

*The Child and Youth Resilience Measure defines resilience as the ability to navigate resources (e.g., individual, cultural) for well-being.

Related resources

Sexuality…Let’s Talk About It! – Case Study

Sexual Health Information Project (SHIP) – Case Study

The Underwear Project – Case Study

Fostering Open eXpression among Youth (FOXY) – Website


  1. Public Health Agency of Canada. Summary: Estimates of HIV Incidence, Prevalence and Canada’s Progress on Meeting the 90-90-90 HIV targets, 2016. Ottawa: Public Health Agency of Canada; 2018. Available from:
  2. Public Health Agency of Canada. HIV/AIDS Epi Updates, July 2010, Chapter 8: HIV/AIDS Epi updates, July 2010 – HIV/AIDS among Aboriginal people in Canada. Ottawa: Surveillance and Risk Assessment Division, Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada; 2010. Available from:
  3. Lys CL, Logie CH and Okuma M. Pilot testing Fostering Open eXpression among Youth (FOXY), an arts-based HIV/STI prevention approach for adolescents women in the Northwest Territories, Canada. International Journal of STD & AIDS. 2018;29(10):980–6.
  4. Lys C, Logie CH, MacNeil N et al. Arts-based HIV and STI prevention intervention with Northern and Indigenous youth in the Northwest Territories: study protocol for a non-randomised cohort pilot study. BMJ Open. 2016;6(10):e012399.