The Promise of Technology to Advance Rigorous Evaluation of Adolescent Pregnancy Prevention Programs in American Indian and Alaska Native Tribal Communities

Despite high levels of adolescent childbearing and sexual risk taking among American Indian and Alaska Native (AI/AN) youths,¹ to date, no adolescent pregnancy prevention programs adapted or developed for AI/AN youths have been identified by federal review systems as effective. The lack of evidence-based interventions (EBIs) for this population may arise from the challenges of implementing rigorous evaluation designs within tribal communities. Advances in technology hold promise to offset these challenges by providing engaging and culturally appropriate adolescent pregnancy prevention programs with high fidelity, while also easing some of the burdens associated with conducting rigorous research in low-resourced settings.

Challenges to conducting rigorous research with tribes are numerous. Vast geographic distances between small diverse tribes and poorly maintained roads connecting communities within tribes impede timely recruitment and consistency in program participation. Varying tribal review and approval processes and timelines can pose delays.² Pervasive community poverty is often coupled with financially fragile community partner organizations; this fragility may result in temporary closures, youth attrition, personnel turnover, or compromised intervention fidelity. Furthermore, fiscal regulations may not easily accommodate the fluid field conditions extant on remote tribal sites.³

Evaluating program effectiveness where youths live, however, is critical to establishing relevance, feasibility, and sustainability. This call for in situ evaluation of promising, culturally appropriate adolescent pregnancy prevention interventions is not just academic. Building evidence for adolescent pregnancy prevention programming with tribal communities is necessary to improve services for AI/AN youths. Moreover, program or service provision grants—the lifeblood of many AI/AN organizations—frequently favor implementation of EBIs; however, EBIs have often been evaluated in settings and with populations that are quite distinct from tribal communities. While the OAH Teen Pregnancy Prevention (TPP) Tier 2 funding award—supporting the project from which we draw examples here—included time and resources for adaptation, such conditions are rare in grants. Absent committed resources to support local adaptation, tribal organizations struggle to achieve the fidelity, reach, and effectiveness witnessed in the original evaluation, and all too often experience weak outcomes and poor program sustainability.

TECHNOLOGY AND RESEARCH WITH TRIBES

Technology in intervention research can take many forms, including social media recruitment, online intervention delivery, video-sharing Web sites, and mobile health applications. Successful technology-based components require prior and ongoing community engagement during development and implementation. Through strong partnerships, technology may assist in recruitment, retention, fidelity, and ultimately, sustainability.

Recruitment through the Internet or social media, either independently or in concert with community partners, may greatly expand the number of participants. Inviting AI/AN parents through social media advertisements to consider their children’s participation in research potentially extends targeted reach and provides opportunity to review the materials at their convenience. In AI/AN communities, such convenience is a key advantage because many parents face time or transportation obstacles to travel to recruitment sites. For older adolescents not requiring parental consent, social media recruitment may be particularly effective, catering to adolescents’ communication preferences. Finally, technology-based recruitment methods provide multiple platforms (e-mail, discussion boards, text) for participants to ask salient and sensitive questions about the research, thereby enhancing the informed consent process.

In-person instruction certainly offers great benefits to intervention delivery, particularly for sensitive topics. However, online interventions can provide developmentally and culturally tailored skills-building content to populations who otherwise may not have access to such material. Furthermore, a single intervention can be programmed so that tribal-specific content is tailored to particular communities (e.g., Northern Plains or Southwest teachings) or to specific types of individuals within those communities (e.g., girls or boys). Such responsiveness to cultural sensitivities will also likely increase tribes’ willingness to participate in research, though they may require time to observe the potential benefits. For example, in our recently completed work, tribal communities were highly receptive to an online intervention, but requested an additional in-person component, which we created with their input. At the end of the project, tribes suggested a family oriented online version of the program would be well received in their communities. Indeed, online interventions could target parents, guardians, or others involved in conversations regarding sex and childbearing, providing prompts for culturally age-appropriate conversations. Such an approach will likely resonate with family centric ideals of many tribal cultures.

Online intervention delivery also ensures that youths receive high fidelity, engaging content at asynchronous times. In addition, for class-based administration, youths who do not attend programs or schools regularly can make up the lessons at a later time without loss of quality. For example, in our hybrid online and in-person intervention, youths engaged with an average of six out of seven online intervention sessions and only 3.5 out of seven live-group sessions. Delivery of online content, of course, was not without challenges, including browser incompatibility, limited bandwidth, and power outages. Resources from the TPP Tier 2 grant, however, allowed us to provide support to address these challenges. In summary, within the context of large distances and limited household or community infrastructure to provide transportation, such flexibility in high-fidelity implementation may assist greatly in engagement and retention of participants—particularly for adolescents.

THE TECHNOLOGY DIVIDE—WHERE IS IT NOW?

Technology in adolescent pregnancy prevention research is not new. However, with few exceptions,^4,5 technology-based adolescent pregnancy prevention research in tribal communities has not kept pace with adolescent pregnancy prevention research among other populations. The “technology divide” that disadvantages some people because of economic constraints or lack of infrastructure still affects AI/AN communities, which may hamper technology-involved research. Slow uptake may also be the result of community leadership preference for in-person interventions or researchers’ concerns around cultural incompatibility. However, our experience with tribal communities indicates openness to technology, especially for youths. This openness reflects recent statistics on technology use: compared with other racial groups, AI/ANs were the least likely to indicate a lack of interest or a need to go online at home, and the most likely to report having a home computer. Though infrastructure shortcomings and cost remain concrete barriers—especially with respect to broadband Internet service—AI/ANs have the highest rate of mobile broadband use among minority groups.⁶ This may be particularly true for AI/AN youths. In the Pacific Northwest, for example, AI/AN youths aged 13 to 21 years reported levels of technology use similar to those in the general population, with 75% using the Internet and 78% using a cell phone at least daily or weekly.⁷ And, as with the rest of the country, AI/AN Internet use will only expand. Anecdotally from our work, many tribal members attest to the pervasiveness of social media for connecting people and families within and across tribes, particularly among tribal youths.

TECHNOLOGY IS NOT A PANACEA

Technology, of course, does not solve every challenge commensurate with conducting rigorous adolescent pregnancy prevention research within tribal communities. Aside from issues of hardware, connectivity, data plans, and the fast pace of industry change, technology cannot replace community engagement and meaningful participation in the research process, or the trust and rapport such partnership builds. Technology cannot replace the value of cultural connectedness among family, kin, and community that makes AI/AN tribal communities unique, vital, and resilient. However, when used judiciously and in the context of strong research partnerships, technology can complement the community and cultural life of AI/AN adolescents, provide adolescent pregnancy prevention information and skills-building they may otherwise not receive, and facilitate youth and family participation in rigorous evaluation research to generate evidence for interventions relevant to their communities.