Reducing Disparities in Adolescent Pregnancy Among US Tribal Youths

Systemic inequities, including a lack of culturally appropriate sexual health education, put American Indian and Alaska Native (AI/AN) adolescents at higher-than-average risk for adverse sexual and reproductive health outcomes. For example, in 2013, the birth rate among AI/AN adolescents aged 15 to 19 years was 31.1 per 1000 individuals, compared with 18.6 for White adolescents.¹ AI/AN youths report earlier onset of sexual activity and greater numbers of sexual partners than do youths in general.² In 2011, among all races and ethnicities, AI/ANs had the second highest rates of chlamydia and gonorrhea and the third highest rates of primary and secondary syphilis.³ From 2011 through 2014, the US Department of Health and Human Services’ Family and Youth Services Bureau, through the Tribal Personal Responsibility Education Program (Tribal PREP), funded 14 tribes and tribal organizations to select, adapt, and implement culturally relevant, evidence-informed contraceptive and abstinence education curricula for their communities. Grantees also promoted successful transitions to adulthood by providing content on selected adulthood preparation subjects.

Addressing these longstanding health inequities requires intervention and evaluation approaches that are culturally consonant with the tribal communities in which they will be used. An abundance of research^4–6 emphasizes the importance of incorporating community-based participatory research approaches for culturally tailoring these interventions and evaluation methods. Drawing on this rich history, we extend the concept here by directly including the voices from front-line staff responsible for Tribal PREP program implementation as authors. Because there is little empirical research on evidence-based curricula and practices for AI/AN youths, the lessons learned by these program implementers offer firsthand experiences to further increase cultural awareness and improve future adolescent pregnancy prevention (APP) interventions for AI/AN adolescents, helping fill the gap in empirical research.

METHODS

Program implementers from six Tribal PREP grantees participated in semistructured discussions about their program implementation experiences. Tribes and tribal organizations were selected to reflect diversity in the types of programs included. Programs were implemented in schools (tribal and public) and after-school programs in both rural and urban locations from Alaska to the Southwest to the Midwest. Data derived from the discussions were coded using NVivo version 10 (QSR International, Burlington, MA) to identify common themes and activities across programs, using standard qualitative coding procedures; code having less than 80% agreement was reconciled.

RESULTS

Tribal youths face daunting risk factors such as higher rates of suicide, drug and alcohol abuse, and violence. Thus, gaining attention for what some perceive as less dire risk behavior, such as unprotected sexual intercourse, can be difficult. Implementers emphasized the value of providing local data to gain buy-in for APP efforts. Results from needs assessments helped build awareness of the magnitude of the adolescent pregnancy issue for each community. Implementers also showed their communities the link between APP and other risk factors, such as depression and dropping out of school. Using a holistic developmental approach by integrating relationship education and adulthood preparation into the APP programs helped make the programs more acceptable in socially conservative communities.

Stakeholder Engagement

Implementers found that AI/AN parents and other caregivers (“parents”) desired information about programmatic content and careful oversight for how the information was presented. Having a stranger talk with their adolescents about sex concerned many parents, so engaging parents early and throughout implementation helped to gain their trust.

More specifically, implementers described the importance of giving parents some level of control in program activities. For instance, though it may not be appropriate for all tribes, two implementers chose to show a video of the condom demonstration, which parents had an opportunity to review in advance, in lieu of a live demonstration. This strategy helped remove the mystery and decreased parents’ hesitation for their adolescents to participate in the programs.

Tribal schools and traditional public schools, both of which were trusted by parents, were critical in securing program buy-in. Implementers noted that superintendents served at the will of the community, and as a result, they were reluctant to allow activities that the community could view adversely. Several implementers noted that their community’s level of tolerance for implementation mistakes within a school was extremely low and hard to overcome.

Engaging and securing the approval of tribal elders was particularly valuable. These respected traditional leaders served as key gatekeepers, aided community acceptance, and helped to integrate tribal values and traditions into selected curricula. Implementers also noted that using former program participants as staff increased community support. Partnerships with other organizations assisted in promoting the programs.

Culturally Appropriate Curricula

Implementers noted that finding culturally appropriate, evidence-based pregnancy prevention curricula is challenging. They called on program developers to help address this gap. The flexibility that allowed implementers to select a curriculum for their specific program was key to making the intervention culturally relevant. Culture committees, elders, and tribal councils played important roles in adapting curricula to reflect each tribe’s cultural context and values. Their participation helped bridge the gaps between the curriculum content and traditional tribal teachings unique to each community.

Implementers from different tribal organizations stressed the importance of avoiding a “pan-Indian” approach, in which the heritage and cultural traditions of multiple tribes are combined into a single curriculum, because it can be perceived as promoting stereotypes. Allowing tribal organizations to select their own curricula helped to overcome this challenge by demonstrating respect for the many differences between and across tribal groups. Implementers also stressed the importance of mirroring each group’s unique culture, beliefs, and history in the adaptation process.

Challenges

Challenges of recruitment, retention, transportation, and staff turnover are common in adolescent-focused programming. However, these issues were often magnified in Tribal PREP’s programs. Some implementers, for example, served tribes that spanned hundreds of square miles in rural, difficult-to-access settings with no public transportation options. Such settings may lack reliable Internet connectivity and other amenities that are the norm for other places. Other implementers noted that members of some tribes resided in both cities and isolated rural areas. Some AI/AN youths attended tribal schools and others were enrolled in local public or private schools, also posing access challenges.

DISCUSSION

The knowledge gained from interviews with Tribal PREP implementers underscores the importance of viewing tribal interventions from a sociocultural perspective and as part of an integrated approach tailored to each unique setting and group. Although inclusion of tribal culture and tradition is a key consideration, the interface with other layers within the community—such as family, schools, service organizations, and community perspectives—needs to be considered as well. Likewise, programs serving multiple AI/AN communities need to emphasize and respect the unique aspects of the different AI/AN cultures to avoid AI/AN stereotyping.