Navajo Area Research Articles

Navajo Area Fresh Fruit and Vegetable Prescription Program

Navajo Area Fresh Fruit and Vegetable Prescription Program

Glycemic control and healthcare utilization following pregnancy among women with pre-existing diabetes in Navajo Nation

BackgroundNative American communities experience greater burden of diabetes than the general population, including high rates of Type 2 diabetes among women of childbearing age. Diabetes in pregnancy is associated with risks to both the mother and offspring, and glycemic control surrounding the pregnancy period is of vital importance.MethodsA retrospective chart review was conducted at a major Navajo Area Indian Health Service (IHS) hospital, tracking women with pre-existing diabetes who became pregnant between 2010 and 2012. Logistic regression was performed to find patient-level predictors of our desired primary outcome—having hemoglobin A1c (HbA1c) consistently < 8% within 2 years after pregnancy. Descriptive statistics were generated for other outcomes, including glycemic control and seeking timely IHS care.ResultsOne hundred twenty-two pregnancies and 114 individuals were identified in the dataset. Baseline HbA1c was the only covariate which predicted our primary outcome (OR = 1.821, 95% CI = 1.184–2.801). Examining glycemic control among pregnancies with complete HbA1c data (n = 59), 59% were controlled before, 85% during, and 34% after pregnancy. While nearly all women received care in the immediate postpartum period, only 49% of women visited a primary care provider and 71% had HbA1c testing in the 2 years after pregnancy.ConclusionsThis is the first analysis of outcomes among women with diabetes in pregnancy in Navajo Nation, the largest reservation and tribal health system in the United States. Our findings demonstrate the positive impact of specialized prenatal care in achieving glycemic control during pregnancy, while highlighting the challenges in maintaining glycemic control and continuity of healthcare after pregnancy.

Successful newborn screening for SCID in the Navajo Nation

Newborn screening (NBS) for severe combined immunodeficiency (SCID) identifies affected infants before the onset of life-threatening infections, permitting optimal treatment. Navajo Native Americans have a founder mutation in the DNA repair enzyme Artemis, resulting in frequent Artemis SCID (SCID-A). A pilot study at 2 Navajo hospitals assessed the feasibility of SCID NBS in this population. Dried blood spots from 1800 infants were assayed by PCR for T-cell receptor excision circles (TRECs), a biomarker for naïve T cells. Starting in February 2012, TREC testing transitioned to standard care throughout the Navajo Area Indian Health Service, and a total of 7900 infants were screened through July 2014. One infant had low TRECs and was diagnosed with non-SCID T lymphopenia, while 4 had undetectable TRECs due to SCID-A, all of whom were referred for hematopoietic cell transplantation. This report establishes the incidence of SCID-A and demonstrates effectiveness of TREC NBS in the Navajo.

Newborn screening for severe combined immunodeficiency in 11 screening programs in the United States.

Newborn screening for severe combined immunodeficiency (SCID) using assays to detect T-cell receptor excision circles (TRECs) began in Wisconsin in 2008, and SCID was added to the national recommended uniform panel for newborn screened disorders in 2010. Currently 23 states, the District of Columbia, and the Navajo Nation conduct population-wide newborn screening for SCID. The incidence of SCID is estimated at 1 in 100,000 births. To present data from a spectrum of SCID newborn screening programs, establish population-based incidence for SCID and other conditions with T-cell lymphopenia, and document early institution of effective treatments. Epidemiological and retrospective observational study. Representatives in states conducting SCID newborn screening were invited to submit their SCID screening algorithms, test performance data, and deidentified clinical and laboratory information regarding infants screened and cases with nonnormal results. Infants born from the start of each participating program from January 2008 through the most recent evaluable date prior to July 2013 were included. Representatives from 10 states plus the Navajo Area Indian Health Service contributed data from 3,030,083 newborns screened with a TREC test. Infants with SCID and other diagnoses of T-cell lymphopenia were classified. Incidence and, where possible, etiologies were determined. Interventions and survival were tracked. Screening detected 52 cases of typical SCID, leaky SCID, and Omenn syndrome, affecting 1 in 58,000 infants (95% CI, 1/46,000-1/80,000). Survival of SCID-affected infants through their diagnosis and immune reconstitution was 87% (45/52), 92% (45/49) for infants who received transplantation, enzyme replacement, and/or gene therapy. Additional interventions for SCID and non-SCID T-cell lymphopenia included immunoglobulin infusions, preventive antibiotics, and avoidance of live vaccines. Variations in definitions and follow-up practices influenced the rates of detection of non-SCID T-cell lymphopenia. Newborn screening in 11 programs in the United States identified SCID in 1 in 58,000 infants, with high survival. The usefulness of detection of non-SCID T-cell lymphopenias by the same screening remains to be determined.

IUD-related knowledge, attitudes and practices among Navajo Area Indian Health Service providers.

The IUD once accounted for about half of contraceptive use among Navajo women but is now little used in this population, which has a high rate of unintended pregnancy. Identifying barriers to use--including those stemming from providers' IUD-related knowledge, attitudes and practices--could help expand use of the method. In 2000, 107 Navajo Area Indian Health Service providers who offer contraceptive services completed a mailed survey. Responses of women's health providers and other types of providers were compared, using the Cochran-Mantel-Haenszel method. Overall, 69-78% of providers had good factual knowledge about the IUD and felt adequately prepared to insert a device or counsel women about it; considerably larger proportions of women's health providers than of others felt able to counsel about and insert IUDs. Sixty-five percent of providers (88% of women's health providers and 50% of others) currently inserted IUDs, and only 8% (none of them women's health providers) never recommended the method. The main reasons providers cited for not recommending the IUD were concerns about its safety and about side effects (mentioned by 69% and 44%, respectively); these concerns did not differ by provider type. Provider education and training should focus on insertion techniques and on the safety of available IUDs. Training should be targeted not only to women's health providers, but to family practice physicians, nurse practitioners and other providers who offer family planning counseling and services.

Organizing in the Context of Tribal Sovereignty: The Navajo Area Indian Health Service Campaign for Union Recognition

Organizing in the Context of Tribal Sovereignty: The Navajo Area Indian Health Service Campaign for Union Recognition

Organizing in the Context of Tribal Sovereignty: The Navajo Area Indian Health Service Campaign for Union Recognition

This article considers the relationships among labor union organiz ing, American Indian tribal sovereignty, and economic development, focusing on a 2001 campaign by the Laborers' International Union of North America to organize employees of the Navajo Area Indian Health Service. Relying on ethnographic methods, I examine the practices, actions, and attitudes of professional and volunteer organizers of this campaign to consider how organizers connect political conditions and strategies to verbal strategies of face-to-face interaction. This article illustrates how organizing drives conducted in Indian country must negotiate the mutually constitutive political and economic interests of tribal members. The LIUNA campaign succeeded by addressing workplace concerns within an overall context of respect for the Navajo Nation tribal government, tribal sovereignty, and tribal members' feel ings about sovereignty, even when the tribal government's actions po tentially threatened the stability and security of tribal workers' jobs.

IUD-Related Knowledge, Attitudes and Practices Among Navajo Area Indian Health Service Providers

CONTEXT: The IUD once accounted for about half of contraceptive use among Navajo women but is now little used in this population, which has a high rate of unintended pregnancy. Identifying barriers to use–including those stemming from providers’IUD-related knowledge, attitudes and practices–could help expand use of the method. METHODS: In 2000, 107 Navajo Area Indian Health Service providers who offer contraceptive services completed a mailed survey. Responses of women's health providers and other types of providers were compared, using the Cochran-Mantel-Haenszel method. RESULTS: Overall, 69-78% of providers had good factual knowledge about the IUD and felt adequately prepared to insert a device or counsel women about it; considerably larger proportions of women's health providers than of others felt able to counsel about and insert IUDs. Sixty-five percent of providers (88% of women's health providers and 50% of others) currently inserted IUDs, and only 8% (none of them women's health providers) never recommended the method. The main reasons providers cited for not recommending the IUD were concerns about its safety and about side effects (mentioned by 69% and 44%, respectively); these concerns did not differ by provider type. CONCLUSIONS: Provider education and training should focus on insertion techniques and on the safety of available IUDs. Training should be targeted not only to women's health providers, but to family practice physicians, nurse practitioners and other providers who offer family planning counseling and services.

IUD‐Related Knowledge, Attitudes and Practices Among Navajo Area Indian Health Service Providers

CONTEXT: The IUD once accounted for about half of contraceptive use among Navajo women but is now little used in this population, which has a high rate of unintended pregnancy. Identifying barriers to use–including those stemming from providers’IUD‐related knowledge, attitudes and practices–could help expand use of the method. METHODS: In 2000, 107 Navajo Area Indian Health Service providers who offer contraceptive services completed a mailed survey. Responses of women's health providers and other types of providers were compared, using the Cochran‐Mantel‐Haenszel method. RESULTS: Overall, 69‐78% of providers had good factual knowledge about the IUD and felt adequately prepared to insert a device or counsel women about it; considerably larger proportions of women's health providers than of others felt able to counsel about and insert IUDs. Sixty‐five percent of providers (88% of women's health providers and 50% of others) currently inserted IUDs, and only 8% (none of them women's health providers) never recommended the method. The main reasons providers cited for not recommending the IUD were concerns about its safety and about side effects (mentioned by 69% and 44%, respectively); these concerns did not differ by provider type. CONCLUSIONS: Provider education and training should focus on insertion techniques and on the safety of available IUDs. Training should be targeted not only to women's health providers, but to family practice physicians, nurse practitioners and other providers who offer family planning counseling and services.

Diabetes and depot medroxyprogesterone contraception in Navajo women.

Depot medroxyprogesterone acetate contraception is widely used in Navajo women, a high-risk population for diabetes mellitus. However, depot medroxyprogesterone may lead to weight gain and independently decrease insulin sensitivity. We studied the association between depot medroxyprogesterone and development of diabetes in Navajo women. We studied Navajo women aged 18 to 50 years who had seen a health care provider at a Navajo Area Indian Health Service clinic at least once in 1998. Diabetic cases (n = 284) and nondiabetic controls (n = 570) were matched by age. Medical records were reviewed to determine contraception use before the diagnosis date of diabetes. Users of depot medroxyprogesterone were more likely to develop diabetes than patients who had used combination estrogen-progestin oral contraception only (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.8-7.9). The excess risk persisted after adjustment for body mass index (OR, 3.6; 95% CI, 1.6-7.9). Longer use was associated with greater risk of diabetes. Users of depot medroxyprogesterone were also more likely to develop diabetes than patients who had never used hormonal contraception, although excess risk was smaller (OR, 2.4; 95% CI, 1.4-3.6). Depot medroxyprogesterone contraception was associated with a greater risk of diabetes compared with combination oral contraceptive use only. Risk was associated with length of use and persisted after adjustment for body mass index. Additional research is needed for confirmation, but this risk should be considered in contraceptive choice for women at high risk for diabetes.

Recruitment and retention in the Navajo Area Indian Health Service.

To determine why physicians and midlevel providers join, leave, or stay in Navajo Area Indian Health Service (IHS). Cross-sectional analysis of data obtained from questionnaires. Navajo Area IHS hospitals. Navajo Area health care physicians and midlevel health care providers. Main outcome measures The prevalence of physicians and midlevel providers who plan to leave the Navajo Area IHS, the demographic characteristics of these physicians and midlevel providers, and the most common reasons for staying or leaving. A total of 221 (64%) physicians and midlevel providers responded. Of these, 58% planned to leave eventually, and 47% of all physicians and midlevel providers planned to leave in the next 3 years. Physicians and midlevel providers planning to leave tended to be younger than those planning to stay (P: = 0.009). The most common reason to join the IHS was a desire to work in the Southwest, to stay was the quality of the medical staff, and to leave was lack of administrative support. A high turnover rate of physicians and midlevel providers may occur in the next 3 years. A combination of factors specific to the provider, the institution, and the environment attracts physicians to the Navajo IHS and encourages them to stay. Factors that push physicians and midlevel providers to leave tend to be specific to the institution and are potentially amenable.

How long will you be staying, doctor?

How long will you be staying, doctor?

Bronchiolitis-associated hospitalizations among American Indian and Alaska Native children.

Respiratory syncytial virus (RSV) is the leading cause of lower respiratory tract illness among infants and young children. Respiratory system diseases account for a large proportion of hospitalizations in American Indian and Alaska Native (AI/AN) children; however, aggregate estimates of RSV-associated hospitalizations among AI/AN children have not been made. We used Indian Health Service hospitalization data from 1990 through 1995 to describe hospitalizations associated with bronchiolitis, the most characteristic clinical manifestation of RSV infection, among AI/AN children <5 years old. The overall bronchiolitis-associated hospitalization rate among AI/AN infants < 1 year old was considerably higher (61.8 per 1,000) than the 1995 estimated bronchiolitis hospitalization rate among all US infants (34.2 per 1,000). Hospitalization rates were higher among male infants (72.2 per 1,000) than among females infants (51.1 per 1,000). The highest infant hospitalization rate was noted in the Navajo Area (96.3 per 1,000). Hospitalizations peaked annually in January or February, consistent with national peaks for RSV detection. Bronchiolitis hospitalizations accounted for an increasing proportion of hospitalizations for lower respiratory tract illnesses. Bronchiolitis-associated hospitalization rates are substantially greater for AI/AN infants than those for all US infants. This difference may reflect an increased likelihood of severe RSV-associated disease or a decreased threshold for hospitalization among AI/AN infants with bronchiolitis compared with all US infants. AI/AN children would receive considerable benefit from lower respiratory tract illness prevention programs, including an RSV vaccine, if and when one becomes available.

Liver disease in Navajo neuropathy

Objective: To describe clinical and histologic features of liver disease in infants and children with Navajo neuropathy (NN). Methods: Physicians at Navajo Area Indian Health Service facilities and neurologists and gastroenterologists at regional referral hospitals were surveyed for identification of patients born between 1980 and 1994 with known or suspected NN. Clinical records and liver histologic findings were reviewed. Results: Liver disease was present in all children with NN. Three clinical phenotypes of NN were observed, based on age at presentation and course: infantile NN presented in 5 infants before 6 months of age with jaundice and failure to thrive and progressed to liver failure before 2 years of age; childhood NN presented in 6 children between 1 and 5 years of age with liver dysfunction, which progressed to liver failure and death within 6 months; and classical NN presented in 9 children with variable onset of liver disease but progressive neurologic deterioration. Liver histologic findings were characterized by multinucleate giant cells, macrovesicular and microvesicular steatosis, pseudo-acini, inflammation, cholestasis, and bridging fibrosis and cirrhosis. Cases of all 3 phenotypes occurred within the same kindred. Conclusions: Liver disease is an important component of NN and may be the predominant feature in infants and young children. We propose changing the name of this disease to Navajo neurohepatopathy. (J Pediatr 1999;135:482-93)

Suicide and Homicide among Native Americans: Anomie Or Social Learning?

Analysis of data for 12 areas of the Indian Health Services from the US Department of Health and Human Services yielded a rho of .61 between poverty and suicide for men and a significant rho of .65 for poverty with homicide rates. The Navajo area is an exception, raising for study questions about social disintegration. For the women, poverty was not significantly related to suicide or homicide rates, raising additional questions about social disintegration.

Poverty, Suicide, and Homicide among Native Americans

Analysis of data for 12 areas of the Indian Health Services available from the US Department of Health and Human Services yielded a correlation (rho) of .65 between poverty and suicide and a significant rho of. 52 with homicide rates. The Navajo area is an exception, raising for study questions about social disintegration.

The Expected Impact of a Smoking Cessation Program for Pregnant Women on Infant Mortality among Native Americans

To quantify the expected impact of a smoking cessation program for pregnant women on infant mortality among Native Americans, we estimated the proportional reduction (impact fraction) and the absolute reduction (impact risk) in neonatal and postneonatal mortality as a result of the intervention program. The estimated attributable fraction due to maternal smoking was 16.6% of infant deaths in the Aberdeen Indian Health Service (IHS) Area, 16.2% in the Alaska IHS Area, and 5.2% in the Navajo IHS Area. Under the assumptions that 14% of the smokers participating in a smoking cessation program would quit and that the intervention would have 60% relative efficacy in preventing infant deaths attributable to smoking, the impact fraction was estimated to be 0.9% of all infant deaths in the Aberdeen Area, 1.0% in the Alaska Area, and 0.3% in the Navajo Area. Under the "best" model assumptions (28% cessation rate and 90% relative efficacy), 2.6% of all infant deaths, 3.7% of postneonatal deaths, and 1.2% of neonatal deaths would be prevented by a smoking cessation program in the Aberdeen Area. When applied to 1984-1986 infant mortality data, the impact risk per 100,000 live births under the "best" model assumptions was 10 neonatal deaths and 41 postneonatal deaths in the Aberdeen Area, 10 neonatal and 34 postneonatal deaths in Alaska, and 2 neonatal and 8 postneonatal deaths in the Navajo Area. This report points to the need to develop effective smoking cessation programs for Native Americans, targeted in particular to women of reproductive age.

A critical appraisal of the Navajo health care system.

The purpose of this study is to assess the health needs of the Navajo Indians of North America, and the appropriateness of the health care services provided by the Navajo Health Care System with respect to these health needs. Our study is based on the analysis of the secondary socioeconomic and health related data collected and compiled in the Navajo area, and on the interviews conducted among health care professionals and administrators working in the Area. The 'Q index' was used for priority ranking of the most prevalent diseases. Appraisal is based on the holistic health concept components. Navajo Indians have not yet reached the health status of the general US population. In spite of the fact that the Indian Health Services has decreased the disparity between the Indians and the US population in general, especially regarding communicable diseases, other more complex health problems created by biculturalism and the on-going acculturation exceed the limits of the Navajo Health Care System which is basically oriented toward medical care. Alcoholism and alcohol abuse, inadequate nutrition and lack of geographic and socio-organizational accessibility are the main risk factors in the Area. This situation is further aggravated by economic problems and the high unemployment rate of the Navajo Indians.

The Navajo Homestead: Situation and Site

The Navajo Homestead: Situation and Site Stephen C. Jett* Spread over some 16 million acres (c. 6.5 million ha) of Arizona, New Mexico, and Utah is a cultural landscape quite distinct from that of the nation's dominant Anglo-American culture. It is a landscape created by the more than 150,000 Navajo, the nation's most numerous Indian tribe. Several centuries ago, the ancestral Navajo migrated to the Southwest from what is now western Canada, bringing with them settlement patterns characteristic of Northern Hunters.1 Despite the eventual adoption of an economy based on subsistence sheepherding and farming, the Navajo have retained, in modified form, their northern habits of settlement. These include a dispersed population, qualified by small agglomerations representing economically cooperating extended families ("homestead groups").2 Villages and towns have never characterized Navajo settlement.1 Single-individual and nuclear-family residences, as well as larger homestead-group agglomerations, form homesteads (popularly , "camps") consisting of one or more dwellings and, usually, * Dr. Jett is a Professor of Geography at the University of California, Davis. Field and archival work for this project was supported by intramural research grants of that institution. Aid was received from many individuals and libraries, but particular thanks are due David M. Brugge and Virginia Evelyn Spencer. My Navajo informant was Chauncey Neboyia, of Canyon de Chelly, Arizona. 1 Homer Aschmann, "Athapaskan Expansion in the Southwest," Yearbook, Association of Pacific Coast Geographers, Vol. 32 (1970), pp. 79-97. 2 Stephen C. Jett, "Origins of Navajo Settlement Patterns," Annals, Association of American Geographers, Vol. 68 (1978), pp. 351-362. ;i Elliot G. Mclntire, "Central Place Studies on the Navajo Reservation: A Special Case," Yearbook, Association of Pacific Coast Geographers, Vol. 29 (1967), pp. 91-96. 101 102ASSOCIATION OF PACIFIC COAST GEOGRAPHERS corrals and other structures. Typically, each homestead group maintains permanent dwellings at two or more camps, which are occupied in response to changing seasonal availabilities of, and requirements for, farmland, pasturage, firewood, and stock water—or, today, wage-work opportunities, schools and shopping, and the like. Homestead Morphology In the broadest sense, a Navajo homestead may consist of anything from a simple log-and-brush summer shade (ramada) or tent, to a grouping of 20 or more hogans (traditional circular or polygonal dwellings), houses, and shades, one or more corrals, and often, other structures such as privies, beehive ovens, animal shelters, root cellars , sudatories, and the like.4 A camp may be the permanent homesite or temporary camp of an individual, a nuclear family, or a man and his plural wives and their children; or, it may comprise the several dwellings and other structures belonging to members of a homestead group which, in addition to the aforementioned relatives, may include grandparents, siblings and their spouses and children, and occasionally other persons. Sometimes, too, loose clusters of dwellings of adjacent homestead groups may be fairly close to each other, forming what appears to be a single large camp or small hamlet . There is, therefore, no "typical" Navajo homestead, although a 4 "Camp" is often used but seldom defined. Richards defined it as being a household's or extended family's residence cluster, geographically or socially isolated from neighboring clusters; Cara E. Richards, "Modem Residence Patterns Among The Navajo," El Palacio, Vol. 70 (1963), p. 26. For detailed descriptions and bibliography of dwelling types and homesteads, see Cosmos Mindeleff, "Navajo Houses," Bureau of American Ethnology, Annual Report 17 (1898), pp. 475-517; Virginia Evelyn Spencer, "The Geography of Navajo Dwelling Types with Special Reference to Black Creek Valley, Arizona-New Mexico," unpublished M.A. thesis, Department of Geography, University of California, Davis, 1969; Virginia E. Spencer and Stephen C. Jett, "Navajo Dwellings of Rural Black Creek Valley, Arizona-New Mexico," Plateau, Vol. 43 (1971), pp. 159-175; Stephen C. Jett and Virginia Evelyn Spencer, Navajo Architecture: Forms, History, and Distributions (Tucson, University of Arizona Press), in press; John Leslie Landgraf, Land-Use in the Ramah Navajo Area, Peabody Museum of American Archaeology and Ethnology Papers, Vol. 42, No. 1 (1954), pp. 47-51; Edwin N. Wilmsen, "The House of the Navajo," Landscape, Vol. 10 (1960), pp. 15-19. YEARBOOK · VOLUME 42 · 1980103 couple of hogans (or, today...

Lung Aspiration in Pneumonia-Reply

<h3>In Reply.—</h3> We read with interest and concern the letter of Dr Scott commenting on our investigation of the bacteriologic causes of pneumonia in a group of Navajo patients with community-acquired infections. The ethical considerations involved in this investigation were rigorously examined first by us and other physicians involved in the care of the Navajo patients to ensure appropriate safeguards for patients' rights and health. The protocol was then carefully scrutinized, and final approval was given by the Human Research Committee of the University of New Mexico School of Medicine and by the Navajo Area Research Committee (made up of Navajo and Indian Health Service representatives). The latter is the final arbiter for any research done on the Indian reservation. This investigation was an attempt to improve the diagnostic methods used in pneumonia and to clarify and better understand the often confusing bacteriologic data of this disease.¹It was