Navajo Nation Research Articles

Designing and implementing equity-based pandemic preparedness and response learning modules: lessons from a multi-country short-course

ABSTRACT Background The COVID-19 pandemic has had disproportionate impacts across race, social class, and geography. Insufficient attention has been paid to addressing the massive inequities worsened by COVID-19. In July 2020, Partners In Health (PIH) and the University of Global Health Equity (UGHE) delivered a four-module short course, ‘An Equity Approach to Pandemic Preparedness and Response: Emerging Insights from COVID-19 Global Response Leaders.’ Objective We describe the design and use of a case-based, short-course education model to transfer knowledge and skills in equity approaches to pandemic preparedness and response. Methods This course used case studies of Massachusetts and Navajo Nation in the US, and Rwanda to highlight examples of equity-centered pandemic response. Course participants completed a post-session assessment survey after each of the four modules. A mixed-method analysis was conducted to elucidate knowledge acquisition on key topics and assess participants’ experience and satisfaction with the course. Results Forty-four percent of participants identified, ‘Immediate need for skills and information to address COVID-19’ as their primary reason for attending the course. Participants reported that they are very likely (4.75 out of 5) to use the information, tools, or skills from the course in their work. The average score for content-related questions answered correctly was 82–88% for each session. Participants (~70-90%) said their understanding was Excellent or Very Good for each session. Participants expressed a deepened understanding of the importance of prioritizing vulnerable communities and built global solidarity. Conclusion The training contributed to a new level of understanding of the social determinants of health and equity issues surrounding pandemic preparedness and response. This course elucidated the intersection of racism and wealth inequality; the role of the social determinants of health in pandemic preparedness and response; and the impacts of neocolonialism on pandemic response in low- and middle-income countries.

Diné Navajo Resilience to the COVID-19 pandemic.

ObjectiveTo date, there are no studies of COVID-19 cases and deaths in the Navajo Nation, US. The primary objective of this manuscript is to understand whether counties with a higher proportion of Navajo (Diné) population also had higher cases and deaths of COVID-19 and whether these dropped with vaccination.MethodWe undertook a cross-sectional analysis of county level data from March 16, 2020—May 11, 2021. Data were obtained from public repositories and the US Census for the Navajo Nation, including northeastern Arizona, southeastern Utah, and northwestern New Mexico. The primary outcome measure is the number of individuals with confirmed cases or deaths of COVID-19. A secondary outcome was COVID-19 vaccinations.ResultsThe 11 counties in Navajo Nation have a wide variation in the percent Navajo population, the resources available (ICU beds and occupancy), and COVID-19 outcomes. Overall, there was a substantial increase in the number of cases from March 16 –July 16, 2020 (the height of the pandemic) with a doubling time of 10.12 days on Navajo Nation. The percent Navajo population was a strong predictor of COVID-19 cases and deaths per million population. COVID-19 vaccinations were inversely associated with COVID-19 cases and deaths in these counties.ConclusionsThe COVID-19 pandemic on the Navajo Nation is a story of resilience. Navajo Nation was one of the hardest hit areas of the United States, with peak cases and deaths due to COVID-19. With an aggressive vaccination effort, these cases and deaths were strikingly curtailed, showing the resilience of the Navajo (Diné) people.

A mass-balance approach to evaluate arsenic intake and excretion in different populations.

Unless a toxicant builds up in a deep compartment, intake by the human body must on average balance the amount that is lost. We apply this idea to assess arsenic (As) exposure misclassification in three previously studied populations in rural Bangladesh (n=11,224), Navajo Nation in the Southwestern United States (n=619), and northern Chile (n=630), under varying assumptions about As sources. Relationships between As intake and excretion were simulated by taking into account additional sources, as well as variability in urine dilution inferred from urinary creatinine. The simulations bring As intake closer to As excretion but also indicate that some exposure misclassification remains. In rural Bangladesh, accounting for intake from more than one well and rice improved the alignment of intake and excretion, especially at low exposure. In Navajo Nation, comparing intake and excretion revealed home dust as an important source. Finally, in northern Chile, while food-frequency questionnaires and urinary As speciation indicate fish and shellfish sources, persistent imbalance of intake and excretion suggests imprecise measures of drinking water arsenic as a major cause of exposure misclassification. The mass-balance approach could prove to be useful for evaluating sources of exposure to toxicants in other settings.

Newborn tandem mass spectroscopy screening for adenosine deaminase deficiency

BackgroundNewborn screening (NBS) by means of T cell receptor excision circles (TREC) is now universal in the United States, Puerto Rico, and the Navajo Nation as a strategy to identify severe combined immunodeficiency (SCID) in newborns. Owing to the characteristics of adenosine deaminase (ADA) deficiency, a small but important number of cases can be missed by this screening. ObjectiveTo evaluate the results of the first year statewide NBS for ADA by means of dried blood spot NBS. MethodsOn October 7, 2019, the state of Michigan began screening newborn dried blood spots for ADA deficiency by means of the Neobase-2 tandem mass spectroscopy (TMS) kit. We report 1 known case of ADA deficiency in the 18 months before screening. We then reviewed the results of the first 2 years of TMS ADA screening in Michigan. ResultsThere was 1 patient with ADA deficiency known to our centers in the 18 months before initiation of TMS ADA screening; this patient died of complications of their disease. In the first 2 years of TMS ADA NBS, 206,321 infants were screened, and 2 patients had positive ADA screen results. Both patients had ADA deficiency confirmed through biochemical and genetic testing. One patient identified also had a positive TREC screen and was confirmed to have ADA-SCID. ConclusionIn our first 2 years, TMS NBS for ADA deficiency identified 2 patients with ADA deficiency at negligible cost, including 1 patient who would not have been identified by TREC NBS. This report provides initial evidence of the value of specific NBS for ADA deficiency.

An asthma collaboration to reduce childhood asthma disparities on the Navajo Nation: Trial protocol for the Community Asthma Program

Navajo children disproportionately experience poor asthma outcomes. Following a one-year community engagement period with key stakeholders from the Navajo Nation, the Community Asthma Program (CAP) was created using evidenced based programs with the goal of reducing asthma disparities among Navajo children. CAP is being evaluated with a six-year, multi-site step-wedge design in three Navajo communities: Tuba City, Chinle and Fort Defiance, Arizona. The primary outcome is asthma exacerbations defined as use of systemic oral corticosteroids, asthma hospitalizations, asthma related ED visits, and ICU admissions. Asthma exacerbations will be measured using data from the electronic medical records of the three community health care centers. Secondary outcomes include will changes in asthma-related events and asthma control. The RE-AIM (Reach and representativeness, 2)Effectiveness, 3) Adoption, 4) Implementation, and 5) Maintenance) framework is being used to guide the implementation evaluation which includes iterative collection and analysis of process data to identify facilitators and barriers, describe relevant organizational contexts, and inform strategies for dissemination. The CAP intervention requires community engagement and participation, building community capacity, incorporating evidenced-based guidelines and practices while ensuring program strategies actively involve Navajo community members during all steps of the intervention. The outcome of this trial will allow us to determine the effectiveness of a multi-component, community-focused intervention to improve asthma in a tribal community.

Maintaining the Partnership Between a Tribal Breast and Cervical Cancer Program and a University-Based Cancer Prevention Center During COVID-19 Lock-Down Restrictions-A Case Study.

To inform women of the Navajo Nation of safety measures implemented to minimize COVID-19 virus exposure during screening and treatment procedures at Navajo Nation based health care facilities, the Navajo Nation Breast and Cervical Cancer Prevention Program (NNBCCPP) and the University-based Partnership for Native American Cancer Prevention Program (NACP) collaborated to develop a podcast to describe the continued availability of services. During the COVID-19 pandemic, women of all ages and ethnicities in the US needing breast and cervical cancer prevention screenings and treatment, have been hesitant to seek services given the advice to avoid crowded spaces and maintain physical distancing. Epidemiological trends indicate that proactive, intensive strategies are needed in Native American communities for early detection and treatment to support early cancer diagnosis and improve cancer survival. The NNBCCPP and Northern Arizona University (NAU) through the National Institute of Health's National Cancer Institute funded NACP had a nascent partnership prior to the onset of COVID-19 pandemic. This partnership relied on face-to-face interaction to allow for informal social interaction, facilitate clear communication and support continued trust building. To adhere to federal, state and tribal recommendations to minimize gatherings and to stay in-place to minimize the spread of the virus, the Navajo Nation and NAU restricted, and in most cases would not approve employee travel for partnership meetings. The plans to develop a podcast necessitated bringing additional members into the collaboration who were unfamiliar to the original partners and due to travel restrictions, required all interactions to be remote. This expanded group met virtually to develop a script, record and edit the podcast. More importantly, group members had to build and maintain trust over months of communicating via a teleconference video platform. This collaborative addressed challenges related to unstable Internet connections and periodic stay-at-home policies; thus, these emerging partners had to modify social and professional communication to respect and accommodate the stress and uncertain circumstances created by the pandemic on the citizens and employees of Navajo Nation. This case study describes strategies used to maintain and respect all members of the partnership.

Patterns of Blindness in the Navajo Nation: A 9-Year Study.

The Navajo Nation is the largest Native American reservation by area and citizenship. The study sought to provide the first large-scale examination of ocular pathology within this population. A retrospective review of all Navajo patients seen at Moran Eye Center Navajo Nation Outreach Clinics from 2013 to 2021 for demographics, visual acuity, refractive, and eye pressure data was undergone. Further variables included comorbidity and eye diagnoses among patients at these clinics. Results: First-time patient visits totaled 2251 from 2013 to 2021. The median age was 53 (range, 18 to 92), and clinics had a predominance of female patients (1387:864). Among patients presenting without glasses, 20.67% (198/958), 9.71% (93/958), and 3.13% (30/958) had mild visual impairment (VI), moderate to severe VI, and blindness, respectively. Cataracts were the most common cause of blindness in these patients (40%, 12/30) and the need for glasses was the second most common cause (33%, 10/30). From 2016 to 2021, 17.71% (48/271) of diabetic patients were diagnosed with diabetic retinopathy (DR). Within the subset of Navajo patients that presented without any correction, 73% of bilateral blindness was preventable via glasses prescription or cataract surgery. This study comments on questions of equitable care for Navajo patients.

Driving Distance and Food Accessibility: A Geospatial Analysis of the Food Environment in the Navajo Nation and Border Towns.

The Navajo Nation, an area home to approximately 173,000 people in the southwest United States, experiences the highest rates of food insecurity in the United States and is classified as a food desert. The present study assessed the accessibility to food outlets (grocery stores, convenience stores, and restaurants) as measured by driving time on the Navajo Nation and in selected surrounding border towns. Food outlets located in neighboring border towns were examined using network analysis tools in ArcGIS Pro to calculate driving distance and examine the potential impact of driving time within the Navajo Nation on accessibility to nutritious foods. There were 14 grocery stores, 21 convenience stores, and 65 restaurants identified in the Navajo Nation using Mergent Intellect, a proprietary database, as compared to border towns which had a total of 542 grocery stores, 762 convenience stores, and 3,329 restaurants equaling a ratio of about 50:1 (grocery, 39:1; convenience, 36:1; restaurants, 51:1) when comparing food outlets nearby versus on the Navajo Nation. This ecological study presents a visual representation of driving time and food accessibility, revealing geographic areas within the Navajo Nation where access to border town food stores is sparse, and food insecurity may be elevated.

Rebalancing the Cold War: Diné Sandpainting and Earth Diplomacy

From 1966 to 1968 the United States government commissioned Diné artist Fred Stevens to demonstrate sandpainting across Eurasia and Latin America, in accordance with a prevailing logic of a “balance of power” in international relations. Stevens’s translations of ephemeral ceremonies worked against the grain, palpably connecting Diné efforts to protect Navajo Nation lands from military-industrial incursions to the acceleration of sand mining to feed a global building boom. Stevens’s demonstrations and gifts serve as exemplars of earth diplomacy, a practice of engendering sensuous material exchanges to facilitate reciprocity among disparate human communities and the lands that sustain them.

Efficacy of air filtration and education interventions on fine particulate matter among rural Native American homes heated with wood stoves: Results from the EldersAIR randomized trial

BackgroundNative Americans living in rural areas often rely upon wood stoves for home heating that can lead to elevated indoor concentrations of fine particulate matter (PM2.5). Wood stove use is associated with adverse health outcomes, which can be a particular risk in vulnerable populations including older adults. ObjectivesWe assessed the impact of portable air filtration units and educational approaches that incorporated elements of traditional knowledge on indoor and personal PM2.5 concentrations among rural, Native American elder households with wood stoves. MethodsEldersAIR was a three-arm, pre-post randomized trial among rural households from the Navajo Nation and Nez Perce Tribe in the United States. We measured personal and indoor PM2.5 concentrations over 2-day sampling periods on up to four occasions across two consecutive winter seasons in elder participant homes. We assessed education and air filtration intervention efficacy using linear mixed models. ResultsGeometric mean indoor PM2.5 concentrations were 50.5 % lower (95 % confidence interval: −66.1, −27.8) in the air filtration arm versus placebo, with similar results for personal PM2.5. Indoor PM2.5 concentrations among education arm households were similar to placebo, although personal PM2.5 concentrations were 33.3 % lower for the education arm versus placebo (95 % confidence interval: −63.2, 21.1). SignificanceThe strong partnership between academic and community partners helped facilitate a culturally acceptable approach to a clinical trial intervention within the study communities. Portable air filtration units can reduce indoor PM2.5 that originates from indoor wood stoves, and this finding was supported in this study. The educational intervention component was meaningful to the communities, but did not substantially impact indoor PM2.5 relative to placebo. However, there is evidence that the educational interventions reduced indoor PM2.5 in some subsets of the study households. More study is required to determine ways to optimize educational interventions within Native American communities.

Food sovereignty, health, and produce prescription programs: A case study in two rural tribal communities

Structural inequities contribute to food systems in which tribal communities in the U.S. are more likely to experience barriers to healthy food access, including financial barriers, lack of geographic proximity, or both. Food sovereignty movements improve food access by shifting power to local people to build food systems that support cultural, social, economic, and environmental needs. Finan­cial incentive programs, including produce pre­scription programs, have emerged as a promising intervention to improve food access and support food sovereignty. This case study describes the implementation of two federally funded produce prescription programs (Produce Prescription Pro­jects or PPR) under the U.S. Department of Agri­culture (USDA) Gus Schumacher Nutrition Incen­tive Program (GusNIP) in two rural tribal communities: the Yukon Kuskokwim Delta region in Alaska, and the Navajo Nation, which spans parts of New Mexico, Arizona, and Utah. We illus­trate how PPR can be tailored to accommodate local and diverse cultures, strengthen community power, and be uniquely suited for the challenges of increasing access to nutritious food in rural tribal communities. We also highlight recommendations and future areas of research that may be useful for other rural tribal communities implementing PPR.

Abstract 5863: The ABID (Assessing the gut microbiota and Individual Diet) Study in the Navajo Nation

Abstract A substantial burden of stomach cancer continues to be observed in American Indians (AI) in the Southwestern United States. The Navajo Nation, the largest tribe in the Southwest, is experiencing higher incidence of stomach cancer compared to the general population in the region, possibly due to high prevalence of Helicobacter pylori (H. pylori) infection and other contributing factors, like diet. To learn about factors linked to stomach cancer, we initiated a cross-sectional study to determine the prevalence, virulence, and dietary correlates of H. pylori infection among Navajo adults. We hypothesized that H. pylori infections, particularly with the virulent cagA gene, would be highly prevalent in Navajo adults compared to other non-AI populations, and that diets high in salt, processed meats, and low in vegetables would be associated with prevalent H. pylori infection. Study recruitment occurred from January to October 2021 in two geographic areas of the Navajo Nation. Participants were recruited using online and offline platforms, including social media (Facebook, Instagram), study website (www.theabidstudy.com), newspapers, flyers, word of mouth, and community outreach events. Eligible, consenting study participants provided a stool sample, which was analyzed by droplet digital PCR assays for H. pylori 16S gene detection and cagA virulence gene typing. Participants also provided health and food information through two questionnaires.Preliminary data indicate that prevalence of H. pylori is high in the included regions of the Navajo Nation. The H. pylori prevalence (51.5%, 95% CI: 38.9-64.0) in this study is higher than the prevalence in the US population (35%). Moreover, the cagA virulence gene prevalence in the Navajo with H. pylori was 55.9% (95% CI: 37.9-72.8), which is comparable to the US prevalence of 50%. These early results point to a need of developing prevention strategies to reduce H. pylori infection in the Navajo Nation. Citation Format: Dornell Pete, Amanda I. Phipps, Nina R. Salama, Johanna W. Lampe, Michael C. Wu. The ABID (Assessing the gut microbiota and Individual Diet) Study in the Navajo Nation [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5863.

Respectful Tribal Partnership: What Philanthropy Can Learn From the Navajo Nation’s Collaborative Response to the COVID-19 Crisis

The gravity of the COVID-19 pandemic and its disparately harsh impact on Indigenous peoples are now well known. U.S. death rates normalized by population, for example, have been far higher for Native Americans than for the white population in the United States. Many funders, realizing that basic human services are lacking for many Native American and Indigenous communities, have responded to the crisis. While this desire to act is laudable, many fail to grasp the complexities and necessity of applying trust-based collaborative principles that respect tribes as sovereign nations.

The Impacts of Drought on Southwest Tribal Economies

AbstractDrought negatively impacts agricultural productivity, often causing reduced crop yields and damage to pasture and rangelands. Droughts are particularly concerning for Native American reservations in the arid United States Southwest, as agricultural production on the reservations provides an important economic base. This study evaluates the impacts of drought on the cattle and hay sectors and resulting economic impacts on tribal communities in Arizona, Nevada, New Mexico, and Utah. Panel data analysis is used to estimate the impacts of drought, assessed using the Palmer Drought Severity Index (PDSI), on reservation cattle inventory and hay yields. Then, the supply‐driven social accounting matrix approach is used to quantify the total economic impacts on tribal economies given hypothetical drought scenarios. Results show that drought impacts cattle production more than hay/forage production. Each additional year of drought reduces cattle inventory by 1.9% in the following year. Furthermore, for every unit decrease in PDSI each year, cattle inventory and hay yields decline by 0.3% and 0.4%, respectively. The drought scenarios examined result in hefty economic losses for large reservation areas such as the Uintah and Ouray Reservation, Navajo Nation, and Tohono O'odham Nation. To alleviate the negative impacts of drought on reservation economies, hurdles that limit tribal ability to mitigate and adapt to drought and climate change impacts should be addressed.

From “trust” to “trustworthiness”: Retheorizing dynamics of trust, distrust, and water security in North America

Assumptions of trust in water systems are widespread in higher-income countries, often linked to expectations of “modern water.” The current literature on water and trust also tends to reinforce a technoscientific approach, emphasizing the importance of aligning water user perceptions with expert assessments. Although such approaches can be useful to document instances of distrust, they often fail to explain why patterns differ over time, and across contexts and populations. Addressing these shortcomings, we offer a relational approach focused on the trustworthiness of hydro-social systems to contextualize water-trust dynamics in relation to broader practices and contexts. In doing so, we investigate three high-profile water crises in North America where examples of distrust are prevalent: Flint, Michigan; Kashechewan First Nation; and the Navajo Nation. Through our theoretical and empirical examination, we offer insights on these dynamics and find that distrust may at times be a warranted and understandable response to experiences of water insecurity and injustice. We examine the interconnected experiences of marginality and inequity, ontological and epistemological injustice, unequal governance and politics, and histories of water insecurity and harm as potential contributors to untrustworthiness in hydro-social systems. We close with recommendations for future directions to better understand water-trust dynamics and address water insecurity.

COVID-19 on the Navajo Nation: experiences of Diné families of children with asthma

Objective The first case of COVID-19 on the Navajo Nation (NN) was found on March 17, 2020. Even with strong public health efforts, NN saw the highest per capita infection rate in the US during May of 2020 with 2450/100,000. To determine the impact of COVID-19 on families of children with asthma on the NN, families participating in the NHLBI funded Community Asthma Program were contacted to see if they would share their experiences. Methods Sixty-six of 193 families (34%) were interviewed. Results: The average age of the child with asthma was 13.5 (SD = 3.9) and 33% were female. Most Diné children with asthma in our study did not contract COVID-19. However, the pandemic had a significant impact on them and their families. Many family members contracted COVID-19, some children lost family members, and half of interviewed parents reported a decline in their child’s mental health. Twenty-five percent of families sought the help of a traditional healer. Many accessed medical care through telehealth and most were able to obtain asthma medications when needed. Conclusions: Despite significant challenges, our research indicated resilience among Navajo families.

Shopper Purchasing Trends at Small Stores on the Navajo Nation since the Passage of the Healthy Diné Nation Act Tax: A Multi-Year Cross-sectional Survey

ABSTRACTBackgroundIn 2014, the Navajo Nation passed the Healthy Diné Nation Act (HDNA), which applies an additional 2% tax on unhealthy foods and beverages and a waiver of Navajo sales tax on healthy foods and beverages. However, the HDNA's impact on purchasing behavior has not been explored.ObjectivesWe assessed beverage and produce purchasing trends among shoppers at small Navajo stores between 2017 and 2019, shopper characteristics associated with buying water, and whether HDNA awareness was associated with purchasing behaviors.MethodsA total of 332 shoppers at 34 stores in 2017 and 274 shoppers at 44 stores in 2019 were surveyed to assess HDNA awareness and same-day purchasing of water, sugar-sweetened beverages (SSBs), fruits, and vegetables. Hypotheses were tested using chi-square analyses and multivariate analysis.ResultsWater purchasing among respondents increased significantly from 2017 to 2019 (24.4% to 32.8%; P = 0.03). Shoppers in 2019 were 1.5 times more likely to purchase water compared with 2017 (adjusted P = 0.01). There was a trend toward reduced SSB purchasing (85.8% in 2017, 80.3% in 2019, P = 0.068), while produce purchasing remained unchanged over time, at approximately 17%. Shoppers were more likely to buy water if they relied on that store for the majority of their groceries (P = 0.006) and if they did not have their own transportation to get to the store (P = 0.004). Most shoppers (56.6%) were aware of the HDNA; of these, 35.6% attributed healthier habits to the HDNA, most commonly buying more healthy drinks (49.2%), fewer unhealthy drinks (37.7%), more healthy snacks (31.1%), and fewer unhealthy snacks (26.2%).ConclusionsShopper habits at small stores located on the Navajo Nation have shifted towards healthier purchasing from 2017 to 2019. Shoppers who were aware of the HDNA reported purchasing more healthy and fewer unhealthy food and drinks as a result of this legislation.

Lessons learned from academic medical centers' response to the COVID-19 pandemic in partnership with the Navajo Nation.

IntroductionStructural forces that drive health inequalities are magnified in crises. This was especially true during the COVID-19 pandemic, and minority communities were particularly affected. The University of California San Francisco and Health, Equity, Action, Leadership Initiative jointly sent volunteer teams of nurses and doctors to work in the Navajo Nation during the COVID-19 pandemic. This presented an opportunity to explore how academic medical centers (AMCs) could effectively partner with vulnerable communities to provide support during healthcare crises. Therefore, the aims of this study were to describe volunteers’ perspectives of academic-community partnerships by exploring their personal, professional and societal insights and lessons learned based on their time in the Navajo Nation during COVID-19.MethodsWe recruited key informants using purposeful sampling of physicians and nurses who volunteered to go to the Navajo Nation during the spring 2020 COVID-19 surge, as well as hospital administrators and leaders involved in organizing the COVID-19 efforts. We used in-depth qualitative interviews to explore key informants’ experiences pre-departure, during their stay, and after their return, as well as perspectives of the partnership between an AMC and the Navajo Nation. We used thematic analysis to systematically identify, analyze and report patterns (themes) within the data.ResultsIn total, 37 clinicians and hospital administrators were interviewed including 14 physicians, 16 nurses, and 7 health system leaders. Overall, we found 4 main themes each with several subthemes that defined the partnership between the AMC and the Navajo Nation. Mission and values incorporated civic duty, community engagement, leadership commitment and employee dedication. Solidarity, trust and humility encompassed pre-existing trust, workforce sustainability, humility and erasure of ‘savior narratives.’ Coordination included logistical coordination, flexibility, selectivity of who and what traveled to the response and coordination around media response. Workforce preparation and support encompassed understanding of historical context and providing healthcare in limited settings, dangers of inadequate preparation and the need for emotional support.ConclusionThis study provides guidelines which AMCs might use to develop and improve partnerships they have or would like to develop with vulnerable communities. These guidelines may even be broadly applied to partnerships outside of a pandemic response. Importantly, such partnerships need to be built with trust and with an eye towards sustainability and long-term relationships as opposed to ‘medical missions’.

Efficacy of Air Filtration and Education Interventions on Indoor Fine Particulate Matter and Child Lower Respiratory Tract Infections among Rural U.S. Homes Heated with Wood Stoves: Results from the KidsAIR Randomized Trial.

Background:Millions of rural U.S. households are heated with wood stoves. Wood stove use can lead to high indoor concentrations of fine particulate matter [airborne particles in aerodynamic diameter ()] and is associated with lower respiratory tract infection (LRTI) in children.Objectives:We assessed the impact of low-cost educational and air filtration interventions on childhood LRTI and indoor in rural U.S. homes with wood stoves.Methods:The Kids Air Quality Interventions for Reducing Respiratory Infections (KidsAIR) study was a parallel three-arm (education, portable air filtration unit, control), post-only randomized trial in households from Alaska, Montana, and Navajo Nation (Arizona and New Mexico) with a wood stove and one or more children of age. We tracked LRTI cases for two consecutive winter seasons and measured indoor over a 6-d period during the first winter. We assessed results using two analytical frameworks: a) intervention efficacy on LRTI and (intent-to-treat), and b) association between and LRTI (exposure–response).Results:There were 61 LRTI cases from 14,636 child-weeks of follow-up among 461 children. In the intent-to-treat analysis, children in the education arm [; 95% confidence interval (CI): 0.35, 2.72] and the filtration arm (; 95% CI: 0.46, 3.32) had similar odds of LRTI vs. control. Geometric mean concentrations were similar to control in the education arm (11.77% higher; 95% CI: , 49.72) and air filtration arm (6.96% lower; 95% CI: , 24.55). In the exposure–response analysis, odds of LRTI were 1.45 times higher (95% CI: 1.02, 2.05) per interquartile range () increase in mean indoor .Discussion:We did not observe meaningful differences in LRTI or indoor in the air filtration or education arms compared with the control arm. Results from the exposure–response analysis provide further evidence that biomass air pollution adversely impacts childhood LRTI. Our results highlight the need for novel, effective intervention strategies in households heated with wood stoves. https://doi.org/10.1289/EHP9932

Traditional Navajo Teachings: A Trilogy—Volume I, Sacred Narratives and Ceremonies; Volume II, The Natural World; Volume III, The Earth Surface People

Traditional Navajo Teachings: A Trilogy—Volume I, Sacred Narratives and Ceremonies; Volume II, The Natural World; Volume III, The Earth Surface People