Telephone-Based Guideline-Directed Medical Therapy Optimization in Navajo Nation: The Hózhó Randomized Clinical Trial.

Importance: Underutilization of guideline-directed medical therapy for heart failure with reduced ejection fraction is a major cause of poor outcomes. For many American Indian patients receiving care through the Indian Health Service, access to care, especially cardiology care, is limited, contributing to poor uptake of recommended therapy. Objective: To examine whether a telehealth model in which guideline-directed medical therapy is initiated and titrated over the phone with remote telemonitoring using a home blood pressure cuff improves guideline-directed medical therapy use (eg, drug classes and dosage) in patients with heart failure with reduced ejection fraction in Navajo Nation. Design, Setting, and Participants: The Heart Failure Optimization at Home to Improve Outcomes (Hózhó) randomized clinical trial was a stepped-wedge, pragmatic comparative effectiveness trial conducted from February to August 2023. Patients 18 years and older with a diagnosis of heart failure with reduced ejection fraction receiving care at 2 Indian Health Service facilities in rural Navajo Nation (defined as having primary care physician with 1 clinical visit and 1 prescription filled in the last 12 months) were enrolled. Patients were randomized to the telehealth care model or usual care in a stepped-wedge fashion, with 5 time points (30-day intervals) until all patients crossed over into the intervention. Data analyses were completed in January 2024. Intervention: A phone-based telehealth model in which guideline-directed medical therapy is initiated and titrated at home, using remote telemonitoring with a home blood pressure cuff. Main Outcomes and Measures: The primary outcome was an increase in the number of guideline-directed classes of drugs filled from the pharmacy at 30 days postrandomization. Results: Of 103 enrolled American Indian patients, 42 (40.8%) were female, and the median (IQR) age was 65 (53-77) years. The median (IQR) left ventricular ejection fraction was 32% (24%-36%). The primary outcome occurred significantly more in the intervention group (66.2% vs 13.1%), thus increasing uptake of guideline-directed classes of drugs by 53% (odds ratio, 12.99; 95% CI, 6.87-24.53; P < .001). The number of patients needed to receive the telehealth intervention to result in an increase of guideline-directed drug classes was 1.88. Conclusions and Relevance: In this heart failure trial in Navajo Nation, a telephone-based strategy of remote initiation and titration for outpatients with heart failure with reduced ejection fraction led to improved rates of guideline-directed medical therapy at 30 days compared with usual care. This low-cost strategy could be expanded to other rural settings where access to care is limited. Trial Registration: ClinicalTrials.gov Identifier: NCT05792085.

The Navajo Nation Healthy Diné Nation Act: Community Support of a 2% Tax on Unhealthy Foods.

CONTEXT: The Healthy Diné Nation Act (HDNA) of 2014 included a 2% tax on foods of little-to-no-nutritious value ("junk foods") on the Navajo Nation. The law was the first ever in the United States and any Indigenous nation worldwide with a population at a high risk for common nutrition-related conditions. To date, research on community support for food tax legislation among Indigenous nations is entirely lacking. OBJECTIVE: To assess the extent of support for the HDNA and factors associated with support including sociodemographic variables, knowledge of the HDNA, nutrition intake, and pricing preferences. DESIGN: Cross-sectional survey. SETTING: The Navajo Nation. PARTICIPANTS: A total of 234 Navajo Nation community members across 21 communities. OUTCOME MEASURES: The percentage of participants who were supportive of the HDNA. RESULTS: Participants were 97% Navajo, on average middle-aged, 67% reported an income below $25 000 annually, and 69.7% were female. Half of the respondents said they "support" (37.4%) or "strongly support" (13.0%) the tax, while another 35% of people said they were neutral or somewhat supportive; 15% did not support the tax. Participants with higher income ( P = .025) and education ( P = .026) and understanding of the legislation ( P < .001 for "very well" vs "not at all") had increased odds of greater support, as did people who believed that the HDNA would make Navajo people healthier (vs not, P < .001). Age, gender, language, and reported nutrition intake (healthy or unhealthy) were not associated with HDNA support, but participants willing to pay 5% or 12%-15% higher prices for fast food and soda had increased odds of greater support ( P values range from .023 to <.001). CONCLUSIONS: The majority of Navajo community members surveyed were moderately supportive of the Navajo Nation tax on unhealthy foods. Higher income and education and understanding of the law were associated with greater support, but nutrition intake was not.

Diné (Navajo) Traditional Knowledge Holders' Perspective of COVID-19.

From the start of the COVID-19 pandemic on the Navajo Nation, Diné (Navajo) traditional knowledge holders (TKHs), such as medicine men and women and traditional practitioners, contributed their services and healing practices. Although TKHs are not always fully acknowledged in the western health care system, they have an established role to protect and promote the health of Diné people. To date, their roles in mitigating the COVID-19 pandemic have not been fully explored. The purpose of this research was to understand the social and cultural contexts of the COVID-19 pandemic and vaccines based on the roles and perspectives of Diné TKHs. A multi-investigator consensus analysis was conducted by six American Indian researchers using interviews with TKHs collected between December 2021-January 2022. The Hózhó Resilience Model was used as a framework to analyze the data using four parent themes: COVID-19, harmony and relationships, spirituality, and respect for self and discipline. These parent themes were further organized into promoters and/or barriers for 12 sub-themes that emerged from the data, such as traditional knowledge, Diné identity, and vaccine. Overall, the analysis showed key factors that could be applied in pandemic planning and public health mitigation efforts based on the cultural perspective of TKHs.