Practicing Tribal Sovereignty Through a Tribal Health Policy: Implementation of the Healthy Diné Nation Act on the Navajo Nation.

INTRODUCTION: The Navajo Nation is a large sovereign tribal nation. After several years of grassroots efforts and overcoming an initial presidential veto, the Navajo Nation passed the Healthy Diné Nation Act (HDNA) in 2014 to promote healthy behaviors in Navajo communities. This was the first such policy in the US and in any sovereign tribal nation worldwide. PURPOSE AND OBJECTIVES: The objective of this study was to describe the process, implementation, and evaluation of the HDNA passage and its 2020 reauthorization and the potential for using existing and tribal-specific data to inform tribal policy making. INTERVENTION APPROACH: The HDNA included a 2% tax on unhealthy foods sold on the Navajo Nation and waived a 6% sales tax on healthy foods. HDNA-generated funds were allocated to 110 local communities for wellness projects. No funds were allocated for enforcement or compliance. EVALUATION METHODS: We assessed HDNA tax revenue and tax-funded wellness projects in 110 chapters over time, by region and community size. The food store environment was assessed for fidelity of HDNA implementation, price changes since pretax levels, and shopper behaviors. HDNA revenue was cross-matched with baseline nutrition behaviors and health status through a Navajo-specific Behavioral Risk Factor Surveillance System survey. RESULTS: HDNA revenue decreased modestly annually, and 99% of revenue was disbursed to local chapters, mostly for the built recreational environment, education, equipment, and social events. Stores implemented the 2% tax accurately, and the food store environment improved modestly. Regions with high tax revenue also had high rates of diabetes, but not other chronic conditions. The HDNA was reauthorized in 2020. IMPLICATIONS FOR PUBLIC HEALTH: Sovereign tribal nations can drive their own health policy. Program evaluation can use existing data sources, tailored data collection efforts, and tribal-specific surveys to gain insight into feasibility, implementation, and impact.

Formative Evaluation and Adaptation of a Navajo Cancer Survivor Physical Activity Intervention to Serve a Broader Native American Cancer Survivor Community.

BACKGROUND: Although exercise has been shown to improve cancer survivorship in other communities, cancer exercise studies among Native American communities are rare. We sought to adapt a Navajo-tailored cancer exercise pilot program to serve a broader Native American cancer community. METHODS: Tribal experts representing 10 different Tribal Nations were engaged in small focus groups (n=2-4) to assess program materials for cultural appropriateness and adaptation to expand tribal inclusiveness. Facilitated by a trained Native American interviewer, focus groups were provided a primer survey and then reviewed intervention materials (protocols, incentives, logo, flyers, etc.). Consensus was reached by the research team on all program adaptations. RESULTS: The program name, Restoring Balance, layout, graphics, and symbols were considered culturally appropriate overall. Program exercises and biomarker measurements were viewed as valuable to health improvements in the community. Important color, linguistic, and logistic program modifications were recommended to improve cultural alignment. The order of incentive items was revised to highlight restoration and the logo rotated to align with the four corners of the earth, an important cultural element. Linguistic modifications primarily related to prior traumatic research experiences in Native American communities where data had been taken without adequate community benefit or permission. Program emphasis should be on nurturing, added value and giving. CONCLUSION AND RELEVANCE: The methodology used for cultural expert review was successful in eliciting adaptations to expand the tribal inclusiveness of Restoring Balance. Culture, as well as historically traumatic research experiences, among Native American populations must be considered when adapting health promotion programming.

The Navajo Nation Healthy Diné Nation Act: A Description of Community Wellness Projects Funded by a 2% Tax on Minimal-to-No-Nutritious-Value Foods.

CONTEXT: To promote the health of the Navajo people, the Navajo Nation passed the Healthy Diné Nation Act (HDNA) in 2014. The HDNA included a 2% tax on "minimal-to-no-nutritional-value" foods and waived 5% sales tax on healthy foods, the first such policy in the United States and any sovereign Tribal nation. Uniquely aligned with Tribal government structures, revenue was directly allocated to 110 small local government entities (Chapters) for self-determined wellness projects. OBJECTIVE: To characterize HDNA-funded wellness projects, test for variation in project type, and funding amount over time by region and community size. DESIGN: Longitudinal study assessing funded wellness projects from tax inception through 2019. SETTING: The Navajo Nation. PARTICIPANTS: One hundred ten Navajo Nation Chapters receiving funding for self-determined wellness projects. OUTCOME MEASURES: The categories and specific types of wellness projects and funding over 4 years by region and community size. RESULTS: Of revenue collected in 2015-2018, more than 99.1% was disbursed through 2019 ($4.6 million, $13 385 annually per community) across 1315 wellness projects (12 per community). The built recreational environment category received 38.6% of funds, equipment/supplies 16.5%, instruction 15.7%, food and water initiatives 14.0%, and social events 10.2%. Most common specific projects were walking trails ($648 470), exercise equipment ($585 675), food for events ($288 879), playgrounds ($287 471), and greenhouses ($275 554). Only the proportion allocated to instruction changed significantly over time (increased 2% annually, P = .02). Smaller communities (population <1000) allocated significantly higher proportions to traditional, agricultural, and intergenerational projects and less to the built environment. CONCLUSIONS: Through 2019, more than 99% of HDNA revenue was successfully disbursed to 110 rural, Tribal communities. Communities chose projects related to promoting the built recreational environment, agriculture, and fitness/nutrition education, with smaller communities emphasizing cultural and intergenerational projects. These findings can inform other indigenous nations considering similar policies and funding distributions.

Perceptions of Cancer Causes, Prevention, and Treatment Among Navajo Cancer Survivors.

Native Americans experience cancer-related health disparities. Yet, little is known about the current cancer experience in one of the largest Native American tribe, Navajo. A qualitative study of among Navajo cancer survivors, in which focus groups and individual interviews included questions related to perceptions of cancer causes, prevention, and treatment, allowed us to evaluate several aspects of the cancer experience from the Navajo perspective. An experienced, bilingual facilitator led the discussions using a standardized guide. Discussions were audio-recorded, documented by field notes, translated, as needed, and transcribed. NVivo software was used to summarize major themes according to the PEN-3 and health belief models. Navajo cancer survivors (N = 32) were both males (n = 13) and females (n = 19) that had been previously diagnosed with a variety of cancers: colorectal, breast, ovarian, cervical, esophageal, gall bladder, stomach, prostate, kidney, and hematologic. Many survivors had accurate knowledge of risk factors for cancer. Barriers to screening and clinical care included language, expense, geography, fear, lack of information, skepticism related to Western medicine, and treatment side effects. While some survivors experienced familial support, others were isolated from the family and community due to the perspective of cancer as a contagion. However, resilience, hope, trust in select community organizations, a desire to restore balance, and to support younger generations were positive attributes expressed regarding the treatment and recovery process. These evaluations need to be replicated across a larger cross-section of the Native cancer survivor community.

Initiating Exercise Interventions to Promote Wellness in Cancer Patients and Survivors.

Exercise is associated with significant reductions in the recurrence and mortality rates of several common cancers. Cancer survivors who exercise can potentially benefit from reduced levels of fatigue, and improved quality of life, physical function, and body composition (ie, healthier ratios of lean body mass to fat mass). The amount of activity required to achieve protective effects is moderate (eg, walking 30 minutes per day at 2.5 miles per hour). However, many healthcare providers report a lack of awareness of the appropriate exercise recommendations across the phases of cancer survivorship, considerations regarding the timing of exercise interventions, and the ability to refer patients to exercise programs specifically aimed at cancer survivors. The American College of Sports Medicine notes that exercise is generally safe for most cancer survivors, and inactivity should be avoided. Their guidelines for exercise call for 150 minutes of moderate or 75 minutes of vigorous aerobic activity per week, and 2 days per week of resistance training (eg, with exercise bands or light weights). Survivors with lymphedema, peripheral neuropathy, breast reconstruction, central lines, and ostomies should follow specific precautions. Providing health professionals with the training and tools needed to provide adequate recommendations to their patients is essential to improving patient outcomes. To facilitate adherence among communities with the greatest need and poor access to services, cultural and environmental adaptations are critical.

Predictors of parent-child relationships that support physical activity in Mexican-American families.

Family-based physical activity (PA) interventions would benefit from research that identifies how to build support for PA among family members. This study examined the extent to which relationships of encouragement to do PA, and co-engagement in PA, exist among Mexican-American parents and children, and sought to identify individual, relational, and household factors associated with these dimensions of support. Participants were 224 Mexican-origin adults, with at least one child aged 5-20 years, participating in a larger study conducted between 2008 and 2010. In baseline surveys, adult participants enumerated the names and attributes of their family and kin; this study focuses on 455 parent-child dyads, nested in 118 households. Parental encouragement of PA in their children was found in about half of dyads, and in 20 % of dyads children encouraged parents. Encouragement relationships were highly reciprocal. Reciprocal parent-child encouragement was also positively associated with co-participation in PA; the latter found in just 17 % of dyads. Results indicated that relational, individual, and socio-cultural attributes were associated with PA support among parents and children, and provide insights into how these relationships might be fostered within Mexican-American families.

Restoring Balance: a physical activity intervention for Native American cancer survivors and their familial support persons.

Introduction/Purpose: Exercise interventions among Native American cancer survivors are lacking, despite major cancer health disparities in survivorship. The purpose of this study was to evaluate a 12-week randomized controlled trial (RCT) of culturally tailored exercise on cancer risk biomarkers and quality of life among Native American cancer survivors and family members. Methods: Participants were randomized to immediate start versus 6-week waitlist control at two rural and two urban sites. Participants enrolled in a small feasibility pilot study (only cancer survivors evaluated, n=18; cohort 1) or larger efficacy pilot study where cancer survivors (n=38; cohort 2) and familial supporters (n=25; cohort 3) were evaluated concurrently. Resistance, aerobic, flexibility, and balance exercises were tailored by cultural experts representing ten tribes. Exercises was supervised on-site one day per week and continued in home-based settings two to five days per week. Fat mass, blood pressure, hemoglobin A1c, 6-min walk, sit-to-stand test, and quality of life (Patient-Reported Outcomes Measurement Information System Global Health short form and isolation subscale) were measured. Mixed effects models evaluated differences between RCT arms from baseline to 6 weeks, and 12-week intervention effects in combined arms. Results: There were no consistent differences at 6 weeks between randomized groups. Upon combining RCT arms, 6-min walk and sit-to-stand tests improved in all three cohorts by 12 weeks (both survivors and familial support persons, p<0.001); social isolation was reduced in all three cohorts (p≤0.05). Familial support persons additionally improved blood pressure and HbA1c (p≤0.05). Conclusion: Exercise improved cardiorespiratory fitness and physical function among Native American cancer survivors and familial supporters. A longer intervention may influence other important health outcomes among Native American survivors. Additional improvements demonstrated among Native American family members may have a meaningful impact on cancer prevention in this underserved population with shared heritable and environmental risks.

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.

Background: In 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. Objectives: We 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. Methods: A 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. Results: Water 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%). Conclusions: Shopper 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.

Changes in food pricing and availability on the Navajo Nation following a 2% tax on unhealthy foods: The Healthy Diné Nation Act of 2014.

INTRODUCTION: In 2014, the Navajo Nation Healthy Diné Nation Act (HDNA) was passed, combining a 2% tax on foods of 'minimal-to-no-nutritional value' and waiver of 5% sales tax on healthy foods, the first-ever such tax in the U.S. and globally among a sovereign tribal nation. The aim of this study was to measure changes in pricing and food availability in stores on the Navajo Nation following the implementation of the HDNA. METHODS: Store observations were conducted in 2013 and 2019 using the Nutrition Environment Measurement Survey-Stores (NEMS-S) adapted for the Navajo Nation. Observations included store location, type, whether healthy foods or HDNA were promoted, and availability and pricing of fresh fruits and vegetables, canned items, beverages, water, snacks and traditional foods. Differences between 2013 and 2019 and by store type and location were tested. RESULTS: The matched sample included 71 stores (51 in the Navajo Nation and 20 in border towns). In 2019, fresh produce was available in the majority of Navajo stores, with 71% selling at least 3 types of fruit and 65% selling at least 3 types of vegetables. Compared with border town convenience stores, Navajo convenience stores had greater availability of fresh vegetables and comparable availability of fresh fruit in 2019. The average cost per item of fresh fruit decreased by 13% in Navajo stores (from $0.88 to $0.76) and increased in border stores (from $0.63 to $0.73), resulting in comparable prices in Navajo and border stores in 2019. While more Navajo stores offered mutton, blue corn and wild plants in 2019 compared to 2013, these changes were not statistically significant. DISCUSSION: The findings suggest modest improvements in the Navajo store environment and high availability of fruits and vegetables. Navajo stores play an important role in the local food system and provide access to local, healthy foods for individuals living in this rural, tribal community.

Only 1 in 10 Patients Told to Lose Weight Seek Help From a Health Professional: A Nationally Representative Sample.

PURPOSE: Receiving weight loss advice from a health-care provider has been associated with more weight loss efforts and greater odds of achieving weight loss. However, whether patients seek help from their provider or other health professional with weight loss after receiving advice from them to lose weight is largely unknown. DESIGN: Cross-sectional data from the 2011 to 2012 National Health and Nutrition Examination Survey (NHANES). SAMPLE: A total of 3862 overweight/obese adults. MEASURES: Questionnaires asked whether participants received advice to lose weight, and whether they sought health professional's assistance with weight management. The NHANES 2011 to 2012 was the most recent year both questions were asked. ANALYSIS: Accounting for NHANES sampling and design, frequency distributions characterized demographics and proportions. Logistic regressions estimated odds of seeking weight loss help by demographics. RESULTS: Of 3682 overweight/obese adults, 1908 were told they were overweight or recommended to lose weight. Of 1908 people, 68% reported weight loss efforts, but only health 10.9% sought a health professional's help (dietician/nutritionist 4.7%, personal trainer 3.0%, doctor 2.8%). Females, people with health insurance and high health-care utilization had 1.5 to 3.5 times greater odds of seeking help; age, ethnicity, and income were not significantly associated with seeking help with weight management. CONCLUSION: In a nationally representative sample, only 10.9% of overweight/obese adults told to lose weight by a provider sought help from a health professional with weight loss. This underscores the opportunity for greater health professional involvement with weight management beyond giving recommendations.

Physical Activity among Navajo Cancer Survivors: A Qualitative Study.

Physical activity (PA) may improve quality of life and survival among cancer survivors; however, little is known about Navajo cancer survivor PA. We evaluated Navajo cancer survivor PA habits, barriers, and preferences through focus groups and interviews (n = 32). Transcripts were coded in NVivo and major themes summarized by consensus. Survivor exercise guidelines were largely unknown, but movement, resilience and life balance were valued. Most participants reported at ≥1 mode of current PA (n = 24; 71% walking, 46% work/homesteading). Barriers to PA included treatment side effects, limited access to programs, fear of "over doing it," and family/friends encouraging rest. Preferences for PA varied.

Let's Move Together.

BACKGROUND: Due to shared health behaviors and disease risk, families may be more effective targets for health promotion. This study assessed whether providing family health history (FHH)-based risk information for heart disease and diabetes affected encouragement to engage in physical activity (PA) and healthy weight (HW) maintenance and co-engagement in physical activity among 320 Mexican-origin parents and their 1,081 children. METHOD: At baseline and 10 months, parents indicated who they encouraged and who encouraged them to engage in PA/HW, and with whom they co-engaged in PA. Households were randomized to receive FHH-based assessments either by one or all adult household members. Primary analyses consisted of regression analyses using generalized estimating equations. RESULTS: At baseline, parents reported encouraging their child for both PA and HW in 37.6% of parent-child dyads and reported receiving children's encouragement for both in 12.1% of dyads. These increased to 56.8% and 17.5% at 10 months ( p < .001). Co-engagement in PA increased from 11.4% to 15.7% ( p < .001), with younger children (30.4%) and mother-daughter dyads (26.8%) most likely to co-engage at 10 months. Providing FHH-based risk information to all adult household members (vs. one) was associated with increased parent-to-child encouragement of PA/HW ( p = .011) at 10 months but not child-to-parent encouragement. New encouragement from parent-to-child ( p = .048) and from child-to-parent ( p = .003) predicted new 10-month PA co-engagement. DISCUSSION: Providing FHH information on a household level can promote parental encouragement for PA/HW, which can promote greater parent-child co-engagement in PA. In this high-risk population with a cultural emphasis on family ties, using FHH-based risk information for all adult household members may be a promising avenue to promote PA.

Randomized trial of exercise and an online recovery tool to improve rehabilitation outcomes of cancer survivors.

PURPOSE: The purpose of this study was to test the effects of a cancer survivor exercise program and an online recovery awareness program (Restwise) on physical outcomes of aerobic capacity and muscle strength. DESIGN: Randomized controlled trial design. SETTING: Treasure Valley Family YMCA, Boise, ID. SAMPLE: Fifty cancer survivors. METHODS: Subjects were randomly assigned to the 12-week exercise program or the exercise program and Restwise. Restwise required users to complete daily objective and subjective ratings. Restwise compiles these data to provide individualized feedback recommending the exercise dose to maximize recovery and minimize fatigue. MAIN RESEARCH VARIABLE: Baseline and posttest measures of physical performance (6-minute walk, 1-repetition maximum of lower and upper body strength). FINDINGS: The exercise plus Restwise group demonstrated significant improvements (P < 0.001) that were found on all 3 physical measurements of strength and endurance. The exercise-only group demonstrated significant within-group improvement only on the 6-minute walk. The exercise plus Restwise group demonstrated an 18.5% greater improvement in the 6-minute walk, and a 35.2% and 45%, respectively, greater improvement on the leg and chest press than the exercise-only group. However, the between-group differences were not significant. CONCLUSION: Cancer survivors who use the Restwise online recovery program in conjunction with an exercise program demonstrated minimal clinically important differences compared with other clinical populations on all 3 measures, whereas the exercise-only group had improvements only on the 6-minute walk. Patient adherence to the Restwise program was good, and patients provided positive feedback.

Improved Cardiovascular Risk among Hispanic Border Participants of the Mi Corazón Mi Comunidad Promotores De Salud Model: The HEART II Cohort Intervention Study 2009-2013.

BACKGROUND: Community resources (parks, recreational facilities) provide opportunities for health promotion, but little is known about how to promote utilization of these resources and their impact on cardiovascular disease risk (CVD). METHODS: This cohort study evaluated the impact of an intervention called Mi Corazon Mi Comunidad (MiCMiC), which consisted of promoting use of community physical activity and nutrition resources by Promotoras de Salud/Community Health Workers. Participants were assessed at baseline and following the 4-month intervention. Attendance records were objectively collected to assess utilization of intervention programing. RESULTS: A total of five consecutive cohorts were recruited between 2009 and 2013. Participants were mostly females (86.0%), on average 46.6 years old, and 81% were low in acculturation. Participants who completed follow-up (n = 413) showed significant improvements in reported health behaviors and body composition. Higher attendance significantly predicted greater improvements. The baseline to 4-month change for the highest vs. the lowest attendance quartiles were for weight (-5.2 vs. +0.01 lbs, p < 0.001), waist circumference (-1.20 vs. -0.56 inches, p = 0.047), hip circumference (-1.13 vs. -0.41 inches, p < 0.001); hours of exercise/week (+3.87 vs. +0.81 hours, p < 0.001), proportion of participants eating five servings of fruits and vegetables/day (+54.7 vs. 14.7%, p < 0.001). CONCLUSION: Following the Promotora-led MiCMiC intervention, substantial improvements in health behaviors and modest improvements in cardiovascular risk factors were found. Greater utilization of community resources was associated with more favorable changes. This study provided preliminary evidence for the effectiveness of Promotora-led interventions for promoting use of existing community resources in CVD risk reduction.

Barriers to care and comorbidities along the U.S.-Mexico border.

OBJECTIVE: While limited access to care is associated with adverse health conditions, little research has investigated the association between barriers to care and having multiple health conditions (comorbidities). We compared the financial, structural, and cognitive barriers to care between Mexican-American border residents with and without comorbidities. METHODS: We conducted a stratified, two-stage, randomized, cross-sectional health survey in 2009-2010 among 1,002 Mexican-American households. Measures included demographic characteristics; financial, structural, and cognitive barriers to health care; and prevalence of health conditions. RESULTS: Comorbidities, most frequently cardiovascular and metabolic conditions, were reported by 37.7% of participants. Controlling for demographics, income, and health insurance, six financial barriers, including direct measures of inability to pay for medical costs, were associated with having comorbidities (odds ratios [ORs] ranged from 1.7 to 4.1, p<0.05). The structural barrier of transportation (OR=3.65, 95% confidence interval [CI] 1.91, 6.97, p<0.001) was also associated with higher odds of comorbidities, as were cognitive barriers of difficulty understanding medical information (OR=1.71, 95% CI 1.10, 2.66, p=0.017), being confused about arrangements (OR=1.82, 95% CI 1.04, 3.21, p=0.037), and not being treated with respect in medical settings (OR=1.63, 95% CI 1.05, 2.53, p=0.028). When restricting analyses to participants with at least one health condition (comparing one condition vs. having ≥ 2 comorbid conditions), associations were maintained for financial and transportation barriers but not for cognitive barriers. CONCLUSION: A substantial proportion of adults reported comorbidities. Given the greater burden of barriers to medical care among people with comorbidities, interventions addressing these barriers present an important avenue for research and practice among Mexican-American border residents.

A path analysis of a randomized promotora de salud cardiovascular disease-prevention trial among at-risk Hispanic adults.

This study assessed effectiveness of an educational community intervention taught by promotoras de salud in reducing cardiovascular disease (CVD) risk among Hispanics using a structural equation modeling (SEM) approach. Model development was guided by a social ecological framework proposing CVD risk reduction through improvement of protective health behaviors, health beliefs, contextual and social factors. Participants were 328 Hispanic adults with at least one CVD risk factor. SEM analyses assessed direct and indirect effects of intervention participation on CVD risk (Framingham score) and latent variables nutrition intake and health beliefs. The model fit was adequate (root mean square error of approximation = .056 [90% confidence interval = .040, .072], comparative fit index = .967, normed fit index = .938, nonnormed fit index = .947). Intervention participation was associated with improved nutritional consumption, but not lower CVD risk. Stronger health beliefs predicted healthier nutritional habits. This project provided evidence for the adequacy of a conceptual framework that can be used to elicit new pathways toward CVD risk reduction among at-risk Hispanic populations.