Source/Disclosures
sources:
Bender B. Asthma among Dine children living on the Navajo Nation. Presented at: American Thoracic Society International Conference; May 19-24, 2023; Washington, D.C
Disclosures:
Bender reports no relevant financial disclosures. The study was funded by a grant from the National Heart, Lung and Blood Institute.
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Key takeaways:
- Researchers conducted training in Tuba City, Chinle and Fort Defiance/Window Rock.
- Providers said they will use this training to provide asthma care.
- Researchers will soon compile and analyze data on outcomes.
WASHINGTON — Clinical training, community engagement and care coordination aim to improve asthma outcomes among Dine children in the Navajo Nation, according to a presentation at the American Thoracic Society International Conference.
The researchers focused on Tuba City, Chinle and Fort Defiance/Window Rock in implementing their outreach program, Bruce Bender, PhD, pediatric neuropsychologist, National Jewish Health, said during his presentation.
Collaboration between the researchers and community stakeholders was essential to the success of the Navajo Community Asthma Program. Images: Bruce Bender, PhD
“We’re conducting this intervention in three different communities in the Navajo Nation, each distinctly separate, with its own health care system and its own school system,” Bender said.
The Navajo Community Asthma Program provides training and clinic implementation for Indian Health Service primary care providers and staff in the most effective and efficient evidence-based asthma care, Bender said.
Bruce Bender
The program also engages with schools and communities to provide asthma education, help identify undiagnosed asthma and coordinate care with primary care clinics, he continued.
“Our first year of the study was spent building bridges and engaging with the community, including meeting with the leadership,” Bender said. “We spent a lot of time learning about the Navajo Nation and its people and its culture, which was essential to the success of this study.”
The researchers formed community advisory committees in Tuba City, Chinle and Window Rock. They also hired local research staff, which Bender called essential as well.
“We had some excellent staff who are Navajo, who live there, who understand the community and who can easily liaison with families and others in that community,” Bender said.
The researchers trained 51 providers with the Tuba City Regional Healthcare Corporation and 60 providers at the Chinle Comprehensive Healthcare Facility in person between July 2019 and June 2020 in evidence-based asthma care according to National Asthma Education and Prevention Program guidelines.
“That included family physicians, pediatricians, nurses and medical assistants, and actually respiratory therapists who wanted to train as many members of the team as possible,” Bender said. “That went well.”
After suspending training between July 2020 and June 2021 due to the COVID-19 pandemic, the researchers provided virtual training for 13 pediatricians at the Tséhootsooí Medical Center in Fort Defiance between July 2021 and June 2022.
“It was just hard to engage. They were still hesitant because of the pandemic. They lost a lot of providers during that time. They were conducting remote parking lot vaccination clinics. It was hard for them to come back to do this,” Bender said.
Leadership in Fort Defiance suggested the use of virtual training.
“Virtual training for a site like that was much less effective than when we could be there and interact with people,” Bender said.
The researchers also trained 11 community health representatives in Tuba City and 12 in Chinle, but they did not train any in Fort Defiance.
“These are the people who are going to look at airways in the schools,” Bender said.
The researchers trained staff at 13 schools as well, using the American Lung Association’s Asthma 101 curriculum, including 21 personnel in Tuba City, 92 in Chinle and 100 in Fort Defiance. Bender attributed the high participation in Fort Defiance to requirements for staff handed down by the school superintendent.
“The success there was training a lot of people, but again, it was virtual. It was very hard to know how well did we really engage all those people, and how well did the training go,” Bender said.
A select group of personnel in these schools also learned how to conduct Open Airways for Schools training, also from the American Lung Association, so such training could continue once the researchers’ involvement in the program was over.
When surveyed, 91.1% of the health care providers who participated in the training responded with “Good” or “Excellent” to the prompt, “How well did the activity improve your ability to treat or manage your patients?”
Also, 97.8% said they were “Somewhat Likely” or “Extremely Likely” in response to the prompt, “As a result of what I learned, I intend to make changes in my practice.” Among those who said they were somewhat or extremely likely to make changes:
- 52.3% said they would change their screening and prevention practices.
- 38.6% said they would incorporate different diagnostic strategies such as spirometry into patient evaluation.
- 43.2% said they would use alternative communication methodologies such as patient education and shared decision-making with patients and families.
- 30.7% said they would modify their treatment plans.
The health centers in Tuba City and Chinle requested additional training as well.
“As the pandemic was settling down and they were reopening clinics, they said, ‘We want to come back to this, but we need to review spirometry, both methodology and administration, as well as interpretation,” Bender said. “So, we did that.”
The Window Rock Unified School District also asked the researchers to return and restart its Open Airways for Schools program.
“Those were very positive indications of the intention of these communities to proceed with the program,” Bender said.
While this training was underground, the researchers also conducted remote family interviews and remote meetings with their community advisory committees, chapter houses, and the Navajo Nation Human Research Review Board.
“Then we did something else different that I thought actually turned out really well,” Bender said.
During the pandemic, the researchers recorded a radio program explaining the project and taking questions from the community. Two radio stations in the Navajo Nation then ran the program six times each.
“The purpose being to make sure people understood we hadn’t stopped, we weren’t quitting, and we were coming back,” Bender said.
The researchers are not done with their work, Bender said. They are analyzing data on primary outcomes, exacerbations, hospitalizations, urgent care visits and oral steroid bursts from the Navajo Nation’s Immune Health Service databases, since the Immune Health Service is the only provider that includes everyone in the community.
Also, the researchers will analyze adherence to guidelines and results from family interviews.
“We’ve interviewed 196 families with a child with asthma, and we interview annually to understand what’s happening with the asthma, is the child doing better, are they doing worse, and how does the family perceive the care they’re getting from the health care centers as well as the support they’re getting from schools,” Bender said.
The researchers plan to complete their collection by the end of this month with all data final as of July 1, Bender said, and begin their final analysis. They also will share their findings with the Navajo Nation Institutional Review Board and the Data and Safety Monitoring Board.
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