ASTHMASEVERITYDETERMINANTSANDNEEDSASSESSMENTINCHILDRENLIVINGONTHENAVAJONATION:APILOTSTUDY

ASHLEYA.LOWE,PHDSTUDENT|UNIVERSITYOFARIZONA

WITHGRATITUDE,WETHANKTHEINDIVIDUALS&COLLABORATORSWHOBROUGHTTHEIRGUIDANCE,EXPERTISE&RESOURCESTOTHISPROJECT

o NavajoNation• NavajoNationHumanResearchReviewBoard(NNHRRB)• PeterNez• CarolGoldtooth Begay• TubaCityRegionalHealthCareCenter,Chinle ComprehensiveHealthCareCenter,&Tsehootsooi MedicalCenter• NavajoEpidemiologyCenter• CommunitymembersofTubaCity,AZ;Chinle,AZ;FortDefiance,AZ;&WindowRock,AZ

o NorthernArizonaAHEC(NAHEC)• SeanClendaniel,MPH,ExecutiveDirector

o UniversityofArizona• NativeAmericanResearchTrainingCenter(NARTC)• DesireeJones,ChantalNez,&JanettePriefert

WHATWEWILLDISCUSSTODAY

o Background

• ChildhoodasthmaontheNavajoNation

• Asthmabasics

o Discussionswithfamilieslivingonthereservation[NNR‐16‐247]

• Semi‐structuredinterviews(i.e.,Standardizedquestionnaires&Qualitativediscussions)

• TubaCity,AZ(n=13)

o Futuredirections

• CollaborationwithNavajoNation,NationalJewishHealth&UniversityofArizona

WHYASTHMAONNAVAJO?

“Ifeelhelpless...Iask,whyus?Itrytounderstanditandjustdealwithit.There’saprocess...withdealingwithit.”

~NavajoMother~

ASTHMA’SIMPACTONNAVAJOFAMILIESLIVINGONTHERESERVATION

o AsthmaPrevalence

• 10%ofU.S.children

• Approximately20%ofNavajochildren

livingonthereservation

o AsthmaSeverity

• ↑EmergencyDepartment(ED)visits

• ↑Overnighthospitalizations

WHATISASTHMA?

o Chronic,inflammatorylungdiseasethatoftenbeginsduringchildhood

ASTHMASIGNS&SYMPTOMS

oMayincludeANYofthefollowing:• Coughing

• Chesttightness/Chestretractions

• Wheezing/Whistlinginthechest

• Shortnessofbreath/Struggling‐to‐breathe/Shallowbreathing

• Difficultyspeaking

• Noisybreathing/Breathinghardorfast

• Nasalflaring

• Bluenessaroundthelipsorfingernails`

COMMONASTHMATRIGGERS

LITERATUREREVIEWo EnvironmentalconcernsforchildrenwithasthmaontheNavajoNation

• SystematicIntegrativeLiteratureReview• Primarysearchtermsincluded“Asthma”AND“Navajo”OR“Navaho”OR“Diné”or“Dineh”• 7EnvironmentalRiskDomains:

1. Woodburningstove2. Indoorstoveheating3. CommercialtobaccosmokeORMountainsmoke4. Indoorallergens5. Coal‐firedpowerplantsANDmining6. Desertification,DesertduststormeventsORWildfireseverity7. Dieselexhaustexposure

• Only4 articleswerespecifictotheNavajoNation

o Findings• Environmentalinjusticeshavehistorically,disproportionatelyandsystematicallyaffectedFirstNationpopulationsincludingNavajo

• Someexposuresarewellrecognized(i.e.,woodburningstoves,coal,duststorms,&wildfires)• Otherexposuresareless recognizedbuteasilymodifiable(e.g.,dieselexhaustfromschoolsbusses)

DISCUSSIONSWITHFAMILIESLIVINGONTHENAVAJORESERVATION

o TubaCity,AZ• TubaCityRegionalHealthCareCenter• October2016

o Interviewed13familieswithchildrenwithasthma• Recruitedbyprimarycarephysicians(PCP)• 11Navajofamilies&2Hopifamilies(n=13)

o Conductedsemi‐structuredinterviews• Standardizedasthmaquestionnaires• Qualitativequestions

ASTHMASURVEYS

o Childhoodasthmaquestionnaires• PediatricAsthmaCaregiver’sQualityofLifeQuestionnaire• ChildhoodAsthmaControlTestforChildren4‐11years

o Additionalquestionsregardingasthmaseverity

o Findings• Children’sagerange(7‐16years)• 47%male• Parentsreportedgoodasthmacontrol(meanChildhoodAsthmaControlTestscore=21.6)• 58.8%ofchildrenhadanasthmaepisodeduringpastyear• 47%ofchildrenhadbeenhospitalizedduringpastyear

QUALITATIVEQUESTIONS:ASTHMACARE

“Thehealthcareprovidersneedtoexplaintome– whyisprednisonebad?Ineedtoknowwhy.”

~NavajoParent~

PRIMARYASTHMACARE

o Healthcareneeds

• Asthmamedicationsaredifficulttorefill

• Healthcareprovidersneedtoexplain

thediseaseprocess&options

• Parentsrequestedmoreasthma

education&communityawareness

“Weburncoalinsideandthereisatamarackgrovebehindourhouse– thepollenisbad.But,thenyoudriveandseepollution.”

~Navajo/HopiParent~

QUALITATIVEQUESTIONS:ENVIRONMENT

o Environmentalconcerns

• Burningwood&coalinsidethehouse

• Blowingdust,dirt,finesand&wildfires

• Uranium&coalmining/Coal‐burning

powerplants

• Animals

• Mold

o Suggestionsbyparents

• Airpurifiers/filtersinthehome

ENVIRONMENT

“Mydaughtercouldn’tcarryherinhalerbecausethenurselockeditaway.Butthenshecouldn’tbreatheandthenursewasatlunch.Thenursewastheonlypersonwithakeytothatcabinet.”

~NavajoMother~

QUALITATIVEQUESTIONS:SCHOOLS

o Familiesexpressedmanyneedsfortheir

childatschool

• Moreawareness/asthmaeducationforschool

principals,teachers&coaches

• Asthmaprotocolforemergencies

• Accesstoasthmamedications

• Asthmatriggers

SCHOOLS

NEXTSTEPS

o Reducechildhoodasthmadisparities

• 6‐yearNIH‐fundedpartnershipwiththeNavajo

Nation,NationalJewishHealth&Universityof

Arizona

• Workwith3Navajocommunities:TubaCity,AZ;

Chinle,AZ;&FortDefiance,AZ

• IHSfacilities,NavajoEpidemiologyCenter,Schools&

ChapterHouses

ANASTHMACOLLABORATIONTOREDUCECHILDHOODASTHMADISPARITIESONTHENAVAJONATION

o ResearchTeam

• HannaPhan,PharmD,FCCP

• WayneMorgan,M.D.

• LynnB.Gerald,Ph.D.,M.S.P.H

• BruceBender,Ph.D.

• PeterNez,NavajoNation

• Teshia Solomon,Ph.D.

• AaronKobernick,M.D.,M.P.H.

• AndyLiu,M.D

QUESTIONS?

Correlations between immunologic alterations and metal exposure within the Navajo Birth Cohort StudyPresented by Jennifer Ong and Shea McClain

• Funding:• Navajo Birth Cohort Study (supports collection of Navajo Nation samples and biomonitoring

data) CDC/ATSDR 5 U01 TS 000135. Content of presentation is solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.

• NIH P50 ES026102 Environmental Health Equity Center supported the phenotypic studies presented here.

Community Environmental Health ProgramDepartment of Pharmaceutical SciencesUNM Health Science Center College of Pharmacy

WITH ACKNOWLEDGEMENT AND THANKS TO OUR TEAM!And thank you to the many others who have contributed and supported this work!

The people of the Navajo Nation:• > 2000 Navajo families • Many supporting chapters• HEHSC, Tribal and Agency Councils, Executive Branch,

NNEPA, GIB• NAIHS & PL-638 hospital laboratory staff, leadership, and

health boards

Our funders:• NIEHS (16 yrs)• CDC/ATSDR (5 yrs)• USEPA Region 9 Superfund Emergency Response (4yrs)• NIMHHD (4 yrs)• NNEPA (1 yr)• NIAAA (4 yrs)• NIGMS K12 (3 yrs)• UNM-COP• UNM-CTSC• NSF-EPSCOR• EPA• NIH-OD

• Research reported here was supported by the National Institute Of Environmental Health Sciences of the National Institutes of Health under Award Number P42ES025589. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

• DiNEH and NBCS Research is reviewed and monitored by Navajo Nation Human Research Review Board

DiNEH, NBCS, & NBCS/EHCO TeamsUNM-HSCJohnnye Lewis, Ph.D.David Begay, Ph.D.Curtis Miller, Ph.D.Eszter Erdei, Ph.D.Courtney Burnette, Ph.D.Laurie Hudson, Ph.D.Debra MacKenzie, Ph.D.Lauren Hund, Ph.D.Karen Cooper, Ph.D.Matt Campen, Ph.D.Jim Liu, Ph.D.Chris Vining, MS, SLPBecky SmithCarla ChavezMiranda CajeroBernadette PachecoJennifer OngMalcolm BenallyCJ LaseluteMalcolm BenallyElena O’Donald, Ph.D.Molly Harmon, Ph.D.Joseph Hoover, Ph.D.Vanessa De La Rosa, Ph.D.Erica Dashner, Ph.D.Sara Nozadi, Ph.D.Tim Ozechowski, Ph.D.Ji-Hyun Lee, Ph.D.Li Luo, Ph.D.Rufei Du, Ph.D.Shea McClainMallery Quetawki (artist-in-residence)Priscilla BegayBenita BrownShasity Tsosie

SRICChris Shuey, MPHLynda LasilooSandy RamoneTeddy NezMaria WelchMonique Tsosie

CDC/ATSDR/DLS/IRATAngela Ragin-Wilson, Ph.D. Candis Hunter, MSPHElizabeth Irvin-Barnwell, Ph.D. Kathleen Caldwell, Ph.D.Cynthia Weekfall

NAIHS Doug Peter, M.D.Johnna Rogers, RNUrsula Knoki-Wilson, CNM, MSNCharlotte Swindal, CNM, RNDiedre SamMarcia TapahaFrancine BegayMyra FranciscoLeShelly Crank

PL-638 HOSPITALSDelila BegayAbigail Sanders

UCSFBennett Leventhal, MDYoung Shin Kim, MD, Ph.D.Somer Bishop, Ph.D.

CONSULTANTSPerry CharleyAdrienne Ettinger, Ph.D.

Navajo NationNNDOHMae-Gilene BegayAnna RondonQutarah AndersonRoxanne ThompsonMelissa SamuelDoris TsinnijinnieJosey WatsonNikki BegayAnita Muneta

NNEPADonald Benn, Ph.D.Stephen EtsittyYolanda BarneyFreida WhiteChandra ManandharVivian CraigEugenia Quintana

USEPA – Region 9Clancy TenleyLinda ReevesHarry AllenRich Bauer

(Navajo Team Members)Community Environmental Health Program

2

Exposure to uranium on Navajo

521 abandoned U mines; >1100 of 10,400 waste sites identified in western USMultiple metals and metalloidsMultiple pathways:Consumption of local water and crops,Contact with contaminated soil and dustInhalation of metals released from combustion for home heatingDrinking water

Map of arsenic (A) and uranium (B) concentrations in Navajo Nation water sources and their proximity to mining areas

(A)

(B)

15% > MCL

13% > MCL

Presence of environmental

metals

Dearth of toxicity

knowledge

Unique exposure pathways

Adverse health effects/health

disparities

Disparities in care

Immune system?

Complex network of cells and organs that work together to protect the body from infection

1) Thymus: Formation of T cells2) Tonsils/Adenoids: Distinguish

invaders for destruction3) Spleen: Filters blood and

distributes T and B cells 4) Lymph Glands: Storage and white

blood cell formation 5) Bone Marrow: B cells are

produced in bone marrow

What is “immune system”?

When infections are present, the cells of the immune system work together to help eradicate the pathogen (such as bacteria or viruses).

CD4 or “helper” cell-Facilitates the activity of other immune cells

CD8 or “killer” cell-kills infected cells after activation by “helpers”

B cell-makes antibodies

Antibodies are produced after infection or vaccination and provide long-term protection

NK cells-kill cells that are infected or foreign (i.e. do not belong).

Introducing some of the key players--

Immune alteration/dysr

egulation

Immune Activation

Chronic inflammation

Autoimmune disease

Immune Suppression

Chronic infection Cancer

Environmental metal exposure??

SignificanceToxicity to immune system can lead to adverse health outcomes

Hypothesis- Chronic low-level environmental exposure to metal mixtures from contributes to immune system dysregulation.

To begin to address this complex question-we can measure immune cell populations to see if there are changes in the numbers of the different types of cells

Experimental Approach

• Measure lymphocyte populations from blood samples from NBCS mothers.

• Perform preliminary statistical analysis to determine if associations are seen between immune cell populations and the following metals as detected in the blood or urine from participants.

• Metals: arsenic, cadmium, mercury, manganese, uranium and zinc• Statistical approaches: Spearman correlations and multivariable regression

analysis

How do we measure different cell types?

Changes in cell populations are observed in association with metal exposures

Cell population affected Metal Statistical Approach

Total # of immune cells Uranium, arsenic, manganese Multivariable, Spearman (Mn)

Total # of T cells Uranium, arsenic, cadmium Multivariable

# of activated CD4 cells(HELPER cells)

Cadmium Multivariable

# of CD8 cells(KILLER cells)

Cadmium Multivariable, Spearman

# of activated B cells(ANTIBODY Producing Cells)

Manganese Multivariable, Spearman

# of NK cells(NATURAL KILLER cells)

Uranium, arsenic, manganese, cadmium

Multivariable, Spearman (Mn)

Conclusions

• Several associations are seen between concentrations of metals and increases or decreases in immune cell populations in the blood of participants in the NBCS.

Importance

• Changes in populations of immune cells can lead to changes in immune functions.

• Immune dysregulation can lead to increased infections, autoimmune responses, and cancer.

Next Steps

• Examine immune cell data along with other immune system markers• Consider the effects of metal mixtures on these populations• Incorporate demographics, dust, and survey data into statistical modeling to

see if there are significant differences in immune cell populations based on this information

Development of a Physical Activity Intervention for Navajo Cancer

Survivors

Jennifer Bea, PhDEtta Yazzie, RN

Dirk de Heer, PhDAnna Schwartz, PhD

Taylor Lane, MA

Funded by NCI: U54 CA143925-06; NNHRRB #: NNR14.192

Overview

Background: Native Americans and Cancer

Perceptions of cancer among Navajo cancer survivors

Intervention Description & Progress Update

Future Directions

American Indians (AI) and Cancer

↓ cancer mortality for White populations, ↑ for AI/AN men and women, 2001 to 2009 (CDC, 2016)

AI/AN lowest 5-year survival rates of any group (59.0%) and only group w/o reductions in cancer mortality from 2001 to 2010 (Siegel, Ma, Zou, & Jemal, 2014).

Most common cancers among AI/AN: Lung, female breast, colorectal and prostate cancer Death rates for some more common among Native populations

(gallbladder, stomach, liver, and kidney cancers) (White et al., 2014).

Cancer is 2nd leading cause of death among Navajo Overall

Crude all-cause mortality rate is 32% higher for males than females. Unintentional Injuries account for nearly 1 in every 5 Navajo deaths. There are nearly 33% more Unintentional Injury deaths than Cancer deaths and 35.5% more than Heart Disease deaths; Foley et al. Navajo Nation Mortality Report, 2006-2009. Navajo Epidemiology Center. 2016.

Project Overview:Two-phased Pilot Study

Phase I (year 1-2): Qualitative Study:AIM 1: Assess current physical activity habits, barriers, and preferences among Navajo cancer survivors using a combination of focus groups and individual interviews

Phase II (years 2-3): Pilot Physical Activity InterventionAIM 2: Evaluate the feasibility and effectiveness of a culturally and clinically sensitive physical activity intervention among Navajo cancer survivors

Recruitment

5 focus groups (N=4 Rural Chapter, 1 Flagstaff)

13 individual interviews (N=11 Flagstaff) 32 Navajo cancer survivors 8 relatives/ spouses/ close friendsAdultsMales and femalesAny prior cancer

Focus group/Interview Flow

Focus groups included Navajo-speaking oncology nurse

Began with Navajo introductions Study explanation and Q/A Consent Discussion guide questions Gratitude and Closing

Characteristics of Navajo cancer survivors participating in focus groups and interviews (N=32)

Characteristic Mean or N SD or %Age, years 56.9 12.3Sex

Male 13 41%Female 19 59%

Primary LanguageEnglish 30 94%Navajo 2 6%

Cancer SiteBreast 10 31%Colon 10 31%Gynecologic, excl. breasta 3 9%Gastrointestinal, excl. colonb 5 16%Otherc 4 13%

Time since diagnosis, yearsd 4.7 4.7aGynecologic, excluding breast cancer, represents ovarian and cervical cancers; bgastrointestinal, excluding colon, represents esophageal, gall bladder, and stomach; cprostate, kidney, hematologic cancers; dbased on year of diagnosis by self report not exact date Missing data: Age: 3; Time since diagnosis: 7;

Project Overview:Two-phased Pilot Study (3 years)

Phase I (year 1): Qualitative Study:AIM 1: Assess current physical activity habits, barriers, and preferences among Navajo cancer survivors using a combination of focus groups and individual interviews

Phase II (years 2-3): Pilot Physical Activity InterventionAIM 2: Evaluate the feasibility and effectiveness of a culturally and clinically sensitive physical activity intervention among Navajo cancer survivors

Physical Activity (PA) and Cancer

Up to 30-60% reduction cancer recurrence and mortality 2,3,4

Improved fatigue, quality of life, body composition, body image, & physical function among survivors 5

How much physical activity to reduce risk for colorectal and breast cancer? Activity at moderate intensity (>4.5 MET) Approx. 3-4 hours per week 6

None of these physical activity interventions among Native American Cancer Survivors

1 Moore JAMA Int Med 2016; 2Irwin Cancer Prev Res 2011; 3Irwin J Clin Oncol 2008; 4 Meyerhardt J Clin Oncol 2006; 5Schmitz Med Sci Sports Exerc 2010; 6Wolin et al., 2009

Components of Physical Activity (US PA Guidelines and ACSM Cancer Survivor Guidelines)

Aerobic/Endurance Training 150min Moderate OR 75 min Vigorous per week OR…An equivalent mix of the two

Strengthening 2 days per week (non-consecutive days per muscle) major muscle groups 2 sets, 8-15 reps (depending on age and health)

Stretching 3-5 times on days that other exercises are performed 10 to 30 seconds each

Balance Training 2 sets 8-15 reps for strengthening styles Pure balance—increase time as you progress (i.e. 1 foot stand)

US Physical Activity Guidelines Advisory Committee Report 2008; Schmitz KH, Courneya KS, Matthews C, et al. ACSM roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010;42(7):1409‐1426.

Design Phase IIRestoring Balance

- Culturally relevant incentives for participation.

- Appropriate exercise for the community setting and participants

- focus on walking and resistance exercise, can be performed without

equipment- Community and peer support

- Cancer-relatededucational materials.

Restoring Balance Program

Preliminary Baseline Characteristics

N=13 Navajo cancer survivors have 5 breast, 3 colon/gastric, 2 uterine/ovarian, 2 multiple myeloma, 1 other cancer

Sex: 3M/10F Age: 55.5 years ±10.4

BMI: 31.2kg/m2±4.3 Body fat: 42.7%±10.5 Waist Circumference:

99.3cm±29.1 HbA1c: 6.8±2.0 6min walk: 0.21mi±0.1 PROMIS QOL

3.0±0.88 PROMIS social

isolation: 1.82±0.81For: American Indian Science and Engineering Society National, Conference, Sept. Denver, Co.

Intervention Status

Recruitment ongoing in Flagstaff and LeuppWorking on further expansionMeasurements ongoing Physical activity ongoing Final pilot measurements expected this Fall

Intervention Support

Native Americans for Community Action Facilitated by outreach Well positioned to facilitate intervention implementation Dedicated and convenient exercise space Trainers for supervision, goal setting, encouragement Space for NAU/UA researchers to conduct measurements

Arizona Oncology Associates Recruitment Space to screen and consent

NCI, NACP, NAU IRB (phase 1), UA IRB (phase 2 and full), Chapter House, Western Agency Council, NNHRRB, NACA board, NDOH,

And Growing……………

Important Lessons for Tribal Research

Design research that supports tribal goals Engage local partners in the research Ensure the research will benefit the community

during the research process, not just afterwards Expand typical direct dissemination efforts Build community relationships Build community capacity Map out your timeline based on community

meetings and approval processes

Acknowledgements

NACP Training Outreach Evaluation Development

NAU Dirk de Heer, PhD, MPH Anna Schwartz, PhD, FNP Chris Repka, PhD Brian Kinslow, BS, SPT, CSCS Stephanie Muther, BS, SPT Rachel Sleeman, BS, SPT Clyde Yellowhair, BS, SPT Shelby Dalgai, BS Pearl Nez Kaitlyn Haskie (Training) Jayme Biakeddy, BS (Training) Alaitia Enjady, BS, SPT

UA Jennifer Bea, PhD Etta Yazzie, RN Luis Valdez, MA Mark Lee Ashlee Irving Ravina Thuraisingam

Bridges to Baccalaureate Shauntey Cleveland, RN (NPC, IHS) Wyatt Betoney (Dine) Jenille Montelongo-Rodriguez (CCC)

Navajo Nation HRRB Chapter House Navajo Nation Western Agency Council Arizona Oncology Associates Native Americans for Community Action

Screening Handout

General Disease Prevention with Exercise

Cancer Exercise Guidelines

Goal Setting Support

Community Relations & Capacity Building

Training and financial support of Native students in cancer prevention research

Training non-Native students, faculty, staff in working with Native populations

Chapter & Western Agency Council Navajo Epidemiology Department NNHRRB NACA Contract Training to expand local, sustainable expertise

Arizona Oncology Associates

Funding Sources

NIH/NCI: U54CA143924 NIH/NCI: P30CA023074 University of Arizona Faculty Seed Grant Undergraduate Biology Research Program HHMI

52006942 Northern Arizona University BRIDGES to

Baccalaureate NIGMS1R25GM102788-01 UA Medical Student Research Training Grant

(NIH #T35HL007479)

Extra slides

Timelines and Planning

Determine which entities must approve your research, when they meet, and what forms and processes they require

Stay up to date on tribal requirements Example: Navajo Western Agency council requirement was added 2016

WAC Meetings are quarterly (in rotating locations) Understand process to get on agenda; need a sponsor at the meeting

Determine order of approval: For Navajo, gain university IRB and local entities approval first Other tribes may differ

Complete tribal IRB forms/paperwork in addition to university forms and submit to appropriate IRB Check submission dates, meeting dates, submission format (ie. hard copy) Travel to IRB meetings for project approval, amendments, annual reports,

closure, manuscripts, presentations Plan for revisions and resubmission to both university and tribal IRBs

DG Part I: defining cancer

How would you define cancer?

How did you learn about cancer?

Do you think cancer is a problem for people of Navajo background? Do you think this has changed over the past years? If yes, why do you think this is?

DG Part II: knowledge of causes, contributors to cancer and prevention and treatment

What do you think are the main causes of cancer?

How did you find out about these causes?

What do you think is the most important cause or contributor to cancer? If you were to rank all the factors you mentioned, what would be the most important and least important in your opinion?

Are there any other contributors to cancer?

Part II: knowledge of causes, contributors to cancer and prevention and treatment

Do you think cancer can be prevented? If so, how?

Do you think lifestyle choices such as diet and physical activity impact getting cancer?

Do you think cancer can be treated well?

What do you think are important factors in cancer coming back after treatment?

Do you think physical activity and other lifestyle factors impact cancer coming back?

Rigor Category NACP Pilot Study Phase II

Scientific Premise -Cancer 1st or 2nd cause of death among Native Americans 45-641

-Disparities in survival rates1,2

-Most common Navajo cancers positively affected by PA in other populations-No PA interventions among Navajo cancer survivors to date-Feasibility study needed to formulate rigorous full study

Scientific Rigor (design) -Randomized controlled trial w/ repeated measures-National cancer exercise guidelines, adapted for cultural factors based on rigorous qualitative study-standardized, bilingual intervention delivery and data collection (feasibility, QOL, PA, biomarkers)-community capacity building to enhance sustainability, recruitment, retention-objective measure of PA, metabolic changes, body habitus-gold standard QOL survey (PROMIS)

Biological Variables -Sex, age, wt, & underlying health conditions captured in survey and accounted for in analyses-limited to Navajo background-Tx & cancer stage by survey, no medical record review; limited power.

Authentication -biomarkers measured B, 6, 12, 18wks; periodicity aligned with detection limits of PA related physiological changes -HbA1c valid and reliable marker of change in metabolic function; portability key so not venipuncture-anthropometric measures valid and reliable markers of change in body habitus; gold standard imaging not feasible

2010 ACSM & 2012 ACS

Cancer-specific resistance training: Recommendations do not need to be modified for prostate, colon, and hematologic cancers Breast: start with a supervised program of at least 16

sessions at a very low resistance; progress resistance at small increments

Prostate: add pelvic floor exercises for those who undergo radical prostatectomy

Colon: for patients with a stoma, start with low resistance and progress slowly to avoid herniation at the stoma

For bone marrow transplant patients, resistance training may be more beneficial than aerobic activity

Slide courtesy of Dr. David Garcia. Schmitz KH, et al. ACSM roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010;42(7):1409‐1426. Rock CL, et al. Nutrition and physical activity guidelines for cancer survivors. CA Cancer J Clin. 2012;62(4): 242‐274.

Cancer‐Specific Safety Precautions

ACSM report identified safety cautions for survivors at risk for lymphedema and skeletal muscle fractures or infections Arm and shoulder problems secondary to breast cancer

treatment, ostomy after colon cancer, or swelling/ inflammation in the abdomen, groin, or lower extremity following gynecologic cancer

Risks of participating in physical activity must be balanced against the risks of inactivity PA reduces the incidence and severity of lymphedema

Slide courtesy of Dr. David Garcia. Schmitz KH, Courneya KS, Matthews C, et al. ACSM roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010;42(7):1409‐1426. Schmitz KH. Balancing lymphedema risk: exercise versus deconditioning for breast cancer survivors. Exerc Sport Sci Rev. 2010;38(1):17‐24.

Intervention Mapping

Framework

Theoretical Construct

Intervention Objectives

Strategies for weekly group sessions

Strategies for individual activities

PEN‐3 and HBM

Perceptions Reinforce accurate beliefs about cancer causes, environmental and behavioral factors.

Reduce inaccurate beliefs about cancer.

Improve understanding of quantity and intensity of physical activity during and after cancer treatment.

Provide education about cancer in Navajo and English.

Challenge fatalism and stoicism towards treatment and health post‐diagnosis.

Promote ethnic pride and alignment of health and balance with cultural beliefs.

Skill building/health coaching to increase perceived control over health.

Personalize the education depending on individuals’ beliefs and level of knowledge.

Framework

Theor. Construct

Intervention Objectives Strategies for weekly group sessions

Strategies for individual activities

PEN‐3 and HBM

Enablers (PEN‐3)/ Perceived Barriers (HBM)

Decrease structural barriers to seeking treatment where possible (financial, logistic, cultural).

Decrease fear about screening and finding out test results.

Promote knowledge regarding the US healthcare system, what services are available and where to access services.

Reinforce trust of community health representatives.

Improve skills to promote communication with healthcare providers and family members about cancer.

Discuss healthy changes that are possible within structural limitations.

Disseminate information about screening recommendations, where to seek treatment and services for translation and patient navigation.

Challenge negative beliefs about screening and learning about results.

Practice communication with medical providers (role‐playing).

Practice goal setting and self‐monitoring as effective techniques for improving diet and physical activity.

Highlight culminating event to facilitate behavioral strategies of (goal‐setting/self‐monitoring).

Review individual structural barriers and ways to address them.

Engage in personalized goal‐setting based on individuals’ activity level.

Review home‐based program activities based on activity monitors.

Practice communication with health provider one‐on‐one for issues participants are not comfortable discussing in group setting.

Reinforce progress towards individual goals and ability to self‐monitor.

Intervention Mapping Cont.Framework

Theoretical Construct

Intervention Objectives Strategies for weekly group sessions

Strategies for individual activities

PEN‐3 Nurturers 

Supportive and/or discouraging influences of families and friends including eating tradition, community and events, spirituality and soul, values of friends.

Reinforce the value of traditional foods and physical activity in cancer, prevention of other chronic disease and overall quality of life.

Reinforce cultural beliefs of restoring balance and aerobic physical activity.

Emphasize importance of and provide skills needed to seek social support.

Reinforce the importance of information about cancer for family members, including appropriate PA recommendations for survivors.

Provide social support of fellow participants due to shared experiences and success/learned lessons; draw on prior successes.

Discuss cultural aspects of balance, health, physical activity and dietary habits.

Emphasize importance of gaining knowledge for dissemination to other family members (who are generally at elevated risk for cancer).

Provide real‐life examples of coping strategies.

Reinforce ability and importance of seeking and providing support.

Provide individualized education based on cultural and clinical knowledge of cancer.

Review success in employing coping strategies.

Intervention Mapping Cont.

Framework

Theoretical Construct

Intervention Objectives

Strategies for weekly group sessions

Strategies for individual activities

HBM Perceived Susceptibility

Reinforce accurate beliefs about susceptibility.

Reduce fatalism about diagnosis.

Provide and discuss culturally and clinically relevant educational materials about susceptibility, screening and physical activity recommendations for cancer survivors.

Review knowledge of physical activity recommendations during and after treatment (back‐teaching)

Review benefits of activity for each individual based on type of cancer.

Intervention Mapping Cont.

Framework

Theoretical Construct

Intervention Objectives Strategies for weekly group sessions

Strategies for individual activities

HBM Perceived Severity

Provide information that although cancer is a serious condition, survival rates of many cancers have improved, particularly with early diagnosis and adequate treatment. 

Develop list of pros/cons of engaging in regular screening, physical activity and healthy/traditional diet, and discuss reasons and consequences of engaging in healthy behaviors.

Challenge inaccurate beliefs, reinforce accurate beliefs.

Intervention Mapping Cont.Framework

Theoretical Construct

Intervention Objectives Strategies for weekly group sessions

Strategies for individual activities

HBM Perceived Benefits

Emphasize the role of physical activity for 13 different cancer types and in recurrence for several cancers.

Emphasize benefits of physical activity for fatigue and quality of life. 

Emphasize the importance of early detection and following treatment and screening recommendations for patient and family members.

Improve knowledge of adequate intensity required to achieve protective benefits.

Provide culturally appropriate education to survivors and family/community members on the importance of activity for cancer prevention and control, fatigue and quality of life.

Group discussion on benefits of early detection.

Group discussion on health behaviors currently engaged in/successful changes made in the past. 

Reinforce accurate individual beliefs, challenge inaccurate beliefs.

Review individual list of pros and cons and emphasize individual reason for engaging in healthy behaviors and personal control.

Intervention Mapping Cont.

Framework

Theoretical Construct

Intervention Objectives Strategies for weekly group sessions

Strategies for individual activities

HBM Self‐Efficacy

Promote self‐efficacy for secondary cancer prevention. 

Promote self‐efficacy to engage in behavioral strategies of physical activity and other health behaviors.

Promote sense of self‐control to improve quality of life and cancer fatigue.

Promote ability to seek and utilize resources.

Provide information on baseline activity status and progress towards goals.

Empower participants to take control of their own health.

Group discussion on successes achieved to overcome health challenges (e.g. treatment side effects) during and post‐treatment.

Emphasize opportunity for participants to improve experiences of other family/community members.

Share successes at the group level.

Positive reinforcement of healthy behaviors; draw upon strengths and successes.

Reduce anxiety or discomfort associated with changes.

Timeline Phase II

May 2016UA IRB approvalChapter resolution

June 2016Western Agency Council approval

July 2016 NNHRRB provisional approval

Phase II

Aug. 2016 cont. revision requests

UA, NNHRRB

Recruitment, Intervention, data collection

ApprovalsMultiple Entities, Revisions, etc.

Spring 2017 Intervention

Cohort II

Analysis

Oct/Nov. 2016 NACA contract

Summer 2017Dissemination

Phase II

Fall 2016Intervention

Cohort I

Emergency Department Non‐Targeted Diabetes Screening Identifies High Rates DiseaseERIK ANDERSON, CHANDIMA DEEGALA, DANIEL DWORKIS,  KIMBERLY MOHS

NORTHERN NAVAJO MEDICAL CENTER, SHIPROCK, NM

BackgroundAI/AN Mortality rates from DM are 177% higher than all U.S. races 

One in three people in the U.S. will develop diabetes◦ 70‐90% of people with prediabetes will go on to develop diabetes

A1c simplifies diagnostic protocols◦ A1c ≥ 6.5 = Diabetes◦ A1c 5.7‐6.4 = Prediabetes

American Diabetes Association recommends A1c testing twice a year in controlled patients, and every 3 months in patients without control

BackgroundThere are 40 IHS EDs that see ~640,000 patients per year. 

EDs act as a safety net for variety of medical and social needs, including access to preventative care services

ED patients have been found to have high rates of undiagnosed diabetes; and those with a prior diagnosis of diabetes have suboptimal control

MethodsCohort study of patients screened in ED as part of a non‐mandated clinical protocol

12 week study period 

Geospatial analysis◦ Included communities where >10 unique patients visited ED

Screening EligibilityInclusion Criteria:◦ All patients undergoing blood draws in the ED over 18 years old

Exclusion Criteria:◦ POC testing performed in Fast Track/Urgent Care

Screening and Linkage ProcessNon‐targeted screening utilizing using bundled lab testing◦ Lab alert if A1c performed within 75 days

Notification to patients in discharge instructions

Weekly downloads of results, all new diagnoses sent to diabetes clinic

Letter sent to all patients with A1c ≥ 5.7 to attend Diabetes Education Class

8,280 Patients presented to the 

ED

2,297 (28%) patients had blood 

drawn

1,026 (45%) had an A1c test performed

341 (33%) patients A1c ≥6.5; 370 

(36%) patients A1c 5.7‐6.5

Results

341 patients A1c ≥ 6.5 

50 (15%) patients previously 

undiagnosed

• 4 patients per week newly diagnosed with Diabetes

Previously undiagnosed Diabetes

Previously Undiagnosed Prediabetes

370 patients A1c 5.7‐6.4 

310 (84%) patients previously 

undiagnosed

• 26 patients per week newly diagnosed with Prediabetes

ResultsAll PatientsN = 1,026

Previous diagnosisN = 355

PreviouslyundiagnosedN = 671

P value

Median A1c (IQR)

6 (5.5‐7.3) 9 (6.8‐11) 5.7 (5.4‐6)

Age (mean) 49.8 58.6 44.6 P<0.001

Femalegender (%)

551 (54%) 210 (59%) 341 (51%) P=0.015

Designated PCP

523 (51%) 265 (75%) 258 (38%) P<0.001

New Dx

Prev. Dx

Density Plot of A1C Levels Stratified by New and Prior Diagnoses

Geospatial Analysis794 unique visits from Communities where >10 patients visited NNMC ED

Community Visits

SHIPROCK 302FARMINGTON 128SANOSTEE 36KIRTLAND 34HOGBACK 32BLOOMFIELD 28TEEC NOS POS‐AZ 27NEWCOMB 19RED VALLEY/RED ROCK 19SWEETWATER 18CORTEZ 17MITTON ROCK 16ROCK POINT 16BECLABITO 14FRUITLAND 14NENAHNEZAD 14GADII'AHI 13TWO GREY HILLS 13AZTEC 12UPPER FRUITLAND 11WATERFLOW 11

A1c Level

Unique Patients From Most Common Communities

A1c Level

New Dx

Prev. Dx

Unique Patients From Most Common Communities Stratified by New and Prior Diagnoses

Discussion and Benefits to Navajo Nation NNMC ED patients have high rates of undiagnosed prediabetes and diabetes

Majority of patients newly identified are prediabetic◦ Represent important opportunity for intervention

Patients with known diagnosis of diabetes were sub‐optimally controlled◦ Diabetes education could take place in ED

Discussion and Benefits to Navajo Nation There were several communities that were outliers in our sample◦ Opportunity for targeted health and wellness interventions◦ What makes certain communities more vulnerable?

ED screening disproportionately identifies younger patients without designated PCPs

Diné Perceptions of Forest Use under Climate Change

Jaime Yazzie, Yeon‐Su KimSchool of Forestry, Northern Arizona University, Flagstaff, AZ

10/25/2017 Jaime Yazzie, NAU School of Forestry

Ya’at’eeh

Taken by Jaime Yazzie10/25/2017 Jaime Yazzie, NAU School of Forestry

Principal Investigator: Jaime Yazzie (Dine’), Yeon‐Su Kim, School of Forestry, Northern Arizona University, PO Box 15018, Flagstaff AZ 86011. joy2@nau.edu

Tribal partners: Navajo Nation, Chapter Officials, Melva James

Funding Source: Intertribal Timber Council/USFS Natural Resources Research Scholarship, UofA Native Nations Institute

Timeline: 2015‐2018

Diné Bikeyah

Territory: 17,544,482 acres•Over 333,000 enrolled members•~173,667 people living on NN

Navajo Forestry Department •Coniferous Forest: 594,728 acres •Woodlands: 4,818,815 acres

10/25/2017 Jaime Yazzie, NAU School of Forestry

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BackgroundChallenges are linked to historical colonialism and assimilation of the Diné by the European settlers and the United States • Cultural and spiritual connections to nature are notmain priority

• Impacts from historical management• Unsupported leasing of land to outside corporations• Pollution from uranium mining and fossil fuel• Navajo Forestry Department and BIA underfunded• Threats of high severity wildfire, insects, disease, drought, and Climate Change

• U.S.A has an unfulfilled trust responsibility toward tribal forest lands

Taken by Jaime Yazzie10/25/2017 Jaime Yazzie, NAU School of Forestry

Purpose of Study• Importance of forest and forest use to Diné people• Setting the groundwork for developing better strategies to mitigate climate change and sustain its natural resources and livelihood. 

• Tribal communities are at high risk of losing natural resources and ecosystem services directly and indirectly

• Lack of research on climate change and impacts on Dine’ forest• Previous research in Diné forestry, botany, anthropology, etc are written from outsider perspective with heavily westernized contexts

Taken by Jaime Yazzie10/25/2017 Jaime Yazzie, NAU School of Forestry

Research Question

What is the community perception of forest use and their changes over time?

• Identify traditional knowledge and perspectives on forest and forest use.

• Evaluate potential impacts of climate change on forest and forest use from tribal members’ view

• Identify responses of tribal communities to these changes

10/25/2017 Jaime Yazzie, NAU School of Forestry

Methods – Participants and Recruitment• NNHRRB approved project• Selected Agencies within forested areas• Locations: selected through voluntary participation(passed resolutions/approved by vote) 

• Oak/Pine Springs (Fort Defiance)• Tsaile/Wheatfields (Chinle) • Sawmill (Chinle)• Red Valley (Shiprock)

• Timeline: May – September 2017

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Methods – Participants and Recruitment• Participants: 

• Diné (Navajo)• living on Navajo Nation, • over 18 years old 

• Recruitment: Flyers distributed at local chapter houses, announced at monthly chapter meetings and on the radio, KTNN.

Pine/Oak Springs Chapter Monthly Meeting

Methods – Focus Group• Focus Group Discussion: 

• Informed consent • Groups ranged from 3 – 7 people• Using semi‐guided structure for 12 questions

• Digitally recorded with permission • Incentive: monetary compensation to cover time and transportation

• Short presentation of Climate Change Impacts follows workshop

Worlshop

Data Analysis• Audio‐recordings transcribed • Analyzed qualitatively using NVIVO• Preliminary analysis for general observations using open‐coding• 2nd analysis for segmented or coded analysis on observations of forest condition, forest use, and intergenerational teachings

• Themes will inform key findings

Results: Forest Changes

•Large ponderosa pine: “they got rid of most of the old big round ponderosa.”•Grasses: “I used to count so many grasses but there's only a few now.”•“Last time, we got 6 to 8 feet of snow was like 8 years ago.”  

•Drier conditions, •Decline in surface water, •Less snow: “We haven’t had a good winter since 2008” •“Too many small trees with small diameters close together”. •More cedar•Insect & Disease

•Fire: “We don't want the forest to be torn down by the fires.•Climate change: “The forest doesn't have a choice except to change and live with it.”•“If we don't have enough rain, it's going to kill off the trees.”•“Prevent tree cutting for economic purposes and clearing the forests with negative consequence. At the same time, we need to keep the trees in 

check so we have no over‐growth…Keep it in balance.”

Past

Present

Future

Results:Forest Use

WaterHome

RangelandConnection to the 

landTimber for structures

Pinon picking

Connection to land/forest•“We have a 

relationship with the mountain because of our prayers and songs 

are related to it” Physical Changes •Woodland species 

encroaching meadows, decline in 

surface water,presence of various 

species, drier conditions, etc. 

Management and Regulations

Threats to forest ecosystem

•Climate change, invasive species, contaminationfrom illegal dumping, impacts and fossil fuel 

extraction, compaction of soil from vehicles, feral 

horses

Livelihoods•Jobs

•Materials for buildings•Firewood collection

Multiple uses of the forest

•Water resources, homes, rangeland, traditional foods, herbal medicine, building materials, links to overall well‐

being

Michael J. Dockry,  Katherine Hall, William Van Lopik, Christopher M. Caldwell. (2016) “Sustainable development education, practice, and research: an indigenous model of sustainable development at the College of Menominee Nation, Keshena, WI, USA”Sustainability Science.11:127–138   DOI 10.1007/s11625‐015‐0304‐x

DiscussionImplications• Document impacts of communities on tribal land• Assess impacts of alternative management scenarios to maintain forest uses that tribal members value

Limitations: • Interpretation of Diné language • Not representative of population but provides insight to perceptions

• Difficult to advertise discussions

Adjacent Project: How will Climate Change impact the Dine’ forest 

and Tree Biodiversity?• Using 273 Continuous Forest Inventory (CFI) from Navajo Forestry Department

• Project CFI plots over 100 years using Climate‐Forest Vegetation Simulator (C‐FVS) under different climate and management scenarios

• Management strategies consist of a combination of current strategies based on the current management plan as well as planting strategies. 

• Climate scenarios two future emission scenarios: RCP 4.5 and RCP 6.0.

10/25/2017 Jaime Yazzie, NAU School of Forestry

Figure 2: Map of CFI locations and Lukachukai, Chuska, mountains and Defiance Plateau. 

10/25/2017 Jaime Yazzie, NAU School of Forestry

Management Scenarios

2105 NoManagement Thin RX 20 Thin/RX

No ClimateChange

RCP 4.5

RCP 6.0

Results: C‐FVS outcomes

2005

Incorporate Climate Scenarios into sustainable framework

Connection to land/forest•“We have a 

relationship with the mountainbecause of our 

prayers and songs are related to it”

Physical Changes •Threats to Ecosystem. 

Management/ RegulationsLivelihoods

Multiple uses of the forest

•Water resources, homes, rangeland, traditional foods, herbal medicine, building materials, links to overall well‐being

Michael J. Dockry,  Katherine Hall, William Van Lopik, Christopher M. Caldwell. (2016) “Sustainable development education, practice, and research: an indigenous model of sustainable development at the College of Menominee Nation, Keshena, WI, USA”Sustainability Science.11:127–138   DOI 10.1007/s11625‐015‐0304‐x

Future Work1) Look at water and carbon services from outcomes and ecosystem resilience

2) Results from the research will be presented to tribal managers at the Navajo Forestry Department

3) Provide a summarized report for public outreach and educational materials for the community members. 

4) Continue to work with community members at chapter communities to document forest use and climate change impacts 

5) Propose projects to develop climate change adaptation strategies

Taken by Larondo Stash Taken by Jaime YazzieTaken by Jaime Yazzie

10/25/2017 Jaime Yazzie, School of Forestry

Ahéhee'Shik’éí dóó shidine’é dóóNavajo Historical Preservation DepartmentLocal Chapter House officials and community members Navajo Forestry Department: Alex Becenti, Frankie Thompson, A.K. Arbab, Tim Jim, Herman YazzieNAU faculty and students: Dr. Serra Hoagland, Dr. Ora Marek‐Martinez, Dr. Karen Jarrett‐Snider, Dr. Peter Z. Fulé, Dr. Kerry Grimm, Dr. Miguel Vasquez

10/25/2017Jaime Yazzie, NAU School of Forestry

ReferencesCostanza, Robert, Ralph Arge, Rudolf De Groot, Stephen Farberk, Monica Grasso, Bruce Hannon, Karin Limburg, et al. 1997. “The Value of the World ’ S Ecosystem Services and Natural Capital.” Nature.doi:10.1038/387253a0.Dockry, Michael J; Hall, Katherine; Van Lopik, William; Caldwell, Christopher. 2015. Sustainable development education, practice, and research: an indigenous model of sustainable development at the College of Menominee Nation, Keshena, WI, USA. Sustainability Science. http://link.springer.com/article/10.1007/s11625‐015‐0304‐xHarris, Stuart; Harper, Barbara .2000.“Using Eco‐Cultural Dependency Webs in Risk Assessment and Characterization of Risks to Tribal Health and Culture.” Environmental Science and Pollution Research 2(2).Bloor, Michael; Frankland, Jane; Thomas, Michelle; Robson, Kate. 2001. “Focus groups in social research: Introducing Qualitative Methods’.” Sage Publications. London.Voggesser, Garrit, Lynn, Kathy; John Daigle, Frank K. Lake, and Darren Ranco. 2013. “Cultural Impacts to Tribes from Climate Change Influences on Forests.” Climatic Change. doi:10.1007/s10584‐013‐0733‐4.Norton‐Smith, Katherine; Lynn, Kathy; Chief, Karletta; Cozzetto, J. Donatuto, M. Hiza Redsteer, L. Kruger, J. Maldonado, C. Viles, and K.P. Whyte. 2016. “Climate change and Indigenous Peoples: a Synthesis of Current Impacts and Experiences”. Gen. Tech. Rep. PNW‐GTR‐944. Portland, OR: U.S. Department of Agriculture, Forest Service, Pacific Northwest Research Station. Pgs 1‐138.

Ecosystem ServicesEcosystem services are benefits and goods derived by human populations through ecosystem processes and functions.

Based research questions on indigenous sustainability framework (Dockry, M. (2016) 

Ecosystem ServicesSupporting• Soil

formation

• Nitrogen cycling

• Understory productivity

• Biodiversity

• Wildlife

• Water Yield

Provisioning• Timber/fuelwood

• Water

• Traditional foods

10/25/2017 Jaime Yazzie, NAU School of Forestry

Regulating• Carbon

sequestration

Cultural• Traditional

building materials

• Knowledge

Examples of Focus Group Questions:

1. Did you visit the forest when you were younger? 

2. When you go back to these places, can you recall any differences in the landscape? 

3. Why do you think these changes are occurring?

4. What does the forest provide? How do you utilize the forest?

Results – Action Tool

Keep Eliminate

Get  Avoid

Results – Action Tool

10/25/2017 Jaime Yazzie, NAU School of Forestry

EVALUATIONOFPATIENT‐CENTEREDHYPERTENSIONCLINICWITHGROUPEDUCATIONSESSIONS

KIMBERLYMOHSMD CHANDIMADEEGALA,PHARMDDIRECTOR‐HEALTHEDUCATIONCENTERFORWELLNESS PHARMACIST– HEC4W

NorthernNavajoMedicalCenter– Shiprock,NewMexico

INTRODUCTION:YÁ’ÁT’ÉÉH

GRANTFUNDINGRECEIVED2007

• Focusedonimprovingriskfactorsforheartdiseaseinatriskpopulations

• Staffing:onepharmacisteducatorandonefitnesstech

• Setting:Largeprimarycareandinpatientfacility,NorthernNavajoMedicalCenter

• Circumstances:Primarycareprovidershortageandlongwaittoobtainaprimarycarephysician

INTERVENTION• Startdate:February2008(ongoing)

• Datacollectionperiod:Feb2008throughAug2010

• Intervention:• Allpatientsdiagnosed(neworold)withhypertensionwithoutaprimarycareproviderwereinvitedtoattenda2parteducationsessions

• MostofreferralscamefromUrgentCareandtheEmergencyRoom• Inadditiontoclasssession,patientsreceived:

• Visitwithphysicianforreviewofdiagnosis,medications,ifneededandevaluation• Completedallstandardsofcareneeded(immunizations,mammographyetc)• Followupvisitswithpharmacistat3,6and12months

RESULTS

• MeanBPdecrease5.79mmHgat3months

• MeanBPdecrease6.69mmHgat6months

• Unexpectedresults• MostpatientswhostartedwithgroupcarehaveelectedtocontinuegroupcareinsteadofpursuingtraditionalcaremodelsatNNMC

• StandardsofcareforHealthHeartpatientsremainconsistentlyhigherthaninourtraditionalprimarycareclinics

QUESTIONS?

Helicobacter Pylori and Stomach Cancer:Assessing knowledge, attitudes, and practices among Navajo people in Northern Arizona

CARMENLITA CHIEF, MPHCenter for Health Equity ResearchNorthern Arizona University

ALFRED “AL” YAZZIEBlack Hills Center for American Indian Health (Winslow)

2017 Navajo Nation Human Research Review Board Conference

What is Helicobacter pylori?

H. pylori is a bacteria commonly found in the human gut.

Can cause infection, which can begin in childhood and persist into adulthood

One of the most common bacterial infections in the world.

Untreated infections can lead to chronic health outcomes.

Chronic gastritis, ulcers, stomach cancer

Leading infectious cause of cancer worldwide.

Background on Stomach Cancer

3rd leading cause of cancer death, globally.

Development of gastric cancer clearly associated with H. pylori infection

Why is this a concern for the Navajo Nation?

Rate for stomach cancer is 3-4 times higher among Navajo Nation residents in Arizona. In comparison with non-Hispanic white population

Incidence rates highest in southwest IHS Region. 10.6/100,000 among all counties

Incidence rates are higher in Navajo Nation 14.2/100,00 (after adjusting for age)

2nd only to colorectal cancer for incidence

Project Team & Study Goal

Greg Jarrin, MD Eyal Oren, PhD

Robin Harris, PhD, MPH

Carmenlita Chief, MPH

Alfred Yazzie

Priscilla R. Sanderson, PhD

To assess and increase understanding of Navajo people’s knowledge, attitudes, and practices (KAP) regarding H. pyloriinfection and stomach cancer.

Focus Group Aims

Conduct 3 focus groups

1 focus group per community (Birdsprings, Leupp, Dilkon)

8-10 participants per group

Findings will be important to provide a foundation for future studies focusing on H. pylori infection

i.e. screening, treatment, education

Recruitment Efforts

Time Period Activities

In Advance of FG • Flyers posted in public places• Word of Mouth

Day of FG • 22 x 28-inch poster board sign in front of chapter house

• Balloons to capture attention• In-person recruitment of visitors & passersby

(in and around chapter house)

Indigenous-Based Approaches

• Give participants some time to reconnect before focus group.• Provide breakfast for participants (“feed your relatives”).Kinship

• Introductions take place in clock-wise direction.Direction

• Prayer before focus group & data analysis sessions.•Seek protection & understanding for a culturally sensitive & powerful topic.Spirituality

• Collaborative analysis; all members have equal stature & acknowledge kinship relationships among team.Consensus

The vast majority have never heard about stomach cancer and H. pylori.

On Stomach Cancer:

Most thought their medical providers did not have adequate knowledge to suspect stomach cancer or H. pylori infection.

I’ve been in and out of the hospital all the time, and doctors and people don’t tell you. Nutritionists, and…they don’t bring up stuff like this to me.

Many were guessing on what they thought were symptoms of stomach cancer – often giving generalized descriptions.

No, because all they’ll say is, “Oh, I have a stomach ache. I have a stomach ache. Or they’ll say, “I’m bloated.”

[Knowledge]

1

The vast majority have never heard about stomach cancer and H. pylori.

On H. pylori:

Focus Group A: The focus group discussion was the actually the first time they heard of it.

Focus Group B: Only one person had heard of it because they had been infected and received treatment.

Focus Group C: 1-2 people said they heard of it because of family members who had ulcers.

[Knowledge]

1

Environmental concerns are perceived to be associated with community health issues.

Concerns about various types of environmental contamination in the local area.

i.e. coal combustion & mining, pesticides, air, water, polluted run-off

Uranium contamination of water sources

Concerns about potential exposure of people & livestock to harmful environmental chemicals.

Irrigation and farming

Uninformed about water quality

2

Feeling vulnerable and afraid.

Vulnerability, fear, and anxiety (worry).

Since hearing this today, it’s kind of just worrying me a little…like the food I eat and the water I drink. So, I’m just listening, trying to find out more.

We’re afraid of it [cancer], that’s why we say, ‘Yes!’

[Attitudes]

3

Confusion

Two (2) types of confusion:

1. Not knowing what was happening with body/health.

2. Inaccurate or unsubstantiated info regarding the stomach and its disorders.

I know a couple of people that got a chili seed stuck in their throat or somewhere, and that chili seed will burn a hole through the lining of the stomach, and they get ulcers from it…

[Attitudes]

4

Frustration toward medical providers

Frustration over the quality of health care received.

I lost my brother in-law recently. He said he’s been vomiting a lot. Every time he eats, he vomits, and the doctor couldn’t find out what the problem was. He just kept saying, ‘Naw, nothing is wrong with him.’ They keep saying ‘Go home,’ and finally one of my relatives got mad at the doctor, and says, “Examine him!” Then they finally find out what, what cause…was the cancer in there.

[Attitudes]

5

Experiences with exhaustive medical evaluation & diagnosis procedures led patients’ to passively accept quality of health care services

Many participants described with some emotional resignation, the following:

Not getting proper medical care within an appropriate time period.

Excessive wait for appointments (months).

Like I said, it took them a long time to diagnose. And I kept going back. I could tell something was wrong with my body. Something’s not right! But they didn’t know how to treat it or what to look for. So it went undetected for a while.

6

Low socioeconomic status drives behavioral and nutritional choices

Low SES constraints

Healthy foods not widely available locally

Lack of refrigeration

Store & prepare only certain types of food.

Increased risk of food-related illnesses.

Distance to clean drinking water sources is too far ($$)

Use of closer, but potentially unsafe, drinking water sources.

[Practices]

7

Want to make individual/community level changes

Individual solutions

Healthier food choices, practice spirituality, & increase physical exercise.

Prefer community-led education

Community discussions = community solutions

H. pylori & stomach cancer education: Talk about the entire process and relationships. Don’t break down into pieces like Western education does.

[Practices]

8

Recommendations

Increase education and outreach More community discussions in community spaces, guided by community members

Increase culturally-appropriate communication of information Inform on entire continuum of disease & relationships

Increase broader awareness of H. pylori and stomach cancer among medical providers Provide more training opportunities with CEU credits

Strengthen environmental protection policies to mitigate and prevent contamination.

Increase the evidence base detailing the extent of H. pylori and associated risk factors among Navajo Nation population.

Carmenlita ChiefNAU Center for Health Equity Research (CHER)Ofc: 928-523-2104carmenlita.chief@nau.edu

Ahehee’!

’Aoo’, feel free to contact us!

Alfred YazzieBlack Hills Center for American Indian Healthalfred.yazzie54@gmail.com

Impact of PCV13 on Carriage October 18, 2017

Melinda Charley and Raymond Reid, MD, MPHCenter for American Indian Health (CAIH)Johns Hopkins Bloomberg School of Public Health

Acknowledgements

• Navajo and White Mountain Apache tribal members• CAIH Faculty and Staff• IHS Clinical and Lab partners• Navajo Nation IRB• White Mountain Apache Health Board and Tribal Council • Phoenix Area IHS IRB

Learning Objectives

1. Characterizing pneumococcal carriage helps explain trends in pneumococcal disease

2. Coverage with pneumococcal conjugate vaccine (PCV) is high among children <5 years of age

3. Some PCV-type pneumococcal carriage persists in children and adults

What is Streptococcus pneumoniae?

• A “germ” or bacteria

• More than 90 types

• Types differ by the type of sugar

coating on the surface of the bacteria

• Can cause serious disease

(pneumonia, meningitis, blood

infection)

How does someone get pneumococcus?

Why do we study pneumococcal carriage?

ear infection

pneumonia

meningitis

blood infection

High burden of pneumococcal disease for Navajo children <5 years old

0

50

100

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25019

9719

9819

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1120

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Dis

ease

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e (C

ases

per

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,000

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Navajo General US

*

* US data available only through 2015

2001: PCV7 introduced 2010: PCV13 introduced

PCV7: a vaccine for pneumococcus • PCV7 (Prevnar), available in 2000• Given to children <5 years old• Prevents carriage of PCV7 types

PCV7

PCV13: a new vaccine for pneumococcus

7F

PCV7 (2000)

PCV13 (2010)

• Contains PCV7 types plus 6 additional types• PCV13 use began 2010 for children• Given to children <5 and adults ≥65 years of age

(starting in August 2014)

PCV13 Study – Part 1: Objectives

1. Track uptake of PCV13 into the community

2. Measure impact of PCV13 on carriage of PCV13-types before and after vaccine introduction

PCV13 Study – Part 1: Study design and activities

• Enrollment period: January 2010 – March 2012• Enrollment population: Convenience sample of all ages• Study sites:

– Chinle, Fort Defiance, Gallup, Shiprock (Navajo)– Whiteriver (White Mountain Apache)

• Study activities:– Administer questionnaire (demographics, risk factors)– Collect nasopharyngeal (NP) swab– Review medical chart (chronic medical conditions, PCV history)– Culture and type pneumococcus from NP swab

62%

80%

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100%

Mar Apr

May

June July

Aug

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2010 2011 2012

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Part 1 Results: PCV13 uptake after introduction in 2010, children <5 years old

Mar 2010: PCV13 introduction

Part 1 Results: PCV13-type carriage in children and adults after PCV13 introduction

Percent of Navajo and Apaches who are PCV13-type positive before and after PCV13 use began

11%

5%

2%3%

1% 1%

0%

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6%

8%

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12%

<5 years 5-17 years 18+ years

Perc

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Pre-PCV13 (March 2010)Post-PCV13 (March 2012)Residual PCV13-type carriage

Question:

After five years of PCV13 use, does PCV13-type carriage continue to persist in the

population?

51 6A3 7F7F

“PCV13-types” - types only in PCV13 -

19A

• Enrollment period: October 2015 – September 2016 • Enrollment population: convenience sample of children

<5 years and adults ≥18 years• Study sites:

– Chinle, Fort Defiance, Gallup, Shiprock (Navajo)– Whiteriver (White Mountain Apache)

• Activities:– Consent participant– Administer questionnaire (demographics, risk factors)– Collect nasopharyngeal (NP) swab– Review medical chart (underlying conditions, PCV history)– Culture and type pneumococcus from NP swab

PCV13 Study – Part 2: Study design and activities

Pneumococcal carriage: PCV13 Study - Part 2

Age groups Total swabs Pneumococcal positive, n (%)

PCV13-type positive,n (%)

<2 years 170 64 (38) 8 (5)

2-<5 years 165 95 (58) 4 (2)

<5 years 335 159 (47) 12 (4)

18-39 years 176 18 (10) 1 (0.6)

40-64 years 172 13 (7) 0 (0)

≥65 years 165 9 (5) 1 (0.6)

≥18 years 513 40 (8) 2 (0.4)

Comparison of pneumococcal carriage: PCV13 Study - Part 1 vs. Part 2

0%

10%

20%

30%

40%

50%

60%

70%

<2 years 2-<5 years <5 years ≧18 years

Perc

ent p

ositi

ve

Part 1 Part 2

Comparison of PCV13-type carriage: PCV13 Study - Part 1 vs. Part 2

0%

2%

4%

6%

8%

10%

<2 years 2-<5 years <5 years ≧18 years

Perc

ent p

ositi

ve

Part 1 Part 2

Comparison of individual PCV13-type carriage: PCV13 Study - Part 1 vs. Part 2

0%

2%

4%

6%

8%

10%

Part 1 Part 2 Part 1 Part 2 Part 1 Part 2<2 years 2-<5 years <5 years

Perc

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Type 3 Type 6A Type 7F Type 19A

PCV13 use among PCV13 Part 2 participants <5 and ≥65 years

17%

75% 80%94% 94%

0%

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40%

60%

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100%

2010 2011 2012 2015 2016

Perc

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Percent of children <5 years, fully immunized with PCV13

Percent of adults ≥65 years, fully immunized with PCV13

67% 70%

2015 2016

Conclusions

• Since PCV use began in 2000, PCV-type carriage has declined

• Residual PCV13-type carriage exists after five years of vaccine use at high coverage

• If PCV13-type disease persists, alternative strategies may be needed to eliminate carriage of residual PCV13-types

Thank you!

Indigenous Subjectivities: Diné Youth (De)Construct Identity

Valerie Shirley, Ph.D.

University of Arizona

College of Education 

Navajo Research ConferenceOctober 18, 2017

Committee Members:Dr. JoAnn Phillion, ChairDr. Chrystal JohnsonDr. Tsianina LomawaimaDr. Erik MalewskiDr. A. G. RudPurdue University

OverviewCritical Indigenous Qualitative Research Study◦Political, Decolonizing, Includes Indigenous Values

Site and Participants◦Tribal Community School◦10 Diné youth participants (12‐14 years of age)◦1 Diné female teacher

Examined how Diné youth conceptualized their identities in relation to the history of colonization, media influences/popular culture and Diné stories, concepts and philosophy

Methodology

• Interviews•Focus Group Discussions•Curriculum Documents•Classroom Obs/Field Notes•Researcher Journal

• Coding• Triangulation of Meaning

•Member Checks

•Diné Youth Make Meaning  of their Identities

• Subjectivities• Personal Agency

• Tribal Critical Race Theory

•Critical Indigenous Research

•Decolonization

Theoretical Framework

Research Questions

Data Sources & Collection

Data Analysis

Pedagogical Framework: DecolonizationA large part of decolonization entails developing a critical consciousness about the cause(s) of our oppression, the distortion of history, our own collaboration, and the degrees to which we have internalized colonialist ideas and practices. Decolonization requires auto‐criticism, self‐reflection, and a rejection of victimage. Decolonization is about empowerment—a belief that situations can be transformed, a belief and trust in our own peoples’ values and abilities, and a willingness to make change. It is about transforming negative reactionary energy into the more positive rebuilding energy needed in our communities. (Winona Wheeler cited in Wilson, 2004, p. 71) 

Engaging Diné Youth with Critical Indigenous Pedagogical Methods

Critical Examination of history, current state, community and self

Dialogue

Self‐Reflections

K’é

Taking Action

Interviews & 4 Focus Group Discussions

Diné Long Walk 

• Unit in Culture Class

• Navajo Stories of the Long Walk Period (Roessel, 1973)

Boarding Schools

• History using photos 

• Discussion of feelings and stories 

• Analyzing identity in relation to past

Popular Culture

• Peter Pan • How Hollywood Stereotypes NA

• Identity Wheel Activity

Diné Philosophy & Epistemology

• Creation Stories• Sa’ah NaaghaaiBi’kehHozhoon: Journey through Life

Examining History: Diné Long Walk

Erase-Replace Policies and Practices: “To kill the Indian and save the man”

Self-Reflection: Recognizing Hegemony

Identity wheel activity:

Western Aspects: school, watching tv, going to church speaking English

Diné Aspects: speaking Diné bizaad, school with focus on Diné cultural contexts, going to ceremonies, ceremonies for self, helping family and relatives

“I knew a little bit about the Navajo but when I wrote it down, I didn’t really know I was more into the Western than the Navajo because usually we’re supposed to be more Navajo and not that much Western but then I realized I was more influenced by the Western way. It made me feel no good.”

Fragile moment: feelings of ambivalence, anger, confusion

Western Diné 

Decolonization entails developing a critical consciousness about the degrees to which we have internalized colonialist ideas and practices

Balance and Take Action

Western Diné

Diné Stories: Moved to Forefront of Consciousness

Changing Woman and diiyindine’é are always by my side.

“Many Diné know the story of God and how he made us from his hands, but not the story of how Changing Woman made us and all of our clans.”  

Text: Denetdale (2007) Reclaiming Diné History

Sa’ah Naghai Bik’eh HozhoonDine Philosophy of Life: Hozhó

Behave more and not make any bad choices: “Stay on the right path”

All of the Diné youth reflected on their personal actions and behavior so as to achieve the state of hozhó (the ultimate goal to restore harmony within oneself and to reach a state of balance, beauty and goodness in life).

A past negative experience that Shawn had undergone clarified how the Diné philosophy of life guided his reasoning to make healthier choices to help him restore harmony and achieve a state of hozhó. He stated:

“It’s like someone bad is following you and if you’re going to do something wrong, they’re going to push you off the path and you got to struggle, struggle through time, and it seems like a long time, but you got to struggle to get back on your path and you got to try and stay strong to stay on your path.” 

Transformative ShiftsPersonal Agency: T’áá hwó ají t’éego(It’s up to you)

Learn the Language

Learn the Stories

Will Behave MoreGive Back

ProtectAdvocate

ImplicationsCritical Frameworks Theory and Practice Student AdvocacyDrawing on such frameworks encourages educators to be conscious and intentional of the ways in which they can implement curriculum & pedagogy that engages students in examining social issues while simultaneously privileging and promoting Indigenous knowledge systems in the classroom.

Be Intentional: Create spaces of learning through critical dialogues and self‐reflections;Promote critical thinking: draw on multiple resources to paint the picture;Teach for social change: Empower youth to become change agents;Emphasize Action

Youth calling for Diné schools to implement similar pedagogical and learning processes in their schools; Elders teach history and share Diné cultural knowledge;Storytelling nights

Ahxé’hee

Questions?Comments?

vshirley@email.arizona.edu

Mark C. Bauer, PhD (Diné College), Kevin Lombard, PhD (New Mexico State University), Felix Nez, BS & Linda Garcia, BA (Diné College)

Goal: To improve community health and wellness by encouraging family gardening activity and improved nutrition.

Specific Aim 1: Evaluate whether the intervention (integrated technical assistance, technical and behavioral workshops, and community outreach) is associated with presence of a garden in the backyard and an increase in frequency of gardening.

Specific Aim 2: Assess whether the association of the intervention (workshops and community outreach) is mediated by social norms about gardening, as well as self-efficacy and behavioral capability to garden.

Economic Considerations

Navajo annual per capita income is $10,547, compared to $27,334 U.S. (U.S. Census 2010).

Percentage of Navajo people below the poverty level is 37.7%, compared to 13.8% in the U.S. overall (U.S. Census 2010)

Cost, availability, & shelf life of foods in remote areas affect dietary choices.

Obesity and Diabetes on the Navajo Nation

Obesity is increasing among the Navajo 67% overweight or obese in NAIHS).

Fruit and vegetable consumption is low: over half of adults 3 or fewer servings daily.

2007: Type-2 diabetes is >14% of those 20-74 years of age.

Stage of Change in Gardening

Frequency Percent

Precontemplation 23 19%Contemplation 41 34%Planning 19 16%Action 7 6%Maintenance 30 25%Total 120 100%

0

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30

35

40

45Gardening Behavior

This question was based on the Stages of Change model. Those in the first three groups were then categorized as “non-gardeners” and the Action and Maintenance groups were considered “gardeners.”

Of those respondents who reported daily fruit and vegetable consumption (24 hour dietary recall):

35 gardeners reported mean servings of 5.5 (SD 3.7)

82 non-gardeners reported mean servings of 3.5 (SD 2.7)

This is a significant difference: gardeners ate on average 2 more servings of fruits and vegetables (TTest p=.0035, with outliers removed)

Non Gardeners

Gardeners

-2

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Hogback/Shiprock

Tsaile/Lukuchukai

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25

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SocialSupport

None Other

Individual Issues

Hogback/Shiprock

Tsaile/Lukuchukai

Provide workshops that feature traditional gardening methods, use of indigenous seeds, as part of “master gardening”

Encourage use of drip irrigation, water collection, dry farming methods in areas where irrigation infrastructure is non-existent or not functioning

Seek partners (chapters, community groups, other programs to work on broader infrastructure issues:◦ Water access – ditches, pumps, improved areas around other

sources◦ Assistance kits for new gardeners◦ Equipment for loan

Family Gardens◦ Fencing◦ Soil Improvements◦ Drip Irrigation

Technical and Behavioral Workshops◦ Site Preparation◦ When/what to Plant◦ Irrigation◦ Weed/Pest Control◦ Harvesting & Seed Saving◦ Healthy Cooking and Preserving

30 participating households from 4 Chapters (communities)

Participants range from 21 to 62 years of age

23 Female; 7 Male 18 live in established

housing areas; 12 rural 26 of the 30 households

had running water

Household gardens in Intervention. Components of these gardens include fencing to keep animals out, small wood gate, drip irrigation from NTUA tap water, and soil improvements.

•1 Shovels, 1 Hoes, 1 Rake, Fencing materials: posts, clippings, metal fencing, and post driver, gloves, face mask, drip irrigation materials: 12-20ft, 9-2ft, 2-4ft

tubing, drip buttons: 10 per 20ft tubing, drip hole puncture: 1 or 2, 2 elbow connectors, 9-10 T-shaped connectors, peat moss, organic compost, and

vermiculite/pearlite

Key Explanatory Variables◦ Knowledge: “Do you know how to…” Prepare a garden Maintain a garden Harest & store fruits and vegetables

◦ Self-Efficacy: “How confident, self-assured are you that you can…” Prepare a garden Maintain a garden Harvest and store fruits and vegetables Prepare fruits and vegetables Eat fruits and vegetables every day

Key Outcome Variables◦ Gardening Frequency (times/week)◦ Servings of fruits/vegetables per day

Knowledge: “Do you know how to…” Prepare a garden 4 13.3 13 46 Maintain a garden 14 53.3 17 60.7 Harvest & store fruits and vegetables 9 30.0 10 35.7 Self-efficacy: “How confident are you that you can… Prepare a garden 12 40.0 16 57.1 Maintain a garden 20 66.7 20 71.4 Harvest & store fruits & vegetables 20 66.7 9 32.1

Baseline Follow-upn % n %

Baseline Follow-up

μ 95% CI μ 95% CIGardening frequency (times/week) 3.3 0.0,6.1 7.6 5.5,9.5

Paired t-test shows significant difference between baseline andmidpoint (p=.004)

Fruit & Vegetable Servings (per day) 2.9 2.3,3.6 3.1 2.3,3.8Difference nonsignificant

Final Data Collection Questionnaire Data Analysis to explore what knowledge, self-efficacy,

and other intervention factors have impact on outcomes Dissemination Efforts:◦ Community dissemination to chapters◦ Extension materials for further dissemination◦ Technical report for area cooperative extension agents◦ Publication and presentation in a variety of Navajo Nation and

additional national conferences

• USDA for the funding to Diné College’s Science Faculty and Land Grant Office, and to New Mexico State University as a collaborator

• The Navajo Nation Human Research Review Board for approval of the research and input on the questionnaire

• NMSU IRB for research approval for the collaborating institution• New Dawn for Donation of Seeds for Incentives• Chapters (Shiprock, Hogback, Lukachukai, Tsaile/Wheatfields) for approval

and participation• Student research assistants in the Diné College Summer Research

Enhancement and NMSU Bridges Program

Preventing Early Childhood Obesity: Family Spirit Nurture Study Design and Methods

NNR-16.264

Olivia Trujillo & Tanya Jones

Navajo Nation Research Conference

October 2017

Presentation Agenda

• Background on Family Spirit Program

• Development of Family Spirit Nurture

• Family Spirit Nurture Study Design and Methods

• Acknowledgements• Questions/Discussion

Home-Based Outreach

Family Involvement

Community ReferralsStructured, home-based

curriculum taught by AI Home Visitors to young mothers from pregnancy – 36 mos

post-partum

Family Spirit: An Indigenous Strengths-Based Early Childhood Home-Visiting

Intervention

What is the Family Spirit Program?

Home-Based Outreach

Family Involvement

Community ReferralsEvidence-based home visiting

program taught by American Indian home visitors to young mothers from pregnancy – 36

mos post-partum

Tribal Communities in Southwest US Co-Created Family Spirit

UTAH COLORADO

NEW MEXICO

ARIZONAAlbuquerque

Tucson

Phoenix

Family Spirit Video

Current Status - Replication Nationwide

Johns Hopkins Center for American Indian Health

New Direction: Family Spirit Nurture

• Goal: In response to community needs, tailor Family Spirit curriculum to address early childhood obesity

• Why is this important?– Childhood obesity (<5 years old) can affect children’s health for the rest of

their lives.

– Native American children suffer the highest rates of early childhood obesity and related lifetime consequences of any racial or ethnic group in the US.

• 41.2% of Native preschoolers are overweight/obese compared to 30.5% of all races/ethnicities.

• Diabetes rates among Native youth ages 10-19 are 2.6 times higher than US general population and 7.0 times higher than whites.

Why Focus on Pregnancy & Early Childhood?Risks for early childhood obesity begin in the womb.• Mothers’ biology and habits matter.

Early childhood overweight starts at birth.• 12% of Native children large for gestational age at birth.

Early childhood is a critical time for obesity prevention. Children are:• Developing taste preferences• Learning to walk and play• Mimicking healthy and unhealthy behaviors of their

caregivers

Goals for Family Spirit Nurture Research

Develop and evaluate a Family Spirit Nurture curriculum that:• Promotes breastfeeding & the proper introduction of

complementary foods• Promotes responsive parenting and feeding practices• Delays the introduction of sugar sweetened beverages (SSBs)• Promotes early childhood physical activity

Family Spirit Nurture Study, Part 1 Evaluation of a Brief Family Spirit Nurture Curriculum (3-9 Months Postpartum)

– Site: Shiprock, NM– Participants: 136 moms with infants– Recruitment Timeline: March 2017 – February 2018– Intervention: 6 home-based Family Spirit Nurture lessons focused on

eliminating/reducing Sugar Sweetened Beverage (SSB) intake among infants and positive infant feeding practices

– Design: Randomized Controlled Trial, with control group receiving home safety education

– Additional key components:• Delivery of drinking water for all participants to look at the impact of

water insecurity on SSB intake• Oral health data collection to inform future intervention development

Part 1: Randomized Controlled

Trial

Family Spirit Nurture Study, Part 2

Evaluation of the Full Family Spirit Nurture Curriculum (Prenatal - 18 Months Postpartum)

– Sites: Shiprock, Fort Defiance, Gallup, Whiteriver– Participants: 338 expectant women age 14-22 years old– Recruitment Timeline: September 2017 – August 2019– Intervention: Home-based Family Spirit Nurture lessons between

pregnancy and 18 months, focused on: optimal infant feeding; infant/toddler physical activity; maternal psychosocial well-being; optimization of food/beverage availability; safe play spaces in the home

– Design: Randomized Controlled Trial, with control group receiving injury prevention education

– Additional Key Components:• All participants receive transportation to prenatal and well-baby visits

Part 2:Randomized Controlled

Trial

Blood Sample Collection

Maternal and infant blood samples will be collected at delivery (cord blood for infants) and at 6 months postpartum. Infant blood samples will also be collected at 12 months postpartum.

The blood samples will be used to measure: • Glucose• Lipids • Insulin• Leptin• Adiponectin• c-reactive protein

Blood Sample Collection Time Point Payment AmountDelivery - Baby $15 gift card

Delivery - Mom $15 gift card

6 months - Baby $15 gift card

6 months - Mom $15 gift card

12 months - Baby $15 gift card

Who Is Delivering the Lessons?Family Health Coaches • Local Community Health Professionals

– Deliver FSN curriculum to intervention participants;– Provide social support, help with problem solving;– Facilitate referrals to community services; and– Maintain relationships with participants and healthcare providers.

Evaluation MeasuresAll measures below are used in the Part 2 study;

a subset of these measures are used in the Part 1 study.

Interviews:• Maternal Demographics• Modified Child Beverage Intake

Questionnaire (BEVQ)• Household Food Security Survey

Self-Report:• Current Eating Environment Assessment• Infant/Toddler Responsive Feeding Scales• Baby/Children’s Eating Behavior

Questionnaire• Perceptions of Growth Scale• Child Physical Activity Assessment• Maternal Knowledge Questionnaire –

Nutrition/Physical Activity Practices• Water Availability Assessment• Parenting Stress Index – Short Form• CESDR-10• Alcohol, Smoking, and Substance

Involvement Screening Test (ASSIST)• Mastery Scale• Infant Temperament• BITSEA• Brief Infant Sleep Questionnaire (BISQ)• Participant Satisfaction Questionnaire• Maternal Knowledge – Injury Assessment

Observations: • Toddler PA Assessment (Accelerometer)• Maternal/Child Height & Weight• Home Safety Environment Scan

Blood Sample Collection (Mother & Child)

Process Form: Session Summary Form

Medical Chart Reviews (Mother & Child)

Current Status

• Part 1 has enrolled 66 participants in Shiprock– 76 lessons taught– 101 assessments completed– 37 water deliveries completed

• Part 2 was recently launched in Fort Defiance/Gallup, Shiprock and Whiteriver.

• The curriculum and study methods are well-received by staff, participants, and community partners.

Acknowledgements

• Thank you to the Navajo Nation Human Research Review Board for their ongoing thoughtful review of this research project (NNR-16.264).

• Thank you to numerous community partners, providers, and families from the Navajo Nation and White Mountain Apache Tribe for their contributions to Family Spirit Nurture program development and evaluation.

• Thank you to Johns Hopkins staff members for their commitment to the program and dedication to all participating families.

Questions / Discussion

1

Kirsten D. Bennett, PhD, RD, LDEnvision New MexicoUniversity of New Mexico Health Sciences Center Department of Pediatrics

2

9%, 47,000 New Mexico children deal with asthma every day

Distance to care and difficulties with self-management present challenges to asthma control

Physician adherence to evidence-based guidelines for clinical asthma management remains poor

Delivery system design in primary care often does not allow for optimal best practice care of any chronic conditions

3

QI approach to change The Model for Improvement

• Improvements are data driven

• Data reported in the fast feedback format using the proficiency model

• Run charts provide a an overview for selected measures

• Physicians awarded MOC• Other medical providers

awarded CME

4

Focuses attention on the core functions of the clinic and staff before moving on to more complex elements of providing care

Data elements are partitioned into Basic (level 1) nearing proficiency (level 2) proficiency (level 3)

Feedback is provided quickly in graphic form to quickly identify areas in need of improvement

5

Intervention consists of: Site visits Training on Model for Improvement and basic QI

methodology Training on best practice asthma care guidelines (in

person and via telehealth) Monthly PDSA developed and completed by site

participants 6 rounds of medical record reviews (MRR) submitted

electronically using REDCap over 6-12 months Structured fast feedback form (FFF) using the results of

the MRR Monthly coaching calls to review data and discuss PDSAs

6

7

4334 MRRs from 2013-2017 for 16 NM practices 1312 MRRs for 3 Navajo Nation Practices

Percent change from baseline adherence to best practice asthma care

8

Measure All Practices* Navajo Nation Practices*

Documentation of asthma severity

23.6% 13.56%

Completion of ACT 33.8% 59.64%

Having current AAP 45.4% 47.79%

Having scheduled follow-up visit

23.4% 8.51%

*% change

9

72.24%

86.76% 88.07% 85.69%

93.03%95.82%84.11% 85.85%

88.65% 87.93%92.31%

97.67%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline 2 3 4 5 Round 6

Severity Documented

All Practices Navajo Nation Practices

10

53.46%

74.32%79.95% 78.06%

82.57%87.26%

27.57%

73.17%78.17%

71.55%75.77%

87.21%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline 2 3 4 5 Round 6

ACT Completed

All Practices Navajo Nation Practices

11

29.72%

45.95%53.47% 54.17%

66.39%

75.10%

24.30%

48.78% 48.47% 48.71%

57.31%

72.09%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline 2 3 4 5 Round 6

Asthma Action Plan (AAP) Current

All Practices Navajo Nation Practices

12

58.18%

73.38%75.75%

79.86%85.36%

81.56%70.56%

84.88%82.53%

86.21%90.77%

79.07%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline 2 3 4 5 Round 6

Follow-Up Visit Scheduled

All Practices Navajo Nation Practices

13

85.14%88.11%

78.24%80.97%

90.79% 89.92%

100.00% 98.05% 99.13% 99.57% 99.62% 100.00%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline 2 3 4 5 Round 6

Quick Meds Prescribed

All Practices Navajo Nation Practices

All Practices Navajo Nation Practices

MOCs 51 15CMEs 121 1

14

Quality Improvement coaching leads to meaningful improvements in the rates of physician

adherence to best practice, evidence-based guidelines for asthma care

Care can be improved systematically A team-based approach can lead to system change and

adoption of best practices Small changes can lead to large and sustained improvements

in care Training in QI methodology increases participants’ ability to

make and manage change on their own

15

US Department of Human Services, National Institutesof Health, National Heart, Lung, and Blood Institute(2007). Langley GL, Nolan KM, (2009).

The Improvement Guide: A Practical Approach toEnhancing Organizational Performance (2nd edition). SanFrancisco: Jossey-Bass.

Global Initiative for Asthma. (2017). GINA reports. http://ginasthma.org/gina-reports/

UNM HSC IRB Study #-09-177

NNHRRB Study # NNR-07-198

16

Envision New Mexico QI Staff DirectoryTelephone 505-925-7600 www.EnvisionNM.unm.eduKirsten Bennett, PhD, RD, LDAssistant Professor Pediatrics

Director kdbennett@salud.unm.edu

Kristine Lucero, MAProgram Operations Managerkrisgonzales@salud.unm.edu

Andrea Andersen, MPHHealth Education Consultantaanderse@salud.unm.edu

Brandon Bell, MA.EdHealth Education Consultant

BRBell@salud.unm.edu

Terri Chauvet, CAPMProgram Coordinator

tchauvet@salud.unm.edu

Carole Conley, LMSWEducation and Outreach Manager: Primary

Care and SBHCcconley@salud.unm.edu

Zachary Johnson, MPAHealth Education Consultantzjohnson@salud.unm.edu

Adrienne McConnell, MSHealth Education Consultantaemcconnell@salud.unm.edu

Courtney McKinney, BAProgram Manager

cacklin@salud.unm.eduMary Ramos, MDAssistant Professor

Principal Investigator-Hilton GrantMRamos@salud.unm.edu

Daisy RoseroProgram Manager-Hilton Grant

DRosero@salud.unm.edu

Eleana Shair, MEdSr. Statistician

elshair@salud.unm.edu

Jeanene SiskAdministrative Assistant II

jsisk@salud.unm.edu

Maya Trujillo, BCH, MPAHealth Education Consultantmaetrujillo@salud.unm.edu

Kevin Werling, BASystems Analyst llI

kwerling@salud.unm.edu

Michelle WidenerProgram Specialist

miwidener@salud.unm.edu

17

18

10/25/2017

1

“Reservation Lands as a Protective Social Factor: An Analysis of two American Indian Tribes”

By Kimberly R. Huyser, PhDAssistant Professor of Sociology

University of New MexicoNNHRRB Protocol #NNR‐15.222T

Email: khuyser@unm.edu

Sociological BackgroundSocial Causes of Psychological Distress

10/25/2017

2

American Indian Reservation Lands as a Place of both Stress and Resilience 

Stress Factors to Psychological Distress• History of Federal policy• Limited employment opportunities• Many reservation lands are geographically isolated• Psychological distress is associated with lower socioeconomic status and experiencing undesirable events.

American Indian Reservation Lands as a Place of both Stress and Resilience 

Resilience Factors to Psychological Distress• Provides geographic and social space for tribal peoples to reclaim their language and traditional ways of life. 

• The community offers social events and social networks that promote inclusion of individuals. 

• It also offers family stories of strength and resilience, which help instill hope and strength within individuals. 

10/25/2017

3

Goal of study:

• To examine the relationship between the amount of time individuals have spent on the American Indian reservation and the psychological distress experienced by members of two American Indian tribes

Data & Methods

• Sample• American Indian Services Utilization, Psychiatric Epidemiology, Risk and Protective Factors Projects (AI‐SUPERPFP) 

• Two tribes• Southwest• Northern Plains

• Quantitative Analysis• Descriptive statistics• Seemingly‐unrelated‐bivariate‐probit models to predict psychological distress and the analyses were stratified by tribe• All models to be presented control for age, sex, marital status, education, poverty, employment status, social support, and stressful lifetime or recent events

10/25/2017

4

Descriptive Statistics of the SampleNorthern Plains Tribe Southwest Tribe

Age % Frequency % Frequency

40+ years 34.42 39.00

25‐39 years 51.03 46.55

20‐24 years 14.55 14.65

Female 50.62 56.86

Martial Status

Married 30.99 47.76

Separated, Divorced, Widowed

27.48 16.31

Never Married 41.53 35.94

Descriptive Statistics of the SampleNorthern Plains Tribe Southwest Tribe

Lifetime Residence % Frequency % Frequency

Completely on Reservation

41.10 44.81

Mostly on Reservation 48.12 42.47

Mostly near Reservation 3.91 9.19

Mostly off Reservation 6.87 3.53

Psychological Distress

Experience any level 57.64 74.04

Median Median

Kessler Psychological Distress Score

0.58 0.75

10/25/2017

5

10/25/2017

6

0.

0.2

0.4

0.6

0.8

1.

0. 0.5 1. 1.5 2.

Pre

dic

ted

Pro

bab

ility

of

Psy

chol

ogic

al D

istr

ess

Negative Social Support

Figure 1. Impact of Negative Social Support on Probability of Experiencing Psychological Distress

across Lifetime Residence for Northern Plains Tribe

Main Finding: Persons who live on reservation lands for 100% of life have lower likelihood of psychological distress than persons who lived off reservation lands for some part of life.

0.

0.25

0.5

0.75

1.

0. 0.5 1. 1.5 2.

Pre

dic

ted

Pro

bab

ility

of

Psy

chol

ogic

al D

istr

ess

Negative Social Support

Figure 2. Impact of Negative Social Support on Probability of Experiencing Psychological

Distress across Lifetime Residence for Southwest Tribe

Conclusion

• This study presents a complex examination of risk and resilience factors against psychological distress. 

• The key finding is that those who have lived completely on the reservation throughout their lives have a lower likelihood of psychological distress as compared to those who spent part of their lives off reservation. 

• This finding suggests a need to reframe the social science perception of life experience on the tribal reservation but also calls for further investigation of the life experience of American Indians overall, both on reservation and off reservation. 

10/25/2017

7

Questions?khuyser@unm.edu

Predicting Psychological Distress ‐ Simple Probit RegressionsNorthern Plains Tribe Southwest Tribe

Social Support Probit Coeff. Probit Coeff.

Isolated 0.74*** 0.48***

Perceived Social Support ‐0.50*** ‐0.32***

Negative Social Support 0.83*** 0.85***

Instrumental Support 0.48 ‐0.14

Poverty

Household not below federal poverty level ‐‐ ‐‐

Household below federal poverty level 0.19** 0.21**

Missing 0.04 ‐0.35+

10/25/2017

8

Predicting Psychological Distress ‐ Full Bivariate Probit RegressionsNorthern Plains Tribe Southwest Tribe

Social Support Probit Coeff. Probit Coeff.

Isolated ‐ ‐ ‐ ‐

Perceived Social Support ‐0.17+ ‐0.10

Negative Social Support 0.36** 0.39***

Instrumental Support ‐0.48* ‐0.27+

Poverty

Household not below federal poverty level ‐‐ ‐‐

Household below federal poverty level 0.09 0.27**

Missing 0.16 0.03

Navajo Nation Research Conference

October 18, 2017

Alicia Tsosie & Reese Foy Cuddy

The Feast for the Future Program: Development, Evaluation and Replication

dd

NNR-11.332

Agenda

• Welcome

• Brief Center Overview

• Feast for the Future (FFF) Video

• FFF Program Overview

• FFF Evaluation Results

• FFF Replication Website

• Acknowledgements

• Q & A/ Discussion

Johns Hopkins Center for American Indian Health

Founded in 1991 by Dr. Mathu Santosham after spending 10 years in tribal communities

Johns Hopkins Center for American Indian Health

MissionTo work in partnership with

American Indian and Alaska Native communities to raise

the health status, self-sufficiency, and health

leadership of Native peoples to the highest possible level.

Center’s Three Core Areas

Training & Scholarship

Behavioral Health

Promotion

InfectiousDisease

Prevention and

Treatment

Feast for the Future Nutrition Promotion Diabetes & Obesity

Prevention Youth Development

Feast for the Future Field Sites

White Mountain Apache (AZ)

UTAH COLORADO

NEW MEXICO

ARIZONAAlbuquerque

Tucson

Phoenix

Santo Domingo Pueblo (NM)

Tuba City (Navajo Nation – AZ)

Key Partner: FoodCorps AZ and NM

Feast for the Future

Feast for the Future Program Overview

PROGRAM OBJECTIVES

• Increase gardening and nutrition knowledge, attitudes, and behaviors

• Increase sustainable practices of traditional farming and capacity building

• Increase access and availability to healthy foods

Program Timeline Goal: To reduce the incidence and prevalence of obesity

and obesity-related diseases among Native American families.

Community Visioning Process

Development of FFF Program Components

Implementation and Evaluation

Community ownership

Replication

Feast for the Future Program Components

• Community Advisory Board

• Edible School Garden Program

• Traditional Foodways Education Program

• Community Gardens, Orchards, and Greenhouses

• Farmers Markets

• Farmers Workshops

• Family Gardens

How it works

Utilize the six different components of FFF

You can tailor how FFF looks in your community based on your CAB’s desires/needs

Start a Community Advisory Board

Foundational step in developing your community’s FFF program

Community Advisory Board

• A Community Advisory Board (CAB) provides vision and leadership

• A strong CAB consists of a diverse group of several community members with a vision to help their community

Edible School Garden Program

• Tailored to 3rd, 4th, and 5th grade

• Curriculum for fall and spring semesters (total 24 weeks)

• Aligns with science and math state education standards for New Mexico and Arizona

• Pilot ESG programs contained elements of gardens, greenhouses, composts, and outdoor classroom spaces

Traditional Foodways Education Program

• Target audience: 5-18 yrs. old

• Seasonal curriculum

• Usually taught by an elder or community leader

• Emphasis on traditional language

Additional Program Components

Community Gardens Family Gardens

Farmers Markets Farmers Workshops

Evaluation Methods

The Feast for the Future Program has been rigorously evaluated to establish an evidence base.

- Pre-post surveys with youth in the Edible School Garden Program

- In-depth Interviews with adult participants and community/school partners

- PhotoVoice with youth participants- Focus Groups and surveys with youth participants,

adult participants, and Community Advisory Board members

Evidence Base

Evaluation Results:

Edible School Garden Program

• Increase in nutrition and gardening knowledge

• Improved nutrition & gardening attitudes

• Improved nutrition and garden self-efficacy/ communication

Feast for the Future Programs

• Promoted farming/gardening,• Revitalized traditional cultural

practices. • Empowered participants to

positively changed their behaviors to eat and drink healthier

• Participants passed knowledge from elders to youth

• Participants promoted farming/gardening practices

Next Step: Replication WebsiteAn interactive website toolkit is currently being designed to help tribal communities nation-wide

replicate the Feast for the Future Program.

Websitehttp://www.feastforthefuture.org

Acknowledgements

• Thank you to the Navajo Nation Human Research Review Board for their ongoing thoughtful review of this research project (NNR-11.332).

• Thank you to numerous community partners, school staff and administrators, farmers and elders in Tuba City, AZ, Santo Domingo, NM and Whiteriver, AZ for their contributions to program development and evaluation.

• Thank you to Johns Hopkins staff members and FoodCorps service members for their commitment and dedication to the program and all participating youth and community members.

Q&A Discussion

Contact Information

Email: feastforthefuture@jhu.edu

Phone: (505) 797-3305/3309

Thank you

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Where Health & Horticulture Intersect:

A Navajo Wellness Collaboration

Kevin Lombard, Shirley A.A. Beresford,

India OrnelasDesiree Deschenie

Jesse Jim Mark Bauer

Felix Nez

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Thank You!

• Communities of Shiprock and Crownpoint

• Office of Youth Development and Dream Diné

• NNHRRB

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Project Overview• 3 year pilot project• Two community-based gardens

– Dream Dine Charter School, Shiprock, NM – Office of Dine Youth, Crownpoint, NM

• Survey – 4 assessment time points

• 2 summer gardening workshop series • Main research question: Would a community garden in your

community influence you to change how you eat or how you feel about gardening?

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• The U.S. Department of Agriculture has labeled theentire Navajo Nation a "food desert," because of the lack of healthy foods.

• The Navajo Nation is the largest reservation in the United States, roughly the size of West Virginia - it only has 10 grocery stores.

• 1 of 3 Navajo people suffers from diabetes (Indian Health Service)

Long term goal and context

Enhance the consumption of fresh produce among the Navajo (Diné) people and their neighbors, in order to

reduce the rate of diabetes and reduce cancer risk in the context of local food production.

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Attitudes about Gardening

• Health benefits of gardening

• Nutrition• Economic benefits of

gardening• Gardening was important

in the past.– Some younger generations

didn’t seem to view it as a top priority. Why farm?

– Others were very interested in reconnecting

“I think with the extra movement, hoeing, weeding, it would be good exercise although it would be healthier to eat more fruit and vegetables if it’s ongoing”

Ramah Chapter (Pine Hill, NM)

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Specific Aims

• Develop a multi-component intervention that integrates community gardens, educational workshops and community outreach components in Navajo communities;

• Estimate the effects of an integrated intervention on adoption and frequency of gardening practices, vegetable and fruit intake amongst participating communities

• Estimate the effects of an integrated intervention on self-monitoring, self-efficacy, behavioral capability, and social norms related to gardening and vegetable and fruit consumption

Filling grow boxes at Shiprock site March 2015

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Project Progress and TimelineYEAR 2014  YEAR 2015  YEAR 2016 

 WINTER  SPRING  SUMMER 

FALL

Sept ‐ Nov 

WINTER

Dec‐Feb 

SPRING

Mar‐May 

SUMMER

Jun ‐ Aug 

FALL

Sept‐Nov WINTER  SPRING  SUMMER

Shiprock  A         

Shiprock B                       

Crownpoint A 

Crownpoint B 

                     

T0  T1 

T0 

T0  T1  

T2 Dream Dine 

T2 T3 

T1 

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Gender, Age, and Marital

StatusFemale

70%

Male30%

Gender

18-2927%

30-3922%

40-4922%

50-5917%

60+12%

Age

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Language, Education,

and Employment

English only13%

English>Navajo

50%

English=Navajo

28%

English<Navajo

6%

Navajo only1%

Other2%

Language

01%

HS diploma/GED at

most29%

Some college/vocational degree57%

College degree13%

Education

Year round32%

Day/seasonal

23%

Other45%

Employment status

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Priliminary Results

• Pre-post analysis showed the intervention increased the frequency of gardening activities. There were no changes in vegetable and fruit consumption.

• Explicit focus on healthy eating is needed.– 58% report 2 or fewer fruits and

vegetables daily

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Gardening Frequency

5.8

14.9

10.9

14.5

0

2

4

6

8

10

12

14

16

Crownpoint Shiprock

Axi

s Titl

ePre-InterventionT2

P=0.39

P=0.84

n=17 n=15

• Frequency of gardening increased most in Crownpoint

• Is this because Crownpoint is not located in a farming area ?

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Gardened in the last year

0.35

0.43

0.29

0.67

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

Crownpoint Shiprock

Axi

s Titl

ePre-InterventionT2

P=1.00

P=0.13

n=17 n=15

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Abbreviated FFQ4.62

3.794.03 3.89

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Crownpoint Shiprock

Axi

s Titl

ePre-InterventionT2

P=0.76 P=0.98

n=17 n=15

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Single item FFQ

2.47

2.13

2.59

1.87

0

0.5

1

1.5

2

2.5

3

Crownpoint Shiprock

Axi

s Titl

ePre-InterventionT2

P=0.95 P=0.41

n=17 n=15

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Barriers to Gardening: Shiprock

No Space Available10%

Insects or Pests23%

Weeds14%

Wind5%

Animals31%

Other (eg. Water right issues, lack of time and

livestock)17%

Prairie dog predation decimated Shiprock garden in 2014

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Financial barriers to gardening: Crownpoint and Shiprock

Not at all24%

A little34%

A lot42%

Cost of Water

Emphasize water conservation:• Native plants• Water conserving technologies

NTUA Water Usage Charge• First 3,000 gallons: $3.91 per 1,000 gallons• All Additional gallons: $ 6.05 per 1,000

gallons• According to the NTUA water consumption

fee, the cost of watering a 2,000 sq. ft. garden that received 816.5 gal over 21 days equaled $3.19

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Financial barriers to gardening: Crownpoint and Shiprock

Not at all33%

A little37%

A lot30%

Cost of tools

Not at all20%

A little26%

A lot54%

Cost of fencing

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Summary• Implemented and evaluated community

garden intervention in 2 Navajo communities.– Recruited 186 participants from 161

households, who completed at least one survey

– 300 participants attended at least one of 17 workshops

– Constructed 10 garden beds and 1 greenhouse

• Conducted qualitative ancillary study to further asses barriers to gardening and healthy eating (N = 16)

• Students at San Juan College, Dine College and Fort Lewis College interested in regional health disparities

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• Limitations: Our intervention was not intensive enough

• Present Work: In conjunction with focus groups, we are engaging adults through the family

• Future Directions: Attempt to estimate gardening intervention effect (note there are many programs around gardening – few with formal evaluation).

• Responsive to area of interest among Navajo (Gardening is becoming more prominent on the Navajo Nation)

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Food is Medicine: Examples of Warm Season Crops: Fruit are consumed

Tomato

BeansPeppers

Corn

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Examples of Warm Season Crops: Fruit are consumed

Zucchini

Melons

Cucumber

Squash

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Examples of Warm Season Crops: Generally Fruit are Eaten

Fruit TreesSweet Potato

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Examples of Cool Season Crops: Generally Roots and Leaves Eaten

Lettuce

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Examples of Cool Season Crops: Generally Roots and Leaves Eaten

BroccoliCabbage

Kale

All About Discovery!New Mexico State Universitynmsu.edu

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Examples of Cool Season Crops: Generally Roots and Leaves Eaten

Swiss Chard Mustards

All About Discovery!New Mexico State Universitynmsu.edu

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Examples of Cool Season Crops: Roots and Leaves Eaten

OnionPotato

All About Discovery!New Mexico State Universitynmsu.edu

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Examples of Cool Season Crops: Roots and Leaves Eaten

Radish

Beets

Peas

Beets

All About Discovery!New Mexico State Universitynmsu.edu

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HOW CAN SEASON EXTENSION HELP?

All About Discovery!New Mexico State Universitynmsu.edu

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All About Discovery!New Mexico State Universitynmsu.edu

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All About Discovery!New Mexico State Universitynmsu.edu

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QUESTIONS?

Desiree Deschenieddeschen@nmsu.edu(505)-960-7757

Kevin Lombardklombard@nmsu.edu(505)-960-7757