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Family Spirit: Strengthening Public Health Outreach to Improve Maternal and Child Health on the Navajo Nation

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  1. Family Spirit: Strengthening Public Health Outreach to Improve Maternal and Child Health on the Navajo Nation Darlene Yazzie, CHR¹, Mae-Gilene Begay, MSW, Program Director Navajo Nation CHR Outreach Program¹, Shirley Cisco, CHR Supervisor¹, Sue Nicholls, CHR¹, Shirley Capitan, CHR¹, Doris Tsinnijinnie, CHR¹, Darlene Begay, Community Health Director², Charlene Poyer, HPDP², Michelle Valentine, HPDP² Christa Zubieta, PHN, MPH³, Eric Howser, PHN, MPA³, Thomas Stephens, PHN,MPH³, Marie Bastin, PHN, MPH³, Ann Vaughn, MD, Clinical Director* ¹Navajo Nation Community Health Representative Outreach Program. ² IHS Four Corners Regional Health Center Community Health Services/Health Promotion Disease Prevention. ³ IHS Four Corners Regional Health Center Community Health Services/Public Health Nursing Department. *IHS Four Corners Regional Health Center Ambulatory Care Clinic. Stages of Replication Background Program Replication Program Evaluation Results Con’t • Process, screening, and outcome evaluation measures used throughout the life of the program • Evaluation tools designed & tested by Navajo and White Mountain Apache communities and Johns Hopkins Center for American Indian Health • Table 2: Process Measures • Table 3: Screening and Outcome Measures for Mothers Training -1 week training on the Family Spirit Curriculum provided by Johns Hopkins staff Implementation – social marketing to community and clinic staff; recruit clients via referrals from providers and CHRs Nearly half (46%) of American Indian females begin childbearing in adolescence, and bear twice as many children while teenagers as the general US population (DHHS,2004). Adolescent American Indian parents face a myriad of challenges that adversely impact healthy pregnancies and effective parenting skills, including limited access to prenatal care, poor health status, substance abuse, depression, and low educational attainment (Keppel et al., 2002). Research shows that poor parenting and coping skills can lead to long term maternal and child emotional and behavioral problems and poor health outcomes (Patterson et al., 1989). Navajo and White Mountain Apache communities, in collaboration with the Johns Hopkins Center for American Indian Health, designed the Family Spirit Program in response to the growing needs of adolescent American Indian families. The Family Spirit Program is a comprehensive maternal and child intervention that consists of one on one or group education delivered by a health educator (i.e. health technician, public health nurse (PHN), community health representative (CHR)) to adolescent parents. The goal of the Family Spirit Program is to teach adolescent mothers and fathers effective parenting, coping and problem solving skills by using a culturally appropriate curriculum that consists of 63 lessons, ranging from prenatal care to substance abuse prevention. The curriculum is taught sequentially or individually based on the client’s preference. Family Spirit visits take place any time from early in the prenatal period until the child is 3 years of age. Visit settings include the home, clinic, schools, or other community locations. In January 2013, the Indian Health Services (IHS) Four Corners Regional Health Center (FCRHC) began implementation of the Family Spirit Program via an IHS/Tribal collaboration, consisting of IHS Community Health staff (Health Promotion/Disease Prevention staff and PHNs) and Tribal CHRs. The communities of the FCRHC are dispersed and geographically isolated. Family Spirit home visits have enabled Community Health staff and CHRs to deliver services to the most vulnerable families. • Family Spirit Outcome Data from Pilot Trials • At one year postpartum: • Increased maternal knowledge • Increased maternal involvement • Reduced maternal depression • Reduced parent stress • Increased parent self-efficacy • Improved home safety attitudes • Fewer behavior problems in mothers • Fewer behavior problems in infants at 1 year • Higher impact among mothers who used substances at baseline • Why Family Spirit in the Communities of the FCRHC? • Majority of women of reproductive age in FCRHC communities are 15-30 years old • 75% of pregnant women in FCRHC communities are 15-25 years old and first time parents • Isolated communities with dispersed homes and great distances to clinic limit access to resources • Patient surveys indicated high demand for comprehensive pre- and post-natal education and support • Analysis of social determinants of health identified many factors influencing parenting that could be addressed by Family Spirit • Figure 1: Social Determinants of Health for Adolescent Navajo • Mothers and Their Children (adapted from La Bonte, 1998) • PHN/CHR/HPDP Model of Program Implementation • Better integrate IHS and Tribal community outreach programs with clinic based care • Build local capacity by strengthening CHR program • CHRs have trust with the community and knowledge of at risk clients and traditional Navajo teachings • Improve use of human resources in the community by enhancing team work, communication, & avoiding replication of services • PHNs, CHRs, and HPDP working to the highest licensure • (PHNs as case managersand data collectors; CHRs as health • educators in the home; HPDP as community organizers) • Improve communication and continuity of care with clinic providers via monthly huddles and Electronic Health Record (EHR) documentation of Family Spirit visits Planning – needs assessment; community buy-in; analysis of human resources to carry out program Sustainability –Integration into HPDP/PHN/CHR programs; train the trainer; program expansion Discussion • The pre – and post-natal population in FCRHC communities is highly mobile. Long term participant retention in Family Spirit has posed a challenge. • Family Spirit has only been implemented at two IHS facilities on the Navajo Nation. Family Spirit expansion to other IHS and Tribal facilities is essential to assure continuity of care throughout the Navajo Nation. • IHS Headquarters has expressed interest in piloting Family Spirit using the PHN/CHR implementation model at three sites across Indian Country. Interest in Family Spirit is growing exponentially each year to meet the needs of adolescent American Indian parents. • Tribal CHRs are not currently charting in EHR. Information from their home visits is inaccessible to providers and PHNs, which poses challenges with follow-up care. PHNs currently receive verbal reports from CHRs about patient follow-up. There is a strong push throughout IHS to have the CHR program chart in the EHR to further integrate community outreach programs. • Funding for programs poses a constant challenge. However, there are currently federal funds available for maternal and child health home visiting interventions in Indian Country. The Affordable Care Act (ACA) is also potentially expanding billing for PHN and CHR home visitation services. Recruitment • Providers send Family Spirit pre- and post-natal referrals electronically to Community Health Department • Family Spirit referral template created for efficiency • CHRs, community members, and schools send verbal or written referrals to Community Health Department • Community Health Department received approximately 20 Family Spirit referrals since January 2013 • Table 1: Provider and Community Referrals Insert your text here Table 4: Screening and Outcome Measures for Children Results References • From 1999-2004 and 2005-2011, Navajo and White Mountain Apache communities and the Johns Hopkins Center for American Indian Health conducted three randomized controlled trails (RCTs) to evaluate the effectiveness of the Family Spirit intervention. • Community based participatory research (CBPR) was a key component of each trial. American Indian professionals and paraprofessionals were involved in research design, data collection, and evaluation. Barlow, A., Varipatis-Baker, E., Speakman, K., et al. (2006). Home-visiting intervention to improve child care among American Indian adolescent mother. Arch PediatrAdolescMed, 160, 1101-1107. DHHS. (2004). Trends in Indian health, 2000-2001. Rockville: Public Health Service, Indian Health Service, US Government Printing Office. 3. Keppel, K.G., Pearcy, J.N., Wagener, D.K. (2002). Trends in racial and ethnic-specific rates for the health status indicators: United States, 1990-1998. Healthy People 2000 Stat Note, 23, 1-6. 4. Labonte, R. (1998). A community development approach to health promotion: A background paper on practice tensions, strategic models and accountability requirements for health authority work on the broad determinants of health (selected excerpts). Kingston, Ontario, Canada. Patterson,G.R., DeBaryshe, B.D., Ramsey, E. (1989). A developmental perspective on antisocial behavior. American Psychologist, 44, 329-335. 6. Walkup, J., Barlow, A., Mullany, B., et al. (2009). A randomized controlled trial of a paraprofessional delivered in-home intervention for young reservation based American Indian mothers. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 591-601.

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