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.
Background
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.
Program Replication
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
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
Program Evaluation
 Process, screening, and outcome evaluation measures used
throughout the life of the program
 Patient surveys indicated high demand for comprehensive preand 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)
Sustainability –
Integration into
HPDP/PHN/CHR
programs; train the
trainer; program
expansion
Recruitment
Table 2: Process Measures
 Increased maternal involvement
1)
Session Summary Form
Quality Assurance Form
 Family Spirit referral template created for efficiency
 Community Health Department received approximately 20 Family
Spirit referrals since January 2013
# Received
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 managers and 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
Missed prenatal
appointments
2
Maternal history of
substance abuse
3
Lactation counseling
5
Postpartum referral
5
Client request to enroll in
program
5
Total
Used to evaluate health educators in
three domains: 1) visit structure; 2)
relationship to participant; and 3)
adherence, competence, and flexibility.
 Fewer behavior problems in mothers
Independent Knowledge
Assessments
Multiple choice tests that health
educators must score 80% or higher
on before they are certified to teach the
lesson to a participant.
4)
Satisfaction Questionnaire
A self-report form completed by the
participant to gather feed-back on
Family Spirit visits.
5) Independent Knowledge
Assessments
A series of 5-item multiple choice
tests, one for each Family Spirit
lesson, given to participants before
and after the lesson to assess
knowledge levels.
6)
Maternal Depression Scale
The Centers for Epidemiological
Studies-Depression Scale (CES-D) is
a 20-item self -report depression
scale. If a participant scores higher
than 28 (out of 60), she should be
referred to mental health services.
7)
Parent Self-Efficacy and
Competence
Home Safety Check
Self-report to assess parental
competence.
Observational tool to measure basic
home safety.
8)
Table 1: Provider and Community Referrals
Purpose of Referral
 Reduced maternal depression
3)
 CHRs, community members, and schools send verbal or written
referrals to Community Health Department
20
Table 4: Screening and Outcome Measures for
Children
9)
Child Development Screen
At one year postpartum:
Used by health educator to summarize
the details of each visit, including
length of visit, purpose of visit,
lesson(s) taught, referrals made,
concerns, issues to follow-up on, date
of next visit.
Table 3: Screening and Outcome Measures for Mothers
 Providers send Family Spirit pre- and post-natal referrals
electronically to Community Health Department
Family Spirit Outcome Data from Pilot Trials
 Increased maternal knowledge
2)
Planning – needs
assessment;
community buy-in;
analysis of human
resources to carry
out program
Results Con’t
 Evaluation tools designed & tested by Navajo and White
Mountain Apache communities and Johns Hopkins Center for
American Indian Health
 Isolated communities with dispersed homes and great
distances to clinic limit access to resources
Insert your text here
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.
Stages of Replication
The Ages and Stages Questionnaire
(ASQ) is a structured interview and
evaluation tool used to identify infants
and toddlers who may have
developmental delays and allows for
early referral to services.
Results
 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.
 Reduced parent stress
 Increased parent self-efficacy
 Improved home safety attitudes
 Fewer behavior problems in infants at 1 year
 Higher impact among mothers who used substances at
baseline
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 followup 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.
References
1. 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.
2. 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.
5. 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.