Family Spirit: Strengthening Public Health Outreach to Improve Maternal and Child Health on the Navajo NationDarlene 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 Program Replication

Recruitment

Program Evaluation Results Con’t

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 ofthe 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.

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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 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

     

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

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

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

Stages of Replication

Planning – needs assessment;

community buy-in; analysis of human resources to carry

out program

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

Sustainability –Integration into

HPDP/PHN/CHR programs; train the

trainer; program expansion

Purpose of Referral # Received

Missed prenatal appointments

2

Maternal history of substance abuse

3

Lactation counseling 5

Postpartum referral 5

Client request to enroll in program

5

Total 20

1) Session Summary Form 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.

2) Quality Assurance Form Used to evaluate health educators in three domains: 1) visit structure; 2) relationship to participant; and 3) adherence, competence, and flexibility.

3) 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

Self-report to assess parental competence.

8) Home Safety Check Observational tool to measure basic home safety.

9) Child Development Screen 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.

Table 4: Screening and Outcome Measures for Children

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.

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.

References1. 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.