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Introduction: Developmental Delay (DD) is highly common in American Indian and Alaska Native (AI/AN; Indigenous) toddlers and leads to high numbers of AI/AN children who eventually need special education services. AI/AN children are 2.89 times more likely to receive special education compared to other children in the U.S., yet developmental disorders are more frequently under diagnosed and untreated in AI/AN infants and toddlers. DD, which can be identified as early as toddlerhood, can lead to negative impacts on developmental trajectories, school readiness, and long-term health. Signs of DD can be identified early with proper developmental screening and remediated with high quality early intervention that includes effective parent training. There are many evidence-based language facilitation interventions often used in Early Intervention programs. However, in communities in rural parts of the Navajo Nation where there are limited services and resources, infants and toddlers with early signs of DD are often missed and do not get the culturally responsive support and evidence-based intervention they deserve., Methods: The community-based +Language is Medicine (+LiM) study team partnered with tribal home visitors, community members, and a Diné linguist/elder using a collaborative virtual workgroup approach in 2021 and 2022 to present the +LiM pilot study aims and to discuss strategies for enhancing a language intervention for toddlers experiencing DD in their tribal community. This paper will detail the stages of community engagement, intervention enhancement and preparation for field testing of the +LiM intervention to address elevated rates of DD in toddlers in the Northern Agency of the Navajo Nation., Results: Two major outcomes from this collaborative workgroup included: (1) a team-initiated redefining of language nutrition to align with Indigenous values that center cultural connectedness and native language use and (2) a five-lesson caregiver-facilitated curriculum titled +Language is Medicine which includes caregiver lessons on language nutrition, language facilitation, shared book reading, pretend play, and incorporation of native language into home routines. These two workgroup outcomes were leveraged to develop a pilot pre-/post-intervention study to test the effectiveness of the +LiM intervention with caregiver-toddler dyads living on the Navajo Nation., Discussion: Delivering tailored child interventions through tribal home visiting are cost-effective and innovative methods for reaching reservation-based families who benefit from culturally responsive parent coaching and instruction. The +LiM team has applied a precision tribal home visiting approach to enhance methods of early intervention for children with DD. Our enhancement process was grounded in Indigenous community-based participatory research that centered culture and language., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Billey, Kushman, Meese, Martin, Jim, Austin-Garrison and Allison-Burbank.)

Importance: Underutilization of guideline-directed medical therapy for heart failure with reduced ejection fraction is a major cause of poor outcomes. For many American Indian patients receiving care through the Indian Health Service, access to care, especially cardiology care, is limited, contributing to poor uptake of recommended therapy., Objective: To examine whether a telehealth model in which guideline-directed medical therapy is initiated and titrated over the phone with remote telemonitoring using a home blood pressure cuff improves guideline-directed medical therapy use (eg, drug classes and dosage) in patients with heart failure with reduced ejection fraction in Navajo Nation., Design, Setting, and Participants: The Heart Failure Optimization at Home to Improve Outcomes (Hózhó) randomized clinical trial was a stepped-wedge, pragmatic comparative effectiveness trial conducted from February to August 2023. Patients 18 years and older with a diagnosis of heart failure with reduced ejection fraction receiving care at 2 Indian Health Service facilities in rural Navajo Nation (defined as having primary care physician with 1 clinical visit and 1 prescription filled in the last 12 months) were enrolled. Patients were randomized to the telehealth care model or usual care in a stepped-wedge fashion, with 5 time points (30-day intervals) until all patients crossed over into the intervention. Data analyses were completed in January 2024., Intervention: A phone-based telehealth model in which guideline-directed medical therapy is initiated and titrated at home, using remote telemonitoring with a home blood pressure cuff., Main Outcomes and Measures: The primary outcome was an increase in the number of guideline-directed classes of drugs filled from the pharmacy at 30 days postrandomization., Results: Of 103 enrolled American Indian patients, 42 (40.8%) were female, and the median (IQR) age was 65 (53-77) years. The median (IQR) left ventricular ejection fraction was 32% (24%-36%). The primary outcome occurred significantly more in the intervention group (66.2% vs 13.1%), thus increasing uptake of guideline-directed classes of drugs by 53% (odds ratio, 12.99; 95% CI, 6.87-24.53; P < .001). The number of patients needed to receive the telehealth intervention to result in an increase of guideline-directed drug classes was 1.88., Conclusions and Relevance: In this heart failure trial in Navajo Nation, a telephone-based strategy of remote initiation and titration for outpatients with heart failure with reduced ejection fraction led to improved rates of guideline-directed medical therapy at 30 days compared with usual care. This low-cost strategy could be expanded to other rural settings where access to care is limited., Trial Registration: ClinicalTrials.gov Identifier: NCT05792085.

Tribal Colleges and Universities in the United States and Ethnic Minority-Serving Institutions in China play a significant role in changing the underrepresented status of American Indians and Alaska Natives (AIANs) and Chinese Ethnic Minorities (CEMs) in their respective higher education systems. This comparative study of two ethnic minority-serving institutions—Diné College in the US and Yanbian University in China—examines strategies and practices each institution uses to address challenges in serving Navajo and Korean Chinese students and communities. Through conducting semi-structured interviews with senior administrators from two institutions and AIAN and CEM content area experts, this study confirms that Diné College and Yanbian University play important roles in providing higher education opportunities and preserving indigenous and ethnic cultures and languages. From a comparative perspective, the efforts of Diné College and Yanbian University in addressing challenges differ because of their respective political and higher education contexts. [ABSTRACT FROM AUTHOR]

Background: Drinking water instead of sugary drinks is key to reducing health disparities. Since beverage habits are shaped by complex personal, community, and environmental factors, community input is critical to design any intervention promoting water., Objectives: We worked with community partners to design a program to promote healthy beverage habits among young Navajo children., Methods: The socioecological model, community-based participatory methods, and strengths-based principles shaped our process. In Phase 1, multigenerational feedback taught us about the cultural importance of water and how water quality concerns influence beverage choices. In Phase 2, our Water is K'é Community Advisory Group played a leading role to design the intervention centered around cultural connection, health literacy, and water access., Lessons Learned: Water is K'é was created through community partnership. Community listening and mini-pilots take time but allows the program to meet community's needs and interests., Conclusions: The solutions to health disparities lie within the community itself.

Context: The Healthy Diné Nation Act (HDNA) of 2014 included a 2% tax on foods of little-to-no-nutritious value ("junk foods") on the Navajo Nation. The law was the first ever in the United States and any Indigenous nation worldwide with a population at a high risk for common nutrition-related conditions. To date, research on community support for food tax legislation among Indigenous nations is entirely lacking., Objective: To assess the extent of support for the HDNA and factors associated with support including sociodemographic variables, knowledge of the HDNA, nutrition intake, and pricing preferences., Design: Cross-sectional survey., Setting: The Navajo Nation., Participants: A total of 234 Navajo Nation community members across 21 communities., Outcome Measures: The percentage of participants who were supportive of the HDNA., Results: Participants were 97% Navajo, on average middle-aged, 67% reported an income below $25 000 annually, and 69.7% were female. Half of the respondents said they "support" (37.4%) or "strongly support" (13.0%) the tax, while another 35% of people said they were neutral or somewhat supportive; 15% did not support the tax. Participants with higher income ( P = .025) and education ( P = .026) and understanding of the legislation ( P < .001 for "very well" vs "not at all") had increased odds of greater support, as did people who believed that the HDNA would make Navajo people healthier (vs not, P < .001). Age, gender, language, and reported nutrition intake (healthy or unhealthy) were not associated with HDNA support, but participants willing to pay 5% or 12%-15% higher prices for fast food and soda had increased odds of greater support ( P values range from .023 to <.001)., Conclusions: The majority of Navajo community members surveyed were moderately supportive of the Navajo Nation tax on unhealthy foods. Higher income and education and understanding of the law were associated with greater support, but nutrition intake was not., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc.)

A 2007 study by Regier, Kay, and Khetarpal purports to show that universal categories emerge as a result of optimal partitioning of color space. Regier, Kay, and Khetarpal only consider color categorizations of up to six categories. However, in most industrialized societies eleven color categories are observed. This paper shows that when applied to the case of eleven categories, Regier, Kay, and Khetarpal’s optimality criterion yields unsatisfactory results. Applications of the criterion to the intermediate cases of seven, eight, nine, and ten color categories are also briefly considered and are shown to yield mixed results. We consider a number of possible explanations of the failure of the criterion in the case of eleven categories, and suggest that, as color categorizations get more complex, further criteria come to play a role, alongside Regier, Kay, and Khetarpal’s optimality criterion. [ABSTRACT FROM AUTHOR]

From the start of the COVID-19 pandemic on the Navajo Nation, Diné (Navajo) traditional knowledge holders (TKHs), such as medicine men and women and traditional practitioners, contributed their services and healing practices. Although TKHs are not always fully acknowledged in the western health care system, they have an established role to protect and promote the health of Diné people. To date, their roles in mitigating the COVID-19 pandemic have not been fully explored. The purpose of this research was to understand the social and cultural contexts of the COVID-19 pandemic and vaccines based on the roles and perspectives of Diné TKHs. A multi-investigator consensus analysis was conducted by six American Indian researchers using interviews with TKHs collected between December 2021-January 2022. The Hózhó Resilience Model was used as a framework to analyze the data using four parent themes: COVID-19, harmony and relationships, spirituality, and respect for self and discipline. These parent themes were further organized into promoters and/or barriers for 12 sub-themes that emerged from the data, such as traditional knowledge, Diné identity, and vaccine. Overall, the analysis showed key factors that could be applied in pandemic planning and public health mitigation efforts based on the cultural perspective of TKHs.

Abstract: Background: Indigenous populations around the world have consistently been shown to bear a greater burden of disease, death and disability than their non-Indigenous counterparts. Despite this, little is known about what constitutes cost-effective interventions in these groups. The objective of this paper was to assess the global cost-effectiveness literature in Indigenous health to identify characteristics of successful and unsuccessful interventions and highlight areas for further research. Methods and Findings: A systematic review of the published literature was carried out. MEDLINE, PSYCINFO, ECONLIT, EMBASE and CINAHL were searched with terms to identify cost-effectiveness evaluations of interventions in Indigenous populations around the world. The WHO definition was followed in identifying Indigenous populations. 19 studies reporting on 27 interventions were included in the review. The majority of studies came from high-income nations with only two studies of interventions in low and middle-income nations. 22 of the 27 interventions included in the analysis were found to be cost-effective or cost-saving by the respective studies. There were only two studies that focused on Indigenous communities in urban areas, neither of which was found to be cost-effective. There was little attention paid to Indigenous conceptions of health in included studies. Of the 27 included studies, 23 were interventions that specifically targeted Indigenous populations. Outreach programs were shown to be consistently cost-effective. Conclusion: The comprehensive review found only a small number of studies examining the cost-effectiveness of interventions into Indigenous communities around the world. Given the persistent disparities in health outcomes faced by these populations and commitments from governments around the world to improving these outcomes, it is an area where the health economics and public health fields can play an important role in improving the health of millions of people. [ABSTRACT FROM AUTHOR]

This essay explores the process and issues related to community collaborative research that involves Native Americans generally, and specifically examines the Navajo Nation's efforts to regulate research within its jurisdiction. Researchers need to account for both the experience of Native Americans and their own preconceptions about Native Americans when conducting research about Native Americans. The Navajo Nation institutionalized an approach to protecting members of the nation when it took over Institutional Review Board (IRB) responsibilities from the US Indian Health Service (IHS) in 1996. While written regulations for the Navajo Nation IRB are not dissimilar, and in some ways are less detailed than those of the IHS IRB, in practice the Navajo Nation allows less flexibility. Primary examples of this include not allowing expedited review and requiring prepublication review of all manuscripts. Because of its broad mandate, the Navajo Nation IRB may also require review of some projects that would not normally be subject to IRB approval, including investigative journalism and secondary research about Navajo People that does not involve direct data collection from human subjects. [ABSTRACT FROM AUTHOR]

A commentary on the article "Protecting Navajo People Through Tribal Regulation of Research," by D. Brugge and M. Missaghian is presented. According to Brugge and Missaghian, it is the historical treatment of native communities that frames contemporary research practices. The challenge for researchers and American Indian communities is discovering shared values as well as finding ways to balance disparate belief systems.