CDR Graydon Yatabe, RD, MPHOffice of the Director

NCCDPHP/Division of Community HealthCenters for Disease Control and Prevention

.

Promoting Nutrition in Indian

Country

At the end of this session, At the end of this session, participants will be able to:participants will be able to:

Identify successful strategies for Identify successful strategies for strengthening cultural competency in strengthening cultural competency in Indian communities Indian communities

Describe some of the characteristics of Describe some of the characteristics of traditional foodways and how dietitians can traditional foodways and how dietitians can strengthen the role of these foods in strengthen the role of these foods in health. health.

Identify steps to implementing The Healthy Identify steps to implementing The Healthy Start Act. Start Act.

Eagle Butte, SD

Lodge Grass, MT

Qualla Boundary, NCQualla Boundary, NC

Rough Rock in Rough Rock in Central NavajoCentral Navajo

Road to Fort Defiance Road to Fort Defiance from Tsailefrom Tsaile

Road to Black Mesa from Road to Black Mesa from PinonPinon

Planting the Planting the SeedSeed

What is What is Public Health Public Health Nutrition? Nutrition?

1.1. Improves or maintains optimum Improves or maintains optimum nutritional health nutritional health of the nation, state or of the nation, state or community community

2.2. Emphasizes health promotion and Emphasizes health promotion and disease preventiondisease prevention

What is What is Public Health Public Health Nutrition? (cont.)Nutrition? (cont.)

3.3. Uses Uses multiple, coordinated strategiesmultiple, coordinated strategies to to reach and influence the community, reach and influence the community, organizations and individuals that make up organizations and individuals that make up the communitythe community

4.4. Requires Requires organized and integratedorganized and integrated community nutrition community nutrition effortsefforts with leadership with leadership provided by the state and local health provided by the state and local health agencyagency

Public Health NutritionPublic Health Nutrition Core ResponsibilitiesCore Responsibilities

Needs Assessment and ReassessmentNeeds Assessment and Reassessment SurveillanceSurveillance Resource Identification and AllocationResource Identification and Allocation Evaluation and AssuranceEvaluation and Assurance Strategic Planning Strategic Planning Policy DevelopmentPolicy Development

LOGIC FRAMEWORK ILLUSTRATING CONCEPTUAL APPROACH TO NUTRITION & COMMUNITY HEALTH

Interventions Modifiable Determinants

Food Supply Factors -Agriculture policy

-Nutrition policy-Science and technology

-Food production, processing, storage and distribution

-Food fortification-Food safety

Environmental Factors

Availability & Price-Neighborhoods

-Schools-Worksites

-Homes-State and National

-Food and nutrition

assistance programs

Consumer Demand-Household resources

-Nutrition knowledge

-Cultural practices

-Psychosocial characteristics

-Taste and preferences

-Advertising and marketing

POPULATION FOOD INTAKE

Food Consumption Patterns (e.g. fruits, vegetables)

Intake of Nutrients and Food Components

VitaminsMinerals

FiberFats

Other food constituentsDietary supplements

AlcoholEnergy balance

Life StageRequirements

Pregnancy Lactation Childhood

Adolescence Adulthood

Older Adulthood

Intermediate Outcomes

Community Health

OutcomesPhysiologic Indicators

Growth

Adipose tissueMusculoskeletalGastrointestinal

MetabolicCardiovascularReproductiveImmunologicalNeurological

Genetics,Co-morbidities

Morbidity

Mortality

Measures ofHealth & Fitness

Quality of Life

PhysicalActivityPatterns

Primary Primary

SecondarySecondary

TertiaryTertiary

Three Levels of PreventionThree Levels of Prevention

IndividualIndividual

CommunityCommunity

System or EnvironmentalSystem or Environmental

Three Levels of Intervention Three Levels of Intervention

So We Want to Improve Lifestyle So We Want to Improve Lifestyle Behaviors …Behaviors …

Where do we put our resources and efforts?

6. Policy and Legislation Education

5. Changing Organizational Practices

4. Fostering Coalitions and Networks

3. Educating Providers

2. Promoting Community Education

1. Enhancing Individual Knowledge and Skills

Plan Develop goals and objectives

Create a logic model

Construct a formally facilitated strategic plan

Perform a community assessment

Develop lasting relationships

Plan Regularly review progress

Strategic marketing and product placement

Deliberate and continual evaluation

Data, data, data

Communicate success early and often

Mission Statement

Advancing a holistic approach to supporting healthy food ways in the Chinle Service area, from the seed to the table.

Commitment Statement

We commit to t’aa hwi’ ajit’e’ego (it’s up to you) through Ke’ (partnerships) by fostering evidence-based, community guided, policies and practices that support individuals and communities in making healthy food choices.

Watering the Watering the PlantPlant

Logic Model Objective: Create efficient and creative department that enhances services provided by division and ultimately

facilitates positive and healthy community food habits.

Inputs Outputsactivities

Outputsparticipants

Program Outcomes

initial intermediate long-term

Community Nutrition staff

Division of Public Health dept heads

student interns and other Public Health volunteers/interns

Community based programs and coordinators

CCHCF programs and dept

Resources Time

Direct care servicesWellness on Wheels; Referrals

for home MNT visits; MNT for Chinle Wellness Center users; Lifestyle Balance Program; Point of Purchase projects

Liaison and technical services Program development,

implementation and evaluation for IHS and tribal programs; Helping organization of IHS Navajo area wide nutrition professionals’ and related projects; Helping facilitate service unit and community wide initiatives that have a nutrition or nutrition related component; inservices and presentations for program and clinic staff.

Facilitating changeSocial marketing campaigns (ie,

VERB, Eat Well-Play Hard); Community or School based action planning for creating healthy nutrition policy;

Recruit for profession and department

Division of Public Health staff

CCHCF SUECCommunity

leadership, both formal and informal

Community based programs and coordinators

CCHCF programs and depts

NNDOH-SDPCommunity

within Chinle service area.

Discover and develop mutual goals/objectives

Identify and

coordinate services based on mutual goals and objectives.

Baseline community nutrition assessment.

Broaden knowledge of service area nutrition related challenges.

Full and competent staffing, thereby increasing availability of services.

Create well coordinated program that meets the needs of the community

Establish program as the expert to include in all community nutrition related initiatives and projects.

Create a bridge between NNDOH and other Navajo Nation divisions and programs with a nutrition component or focus.

Provide a basis from which to initiate and maintain nutrition related community coalitions

Bridge gap between clinical and public heatlh services, making connection more efficient.

Recruitment and professional development potential of local or, at the least, Navajo nutrition professionals

Movement towards a positive environmental change in food

ways. Help community

take responsibility and initiative in moving towards a positive environmental change in food ways.

Positive community and individual health outcomes

Three Pronged Service Approach

Direct Services

Technical and Liaison Services

Facilitating Policy and Environmental Change

Three Pronged Service Approach

Direct Services

Technical and Liaison Services

Facilitating Policy and Environmental Change

Three Pronged Service Approach

Direct Services

Technical and Liaison Services

Facilitating Policy and Environmental Change

Three Pronged Service Approach

Direct Services

Technical and Liaison Services

Facilitating Policy and Environmental Change

Our partners include:Our partners include:Local, Regional and National IHSLocal, Regional and National IHSLocal CommunityLocal CommunityRetail Food Retail Food MediaMediaNavajo Nation Navajo Nation Other tribal, state, regional, federal Other tribal, state, regional, federal

agencies and programs. agencies and programs. 

PartnersPartners

Local IHS Partners DietaryDietary Health Promotion Health Promotion Native MedicineNative Medicine Wellness Center Wellness Center Diabetes ProgramDiabetes Program Public Health Nursing Public Health Nursing

ClinicsClinics Clinical DepartmentsClinical Departments Health Care Providers Health Care Providers

Chinle Hospital Employee AssociationChinle Hospital Employee Association

Our Community Partners

• Parents• Elders• Iiná Coalition, Inc• Adabi• Talbot House• Chapter Houses• Farmers• Gardeners• Canyon de Chelly

Comprehensive Health Services

Schools:• Student Association• Teachers • Parent Association• Nurses• Coaches• Wild Cat Den• Dorm Assistants• Wellness Advisory

Committees• Food Service

Partners – Retail Foods

• Shamrock Foods• Aramark• Sysco• Bashas• Subway • Junction Restaurant• Coca Cola Distributors

Partners - Media

• KTNN

• Gallup Independent

• Navajo Times

Partners – Navajo Nation

• Dine’ College• Water Board• Navajo Housing Authority• Aging Services - Senior Centers• Community Health Representatives• WIC• Special Diabetes Project• Office of Dine’ Youth• TANF• Dept of Agriculture• Fire and Rescue• New Dawn• NTUA

• NN Police Department• Dept of Behavioral Health• Daycare/Head start• FDPIR• Chinle Youth Center• Social Services• ARISE• Institute for Integrated

Rural Development

Partners - State

• Dept of Economic Security

• Dept of Aging

• University of AZ Cooperative Extension

• Arizona Nutrition Network

Partners - Region• IHS- Several SRSU partners• University of NM Extension Services• NM State University• NM Farm to Table• Southwestern Regional Marketing

Network• PLANT – Promoting Local Agriculture and

Native Traditions (inactive)• USDA – Risk Management Agency• USDA – Soil Conservation Services• National Park Service• Yavapai County Public Health

Partners – National Level

• IHS Division of Diabetes Treatment and Prevention

• IHS National Nutrition Program

• USDA – Risk Management Agency

• Academic Institutions

FundingFunding

Staffing, staff development and trainingStaffing, staff development and training

Coordinating our vision/approach with partnersCoordinating our vision/approach with partners

Coordinating our progress with partnersCoordinating our progress with partners

No national or area public health nutrition vision or No national or area public health nutrition vision or planplan

Service ChallengesService Challenges

Service ChallengesService Challenges

Service ChallengesService Challenges

Service ChallengesService Challenges

Harvest

Community NutritionCoordinator

Office Assistant

Public Health Nutritionist

Health Technician- Nutrition

CommunityNutritionist

Public Health Nutritionist

Health Technician-Lactation Specialist

Health Technician-Breastfeeding Peer Counselor

Health Technician-Native Lifestyle

Network CoordinatorHealth Technician-

Garden Project (unfilled)

CSUDirector of Public Health

Central Navajo Public Health Consortium

Circle of Growth & Harmony The natural and balanced way to grow and change.

East: Nits1h1kees (Thinking) The first step in the circle is the birth of ideas for change and growth. It flows from the reflections in the fourth step and is the time when a whole group develops the spirit and mind to go steadily toward action. It includes the following thought processes:

Reason with intuition and logic. Think creativity and holistically. Understand needs and requirements. Analyze alternative ideas and solutions. Synthesize and integrate different perspectives.

These Essential Public Health Services support this step: Diagnose and investigate health problems and health hazards in the community. Research for new insights and innovative solutions to health problems. Symbols: Blanca Peak, white, white shell, dawn, sunrise, birth, spirit, spring, white corn South: Nahata (Planning)

The second step in the circle is development of ideas and strategies into action plans. It is a time when the whole group works together to provide the means for implementation. It includes the following actions: Plan and strategize. Determine responsibilities. Communicate through reading, writing, speaking, listening,

body language, and interpreting. Demonstrate systematic organization skills. Develop appropriate knowledge and skills. These Essential Public Health Services support this step: Develop policies and plans that support individual and community health efforts. Assure competent public health and healthcare workforce. Symbols: Mount Taylor, blue, turquoise, midday, high sun, puberty, charity, summer, blue corn.

Doorways: Ahilna’anish and Alhaa’acohwiinidzin (Partnership and Respect)

Consortium members enter into partnership. This provides the following foundations for growth. Mutual respect. Commitment. Positive relationships (k’4). Accountability. Collaboration These Essential Public Health Services support this step: Mobilize community partnerships and action to identify and solve health problems. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. Symbols: Huerfano Mountain, Gobernado Knob, soft goods, jewels, dew drops.

North: Sihasin (Reflecting) The fourth step in the circle is reflecting on the success of the planned change. It is a time when the whole group works together to make the change strong and stable. It includes the following ways: Reflect critically (wisdom). Evaluate outcomes. Demonstrate competency. Demonstrate confidence. Demonstrate effectiveness. Identify future needs. Incubate ideas. These Essential Public Health Services support this step: Monitor health status to identify and solve community health problems. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. Symbols: Mount Hesperus, black, black jet, might, old age, hope, winter, multicolored corn.

West: lin1 (Implementing) The third step in the circle is carrying the action plan. It is the time when the whole group works together to bring the plan to maturity. It includes the following steps: Act based on values, goals and objectives. Demonstrate quality participation, work and services. Achieve the planned change. Work cooperatively with each other. Evaluate progress. These Essential Public Health Services support this step: Inform, educate and empower people about health issues. Enforce laws and regulations that protect health and ensure safety. Symbols: San Francisco Peak, yellow, abalone, evening, sunset, maturity, love, fall, yellow corn.

Adapted from the Chinle Service Unit Performance Improvement Cycle

SHÁBIK’EHGO

AS’AH OODÁÁŁ

!daa !h1y3Taking Care of Self

!d1hod7lzinRespect & Reverence

!d44h1niih Thought and Concern for

Self

!daa H33h HasinLimits

NAVAJO WELLNESS MODEL

Hayoołkááł Dawn

Nohodeetł‘iizh

Daylight

Nohootsoi, Sunset

Chahałheeł

Night Time

Shábik’ehgo Hahod7t’4, Path of Sun Environment

Shábik’ehgo K44hwiit’9, Path of Sun Community

Nitsáhákees Thinking

Nahat’á Planning

Iiná Living

Siihasin Reflecting

Shábik’ehgo K’é Dadii’n7, Path of Sun Kinship

K’é Kinship

!d44hoolz88h Introduction

K’4hodiindzin Kinship Practice

K’é bee siihasin Kinship is stability

Take Home Messages

Know the evidence and data

Have the evidence and data ready

Keep in mind the big picture

Identify supporters, champions and partners early in the game

Take Home Messages

Pick your lowest hanging fruit first

Make a plan and follow it, yet expect to be fluid

Market your public health message… relentlessly

Evaluate your program and data

Navajo Nation Worksite BF Navajo Nation Worksite BF LegislationLegislation

199619962006- Fort Defiance BF Task Force2006- Fort Defiance BF Task ForceGrass roots approachGrass roots approachAgency Council includedAgency Council includedThe NN Worksite BF ResolutionThe NN Worksite BF Resolution

Healthy Start ActHealthy Start Act

Navajo Nation LawNavajo Nation Law

BF women provided a clean private area BF women provided a clean private area to BF or use a breast pumpto BF or use a breast pump

Unpaid flexible breaksUnpaid flexible breaks

Legislative ProcessLegislative Process

Ft. Defiance BF Task ForceFt. Defiance BF Task Force IHS, Tribe partnershipsIHS, Tribe partnershipsConcept paper, Chapter Resolution, Concept paper, Chapter Resolution,

Council ResolutionCouncil ResolutionChapter Resolution Passage; Agency Chapter Resolution Passage; Agency

Councils; Health BoardsCouncils; Health Boards

Percent of Chapters with Workplace Percent of Chapters with Workplace Breastfeeding Resolutions, Navajo Nation, 2008Breastfeeding Resolutions, Navajo Nation, 2008

Chapters

100%

70-95%

Success!Success!

Over 95% of 110 chapters passed the Over 95% of 110 chapters passed the ResolutionResolution

Navajo Nation Council passed it 64 to 0 in Navajo Nation Council passed it 64 to 0 in Oct. 2008 Oct. 2008

Continuance of traditional cultural, Continuance of traditional cultural, maintains kinship responsibilities and maintains kinship responsibilities and promote health to ensure harmony!promote health to ensure harmony!

Navajo Tribal CouncilFort Defiance BF Task

Force Members

2008 Navajo Nation Healthy Start Act

Amanda Singer, Ora Nez, Roberta Duncan

How will the law be enforced?How will the law be enforced?

Department of Personnel Management will write Department of Personnel Management will write the worksite breastfeeding policythe worksite breastfeeding policy

Department of Justice will work in partnership to Department of Justice will work in partnership to make the process work; hear grievances of make the process work; hear grievances of employeesemployees

Navajo Nation Labor Commission is authorized to Navajo Nation Labor Commission is authorized to conduct hearings involving allegations of violations conduct hearings involving allegations of violations of the Act.of the Act.

Office of Navajo Labor Relations will monitor & Office of Navajo Labor Relations will monitor & enforce compliance in accordance to the Navajo enforce compliance in accordance to the Navajo Preference in Employment ActPreference in Employment Act

Our motivation,

Our inspiration

Questions?Questions?