Community Health Representative Workforce: Meeting the Moment in American Indian Health Equity

In 2018, the Community Health Representative (CHR) workforce celebrated their 50th year and serve as the oldest and only federally funded Community Health Worker (CHW) workforce in the United States. CHRs are a highly trained, well-established standardized workforce serving the medical and social needs of American Indian communities. Nationally, the CHR workforce consists of ~1,700 CHRs, representing 264 Tribes. Of the 22 Tribes of Arizona, 19 Tribes operate a CHR Program and employ ~250 CHRs, equivalent to ~30% of the total CHW workforce in the state. Since 2015, Tribal CHR Programs of Arizona have come together for annual CHR Policy Summits to dialogue and plan for the unique issues and opportunities facing CHR workforce sustainability and advancement. Overtime, the Policy Summits have resulted in the Arizona CHR Workforce Movement, which advocates for inclusion of CHRs in state and national level dialogue regarding workforce standardization, certification, training, supervision, and financing. This community case study describes the impetus, collaborative process, and selected results of a 2019–2020 multi-phase CHR workforce assessment. Specifically, we highlight CHR core roles and competencies, contributions to the social determinant of health and well-being and the level to which CHRs are integrated within systems and teams. We offer recommendations for strengthening the workforce, increasing awareness of CHR roles and competencies, integrating CHRs within teams and systems, and mechanism for sustainability.

Development and Dissemination of a Strengths-Based Indigenous Children's Storybook: “Our Smallest Warriors, Our Strongest Medicine: Overcoming COVID-19”

The traditions, strengths, and resilience of communities have carried Indigenous peoples for generations. However, collective traumatic memories of past infectious diseases and the current impact of the coronavirus disease 2019 (COVID-19) pandemic in many Indigenous communities point to the need for Indigenous strengths-based public health resources. Further, recent data suggest that COVID-19 is escalating mental health and psychosocial health inequities for Indigenous communities. To align with the intergenerational strengths of Indigenous communities in the face of the pandemic, we developed a strengths- and culturally-based public health education and mental health coping resource for Indigenous children and families. Using a community-engaged process, the Johns Hopkins Center for American Indian Health collaborated with 14 Indigenous and allied child development, mental health, health communications experts and public health professionals, as well as a Native American youth artist. Indigenous collaborators and Indigenous Johns Hopkins project team members collectively represented 12 tribes, and reservation-based, off-reservation, and urban geographies. This group shared responsibility for culturally adapting the children's book “My Hero is You: How Kids Can Fight COVID-19!” developed by the Inter-Agency Standing Committee Reference Group on Mental Health and Psychosocial Support in Emergency Settings and developing ancillary materials. Through an iterative process, we produced the storybook titled “Our Smallest Warriors, Our Strongest Medicine: Overcoming COVID-19” with content and illustrations representing Indigenous values, experiences with COVID-19, and strengths to persevere. In addition, parent resource materials, children's activities, and corresponding coloring pages were created. The book has been disseminated online for free, and 42,364 printed copies were distributed to early childhood home visiting and tribal head start programs, Indian Health Service units, tribal health departments, intertribal, and urban Indigenous health organizations, Johns Hopkins Center for American Indian Health project sites in partnering communities, schools, and libraries. The demand for and response to “Our Smallest Warriors, Our Strongest Medicine: Overcoming COVID-19” demonstrates the desire for Indigenous storytelling and the elevation of cultural strengths to maintain physical, mental, emotional, and spiritual health during the COVID-19 pandemic.

Cultural Sources of Strength and Resilience: A Case Study of Holistic Wellness Boxes for COVID-19 Response in Indigenous Communities

The COVID-19 pandemic has had disproportionately severe impacts on Indigenous peoples in the United States compared to non-Indigenous populations. In addition to the threat of viral infection, COVID-19 poses increased risk for psychosocial stress that may widen already existing physical, mental, and behavioral health inequities experienced by Indigenous communities. In recognition of the impact of COVID-19 related psychosocial stressors on our tribal community partners, the Johns Hopkins Center for American Indian Health Great Lakes Hub began sending holistic wellness boxes to our community partners in 11 tribal communities in the Midwestern United States and Canada in summer of 2020. Designed specifically to draw on culturally relevant sources of strength and resilience, these boxes contained a variety of items to support mental, emotional, cultural, and physical wellbeing. Feedback from recipients suggest that these wellness boxes provided a unique form of COVID-19 relief. Additional Johns Hopkins Center for American Indian Health offices have begun to adapt wellness boxes for the cultural context of their regions. This case study describes the conceptualization, creation, and contents of these wellness boxes and orients this intervention within a reflection on foundations of community-based participatory research, holistic relief, and drawing on cultural strengths in responding to COVID-19.

Building a Narrative of Equity: Weaving Indigenous Approaches into Community-Engaged Research

In 2020, global injustice has taken center stage during the uprising of the Black Lives Matter movement and other social movements. Activists are calling attention to longstanding disparities in health outcomes and an urgent need for justice. Given the global socio-political moment, how can health researchers draw on current critical theory and social movements to create structures for equitable outcomes in health research and practice? Here, we demonstrate principles for effective health research and social justice work that builds on community-engaged approaches by weaving critical Indigenous approaches into structural project designs. Our project, “Health Resilience among American Indians in Arizona”, brought new and seasoned researchers together to collect and analyze data on the knowledge of healthcare providers concerning American Indian health and well-being. Four years after the conclusion of the project, the team developed and created a post-project self-assessment to investigate lasting impacts of project participation. In this communication, we discuss the principles of defining and measuring the capacity to build together. This work responds to the call from Indigenous scholars and community leaders to build an internal narrative of change. While we will not present the full instrument, we will discuss building a strong foundation using the principles of engagement for planning and implementing justice and change.

Urban American Indian Caregiving during COVID-19

This study examined the experience of caregiving during a pandemic by asking five questions about how COVID-19 was impacting twenty American Indian caregivers providing care to a family member who was disabled, elderly, or had a chronic health condition. Interviews were conducted via Zoom. Themes identified were concern about the care recipient contracting COVID-19, increased caregiving intensity, increased Medical care issues, changes to caregiver health and health behaviors, and support received and increased need for support during the pandemic (material and emotional). Responses indicate that tribes and American Indian health organizations should initiate services that can support caregivers during the pandemic or make changes to their caregiver programs.