By: Sehn, H., Muskett, O., Barton, S., Shirley, L. John, H., Malone, J., Begay, M., Shin, S., presented on behalf of the Navajo Nation CHR Program.
Roughly the size of West Virginia, the Navajo Nation is the largest Native American reservation covering portions of Arizona, New Mexico, and Utah and has a population of over 173,000. It is composed of 110 geographic areas, or Chapters, that are the seat of local government. Community Health Representatives (CHRs) are employed by the Navajo Nation’s Division of Health and collaborate closely with health facilities, especially with the Public Health Nursing (PHN) Department to provide team-based care to their clients. CHRs are a vital resource in the community addressing environmental and clinical factors that contribute to poor health.
Why did you become a CHR?
CHRs are highly qualified professionals, and passionate about their work. A CHR must have a high school diploma, be a Certified Nursing Assistant, have CPR certification, first aid training, food handler’s permit, and complete courses for public health certification. They must be bilingual, and ideally come from the community they serve. Beyond that, they have certifications in FEMA Emergency Management; Lead Trainer in NHLBI’s Honoring the Gift of Heart Health curriculum; Phlebotomy; and Suicide Prevention.
Many CHRs refer to themselves as “jacks of all trades.” During home visits, in addition to providing health education, monitoring vitals, and providing moral support, they make sure clients are safe and assist them to take precautions to prevent falls and injury. In the winter, they help chop wood for clients and make sure they have enough to eat. CHRs frequently check on those living in remote areas to ensure they are well, especially in times of snow and mud. Sometimes they clean for clients, do dishes, or cook for them. Many community members are confronting social and economic challenges; 42% of adults over 25 are unemployed, 44% live below the federal poverty line, many lack access to healthy foods, electricity, and over 70,000 individuals, roughly one-third of the population living in Navajo Nation have no running water. In addition, many individuals are living with health conditions such as obesity, diabetes (affecting 22% of adults), high blood pressure, and, mental and behavioral health challenges.
The Community Outreach and Patient Empowerment (COPE) Project, a partnership between the Navajo Nation CHR Program, Indian Health Service, Brigham and Women’s Hospital and Partners in Health, provides training and resources to CHRs to help them get the tools they need to provide increased support to high-risk patients with poorly controlled chronic conditions.
|CHR Sheila Barton checks blood pressure during home visits.|
CHRs deliver health education in clients’ homes and involve the whole family. They try to see about 6-8 clients a day; high-risk clients are seen more frequently. Lenora Shirley, a CHR, notes, “This is where the COPE flipcharts come in; I use them with everyone for management and even for prevention. It really helps. They get more involved with families.” CHRs refer many clients and are the link between community members and other resources. Lenora explains, “We send referrals for long term in-home healthcare. If clients have appointments but can’t make it to the clinic, then I put in applications for ACCESS (AZ Medicaid). I help explain the Affordable Care Act (ACA). Middle age people and college students don’t know that they can qualify for Medicaid, and parents can claim children until the age of 26. I also make referrals to PHNs and providers.”
CHRs have their share of challenges; Lenora adds, “It’s good to have a 4×4 because of the roads and weather, especially when transporting clients and maneuvering on back roads in snow and mud. Some clients have no electricity or running water; others are on a fixed income and can only make it to town once a month to shop for food.” CHRs have close relationships with their clients. Hilda John explains, “The hardest thing is the passing of a client, sometimes you think what if I did something differently would they still be here? But it’s not in your control.”
Clients really value and appreciate the time their CHR spends with them. Jane Charley, Sheila Barton’s client, explains, “I like that my
CHR comes and checks my blood pressure and vitals. I understand things better when she explains them to me because she takes time to explain with pictures. Teaching about nutrition helps me make good choices. Sheila helps me with a lot of things, like understanding why I need to take my meds and sets up appointments with my doctor. What we talk about helps me improve my life and health. I try to take her advice every day.” Daryl, a client’s family member adds, “She [CHR] takes care of my mom and explains things in Navajo; it’s nice to have her give my mom health education.”
CHRs are community leaders and special people with big hearts who are making a difference every day in their communities. In thinking toward the future and continuing to improve the health of community members, CHRs have ideas of how to bring this to fruition. Lenora adds, “COPE is a good example, people that we didn’t even know at first, are caring to help make our job a little easier, creating flipcharts, doing trainings and helping with some of the things that we need – printers, and other supplies that the program could not fund, little things like that really help. We need more programs like this! It would also be great to have more CHRs!”
 Julia Nania & Karen Cozzetto, et. al. (2014). “Considerations for Climate Change and Variability Adaption on the Navajo Nation.” University of Colorado Boulder.