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CHW Health Disparities Initiative

Partners in Health (PIH) and Navajo Nation

Flexibility Allowed PIH to Better Meet Community Needs

PIH originally planned to work in just two Indian Health Service (IHS) units within the Navajo Area Indian Health Service (NAIHS) region.
After hosting an initial planning meeting with the service unit supervisors and the Navajo Nation community health representative (CHR) director, the team realized that all IHS units in the Navajo region were eager to participate.
They were able to restructure their work plan to include a cadre of Master Trainers, a CHR workforce fully trained in the NHLBI curriculum, and community outreach activities that could be implemented following the training of the CHRs.


Navajo Nation in New Mexico and Arizona

Intended Population:

American Indians in Navajo Nation

Key Partners:

Navajo Nation Community Health Representative Outreach Program, Navajo Area Indian Health Services

CVD Burden:

Cardiovascular disease (CVD) affects many Navajo communities, with 4 percent of women, 5 percent of men, and 11 percent of those over the age of 55 having heart disease. Risk factors for heart disease, such as diabetes, high blood pressure, and being overweight or obese, contribute to these levels: 15 percent of those ages 31-55 and 33 percent of those over 55 have diabetes; high blood pressure affects 25 percent of those ages 31-55 and 51 percent of those over 55; and 55 percent of women and 41 percent of men are obese. To address CVD, a holistic grassroots approach must be taken, one that goes beyond focusing on a single disease or individual and instead focuses on the health of the whole family and community.1


PIH and Navajo Nation adapted the NHLBI’s Honoring the Gift of Heart Health curricula for Navajo communities, to be used by the Navajo Nation community health representative (CHR) program. This program, which began in 1968, is composed of well-trained CHRs (e.g., certified nursing assistants, first and emergency responders, food handlers) who live in the communities in which they work. Navajo Nation CHRs provide direct services to all communities (chapters) throughout the Navajo Nation, a population of approximately 250,000 people spread across a rural area in the Four Corners region of the Southwest. This area, the size of West Virginia, is sprawling and diverse.

PIH trained two CHRs from each of the eight IHS Navajo Area service units to serve as Master Trainers to train and support their CHR colleagues. In turn, all CHRs reached community members through home-based services and community-level health education (e.g., health fairs, chapter house teachings, school events). CHRs worked to coordinate their efforts with other community outreach programs. Key aspects of the PIH and Navajo Nation approach included the following:

  • Trained Master Trainers to instruct other CHRs on Honoring the Gift of Heart Health in all Indian Health Service (IHS) Navajo Area service units.
  • Coordinated closely with the IHS to ensure consistently high-quality education by Navajo Nation CHRs.
  • Modified materials for the Navajo Nation (e.g., low-literacy and flip chart formats) through a participatory and iterative process.
  • Developed and tested methods for delivering the NHLBI curricula in the community.

Through this comprehensive approach, 97 CHRs were trained and 512 community members received heart health education.


PIH and Navajo Nation used the NHLBI’s evaluation forms to assess changes in heart health knowledge, attitudes, and beliefs for the CHWs and community members. In addition to measuring changes in knowledge and behavior intentions among community members and CHRs, the evaluation used surveys and focus groups to identify the attitudes of CHRs and IHS coaches toward the feasibility and acceptability of the project, as well as on specific strategies and aspects of the project. The evaluation examined referrals from providers versus CHRs, one-on-one versus group teachings, the acceptability of heart health materials for Diné individuals, and the level of engagement in program evaluation.

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1 Slattery, M. L., Schumacher, M. C., Lanier, A. P., Edwards, S., Edwards, R., Murtaugh, M. A.,…Henderson, J. A. (2007). A prospective cohort of American Indian and Alaska Native people: Study design, methods, and implementation. American Journal Epidemiology, 166(5), 606-615. doi: 10.1093/aje/kwm109

Last Updated: June 2014