Healthcare access, attitudes and behaviours among Navajo adults during the COVID-19 pandemic: a cross-sectional study

Introduction

Early in the pandemic, the Navajo Nation was experiencing the highest COVID-19 attack rate in the USA.1 Additionally, the Navajo Nation was experiencing some of the highest case fatality rates, nearly 4% based on the Navajo Nation Department of Health dashboard for 24 March 2021. This rate was twice what was reported for Arizona and New Mexico, 2.0% and 2.1%, respectively, during the same time period.2 During the late summer to early fall of 2021, the rate ratio (RR) of COVID-19 among American Indian/Alaska Native (AI/AN) persons was 3.5 (95% CI 1.2 to 10.1) that of the non-Hispanic white population.3

A public health state of emergency for the Navajo Nation was declared on 13 March 2020.4 5 This effectively closed the Nation to visitors, started stay-at-home orders except for essential activities and closed all businesses except for essential businesses. Residents were ordered to remain at home, with exceptions for certain essential workers, first responders and healthcare personnel.6 At the height of the COVID-19 pandemic on the Navajo Nation, leaders implemented nightly curfews and 57-hour weekend lockdowns from 20:00 on Friday through 05:00 on Monday.7 In addition, state universities also implemented travel restrictions and person face-to-face research was restricted sometime between March and May 2020, and the Navajo Nation Human Research Review Board closed access to conducting research in person within the borders of the Navajo Nation.

The Navajo Nation is home to approximately 400 000 people and spans 27 000 miles and three states (Arizona, New Mexico and Utah) in the Four Corners area of the USA. However, in an area roughly the size of West Virginia, Diné (Navajo) citizens have access to only 13 grocery stores (driving an average of 3 hours for groceries) and just 13 healthcare facilities (12 on-reservation and 1 located off-reservation).8 9

Data suggest that the presence of specific cardiometabolic conditions, including cancer, hypertension, diabetes and cerebrovascular disease, is associated with more adverse outcomes for COVID-19 patients.10 11 These conditions are also more frequent among the Navajo Nation population. The leading causes of death, after unintentional injury (107.7 deaths per 100 000) include cancer (72 per 100 000), heart disease (69.5 per 100 000) and diabetes (32.7 per 100 000).12 While unintentional injury results in the highest years of potential life lost, cancers are the second leading cause (6358.9 years of life lost).12 These pre-existing conditions may, in part, explain the excessive COVID-19 mortality experienced by members of the Navajo Nation.

Although several factors have contributed to the high incidence of infection in this population, social and economic factors play a major role.13 14 In our recent study of 73 households in three Navajo Nation chapters (communities and local governing areas), 9.9% of the homes lack electricity and refrigeration, and 83.6% travel distances of over 1 hour for groceries.15 Further, only about 70% of Navajo households have access to regulated water.15 16

Other factors which exacerbate risk of COVID-19 transmission, namely multigenerational households, are common among AI communities with family members providing care for both children and elderly within the home and close living spaces. With lockdown protocols initiated across the globe, reliance on the internet for personal connections, household supplies and shopping, and medical care increased. However, compared with the 82% of the USA for the same period, 52% of homes of AI living on AI lands had high-speed internet connection,17 potentially limiting the capacity for telemedicine, no-touch access and maintaining distant social support.

Centuries of Euro-American colonisation structures and forces, socially designed for control of land and resources through systematic subordination of AI nations and communities, are the culprit in creating these conditions. Colonialism affecting AI/AN well-being and nation rebuilding remains ongoing through contemporary AI/AN experiences of structural and systemic violence, such as the documented failures of the US government to fully uphold its federal trust responsibilities to provide ‘proper care and protection’ to AI/AN nations in exchange for land, resources and cultural losses.9 18–21 The realities of limited infrastructure and scarcity of resources have made engaging with recommendations around basic COVID-19 protective practices, such as frequent handwashing and reduced grocery trips, challenging.

The goal of this 1-year project was to determine the impact of the COVID-19 pandemic for Navajo adults from the individual participant’s perspective on their COVID-19 experiences and potentially associated risk factors, and health-related care delivery, including allopathic and Diné traditional medicine care. These experiences were evaluated using both quantitative and qualitative approaches.

Materials and methods

Results

Survey results

Between June and October 2021, 190 individuals accessed the survey with 154 community members consenting and completing the survey. More than two-thirds of the survey participants (66.9%) were recruited through flea markets, with an additional 27.4% through friends and family, 11.9% through newsletters/fliers and another 10.7% through social media.

All survey respondents reported Navajo as their tribal affiliation. Most respondents resided in Arizona (60.5%), followed by New Mexico (36.7%) and one individual each (0.68%) from California, Utah, Georgia and Colorado. The average age was 44.6 years (range: 18–90 years old) and 66.7% of respondents were female, somewhat higher than the average for the Navajo Nation (51%).31

Vaccine uptake

Vaccine uptake among survey respondents was high, with 85.1% reporting at least one dose of vaccine and six reporting they would get the dose as soon as available. This uptake is higher compared with about 78% of all US adults in early October 2021.32 The most commonly selected reason for vaccination was ‘to reduce my chances of getting COVID-19’ (n=84, 54.5%), followed by ‘so that I don’t give COVID-19 to other people’ (n=40, 26.0%) (table 1).

Table 1

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Reasons for getting or not getting the COVID-19 vaccine, Navajo COVID-19 survey (n=149)

Experience with COVID-19

At the time of the survey, 72.7% (n=112) of respondents had been tested for COVID-19, among them 90 reported either a positive (n=25; 27.8%) or negative (n=65; 72.2%) test result, the rest not reporting the test outcome. COVID-19 symptoms were reported by 27 individuals (17.5% of respondents), 15 of whom sought medical care (65.2%) and 4 (15.4%) were hospitalised (table 2). There were no differences for COVID-19 tests, positive test results, symptoms or care-seeking by gender (p>0.05). Among the comorbidities we asked about, only hypertension and diabetes showed differences by test result. Specifically, 32% of people reporting a positive test were hypertensive compared with only 11% of those with negative tests (p=0.03) and, marginally significant, 32% of those with a positive test result also reported either type 1 or type 2 diabetes compared with only 12% of those with a negative test (p=0.06).

Table 2

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Features of Navajo COVID-19 survey participants (n=154) and among those who tested for COVID-19 stratified by COVID-19 test results (n=90 reporting test result)

The analysis was stratified to assess factors that might be associated with a positive test result (table 2). As expected, experiencing symptoms was associated with a positive result (p<0.001). Of the comorbidities we assessed, only hypertension and diabetes showed differences by test result. Specifically, 32% of people reporting a positive test were hypertensive compared with only 11% of those with negative tests (p=0.03) and, marginally significant, 32% of those with a positive test result also reported either type 1 or type 2 diabetes compared with only 12% of those with a negative test (p=0.06). Travel time to grocery store between 15 and 30 min was associated with positive test results (p=0.04), whereas housing structure, presence of multigenerational households and type of community were not (p>0.05). Additionally, we found no association with the number of household members (median including self=3; range 1–9) and reported test result (p=0.998).

Most people reported bottled or delivered water (n=68; 44.2%) as their primary source of drinking water, followed by Navajo Tribal Utility Authority/community tap water (n=65; 42.2%). When comparing COVID-19 test results by drinking water source, significantly more individuals testing positive reported bottled/delivered water as their primary drinking water source (p=0.02). We found no association between household fuel source and test result (p>0.05; data not shown).

The COVID-19 pandemic affected not only the survey respondents but also their families and their communities (table 3). By the end of our study period (October 2021), two-thirds (67.5%) of respondents had a family member or relative test positive for COVID-19; 40.9% had a friend or family member hospitalised and one-third had a friend or family member pass due to COVID-19.

Table 3

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Navajo COVID-19 survey respondents’ COVID-19 experiences among relations within their community (n=142)

Barriers and access to allopathic healthcare

Over 36% of participants (n=55) reported an in-person general medical appointment had to be cancelled due to COVID-19, 26% chose not to attend an in-person general medical appointment (n=40) and 10% (n=15) had a medical screening appointment cancelled. Of note, 28.8% (n=44) reported choosing a telehealth appointment with 42% reporting satisfaction, 37% neutral and 21% reporting dissatisfaction. Although over one-third (54 of 149) of individuals reported not having internet access at home, there was no difference for choosing telehealth by internet access (p=0.13).

In contrast to the disruption in accessing care, most participants reported that their providers took the necessary measures to address COVID-19 (33.3% agreed and 24.2% strongly agreed, while 26.1% were neutral). In the survey, respondents were asked about barriers to receiving medical services and rate how often certain items (such as knowing where to go, lack of child or elder care, appointment times, insurance, finances or transport) influenced their decisions to receive medical services before the start of and then during the pandemic. Before the pandemic, transportation, where to go, and child or elder care were never or almost never factors influencing healthcare, while finances and appointment times were more commonly obstacles (figure 1). We found no statistically significant differences in respondents’ experiences before and during the pandemic (p>0.05 for all tested comparisons).

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Figure 1

The pre-pandemic responses for the degree to which factors influence decisions around receiving medical care among participants in the Navajo COVID-19 survey. These were compared with responses for during the pandemic, and no statistical significance was observed.

Barriers and access to Diné traditional medicine and healing

Nearly half (n=74, 48.4%) of participants indicated that they sought Diné traditional medicine or healing from a medicine man, roadman, herbalist, diagnostician or other traditional practitioners during the pandemic.

Of the participants who sought Diné traditional medicine or healing, most indicated that traditional practitioners/healers had implemented measures to address COVID-19 (33.8% strongly agreed and 24.3% agreed). Over half of participants either strongly agreed or agreed (29.7% and 25.7%, respectively) that social distancing guidelines had disrupted or delayed their traditional medicine and healing experiences. Likewise, most participants (25.7% strongly agreed and 29.7% agreed) indicated that the Navajo Nation lockdown restrictions had also disrupted or delayed their traditional medical care.

Discussion

This study of Navajo adults showed a highly motivated community that quickly adopted vaccination and other necessary precautions to reduce the transmission of COVID-19. While the pandemic was still peaking in late summer 2021, 27% reported personally testing positive for COVID-19, and more than two-thirds reported a family member who had had experienced COVID-19 infection. Almost one-third reported a member of their household testing positive. Risk factors associated with reporting a positive COVID-19 test in this sample included diabetes and hypertension, a distance of at least 15–30 min from a grocery store and use of bottled/delivered water as the primary drinking water source.

Other studies have reported that AI experienced about three times higher incidence and hospitalisation, intensive care unit admission (RR 6.49; 95% CI 6.01 to 7.01) and in-hospital deaths (RR 7.19; 95% CI 6.47 to 7.99) with white as reference.3 33 34 One proposed explanation for the increased morbidity and mortality for AI was increased comorbidities, including diabetes and chronic liver disease among AI.13 35 In this current survey, hypertension, and, marginally, diabetes were associated with reporting a positive test. However, other studies suggest that, while higher rates of comorbidities are present, AI COVID-19 patients had lower comorbidity risk yet still were hospitalised longer and were more likely to die in hospital than other populations.36 37 This suggests that comorbidities do not explain the disproportionalities observed among AI and points to continued lack of health equity.37

Multigenerational homes are common in the Navajo Nation, which, when combined with crowding, can make adhering to the recommendations to reduce COVID-19 transmission challenging.38 Interestingly, multigenerational housing was not associated with COVID-19 infection in this study despite that 38% of households reported at least two generations within the home. These findings support the findings from a recent ecological study of the 287 tribal nations in the lower 48 US states; namely, that cases were more likely among homes lacking indoor plumbing but not associated with overcrowding.39 That study used COVID-19 incidence data from early in the pandemic and data from the 2018 American Community Survey.

Another explanation for the lack of association between multigenerational households and a positive COVID-19 test result in this current study might be that almost 62% of respondents were in single-generation homes. Crowding in the household (individuals within space) was not assessed, rather only the number of individuals (median=3). However, another explanation may be the protective effect of Diné cultural practices rooted in kinship, relational care and honour of elders (knowledge keepers).9 40 Health messaging on the Navajo Nation, both from the government and between community members, heavily emphasised respect for and protection of elders as reasons for adherence to social distancing, mask wearing and other mitigation guidelines.40 Further, restrictions implemented by the Navajo government including closure of schools and in-person instruction from 13 March 2020 to 7 July 2021 could have reduced transmissions among households with school-age children.41 42

Interestingly, despite the documented food deserts and long travel times associated with many communities in the Navajo Nation and the potential health consequences that exacerbate COVID-19 outcomes,38 there was no association with longer grocery travel distances in this study. In fact, shorter travel times, 15–30 min, were associated with increased positive results. This finding may be for several reasons. One might be the reporting of a positive test was associated with greater access to testing or that the participants were individuals living closer to larger towns where risk of infection was higher. Another might be that more trips were made to grocery stores closer to home, increasing their exposure. Another reason might be that this study’s heavy reliance recruitment at specific chapter flea markets may have meant that the sample surveyed was different. The survey could have missed those people most severely affected by COVID-19 who could not complete the survey or travel to flea markets.

Access to clean water is critical and was even more so during the COVID-19 pandemic with handwashing being one of the primary means reported to break transmission. This is a systemic challenge when over 40% of the Navajo Nation households do not have running water.19 It follows that we found those using bottled water or relying on delivered water as the primary source of drinking water was associated with a positive COVID-19 test in this sample. Hauling water and delivering water often entail travel time which was restricted during the pandemic or restricted amount of water, which likely influenced handwashing frequency.43

Health inequities, in particular lower access to affordable quality healthcare, remain an issue among AI communities. Self-reported access to medical care did not change significantly from pre-pandemic to the time when the individual filled out the survey. This lack of change in access might be because the survey was completed late fall in 2021 and the respondents had figured out how to access care by then, and/or the strong adoption of telemedicine (28.8% chose telehealth and most were satisfied). Also, the pre-pandemic assessment was carried out during the pandemic. Nationally, there was a reported 154% increase in the number of telehealth medical visits compared between March 2019 and March 2020.44 The Indian Health Service (IHS) facilities have been using telehealth since the mid-1970s, and quickly expanded their capability in response to the COVID-19 pandemic.45 Despite challenges including unreliable or poor-quality broadband, the IHS Navajo Area healthcare facilities adopted and provided telemedicine.46 Project ECHO (Extension for Community Health Outcomes) at the University of New Mexico also stepped in to fill the gap between need and services by developing telementoring support to healthcare providers.47 48 Among the seven cancer survivors who completed the survey, satisfaction with telehealth was high and consistent with another study showing telehealth as a viable alternative when sufficient training on using telehealth is provided.49

Only 10% of respondents reported a delayed screening appointment. However, this number is lacking a reference as to how many individuals regularly schedule screening appointments. Modelling efforts for breast and colorectal cancer screening indicate that without adequate strategies, missed screening will yield increased incidence and mortality for both cancers.50 Increased capacity is necessary to overcome this disruption of cancer screening and reduce avoidable cancer deaths.51 52 Communicating with community about the effect of COVID-19 on cancer screening appointments has been shown to be critical in response to other health service interruptions.53 Looking forward, community-based approaches are critical to ensuring culturally appropriate programmes aimed at achieving health equity for these communities.47

Although the qualitative study sample was small and primarily female, their discussions highlighted the resilient nature of participants. Participants expressed that bonding relationships with their family were strengthened and identified community volunteers and healthcare providers as support mechanisms throughout the lockdown of the Navajo Nation.

Conclusion

COVID-19 deeply affected the Navajo Nation communities. By the time of this survey, factors influencing access to medical care were consistent with pre-COVID-19 levels. The members of the community we surveyed quickly adopted the vaccine when available and embraced available telemedicine technologies. The effects of structural vulnerabilities from historical racism, however, remain a contributor to positive COVID-19 testing in this population.