Jacqueline Jim-Shorty, a Diné College Student (right), received her CHR
certificate from (left to right): Dr. Ed Garrison, Diné College faculty;
Ferlin Clark, EdM, President of Diné College, and Doug Taren, PhD,
UA/MEZCOPH Associate Dean for Academic Affairs.
Photo Credits: Ed McCombs, Diné College
On Thursday, May 7, 2009, officials from Diné College, the Institution of Higher Education of the Navajo Nation, and the University of Arizona Mel and Enid Zuckerman College of Public Health (MEZCOPH) bestowed the first Certificates in Public Health awarded jointly by both institutions. The commencement ceremony at the headquarters campus of Diné College at Tsaile, Arizona marked an academic achievement that has been more than seven years in the making for both Colleges. Douglas L. Taren, PhD, Associate Dean for Academic Affairs and Professor of Public Health represented MEZCOPH at the event. Nine Native Americanstudents were awarded the new joint Certificates in Public Health. All of the students are currently working full-time as Community Health Representatives (CHRs) for the Navajo Nation.
The Navajo Nation’s CHR/Outreach Program
The Navajo Nation comprises the largest Native American reservation in the United States and provides a wide range of public health services in their community. Community Health Representatives (CHRs) are important health care workers who typically live and work in their own communities. They provide hands-on health care and information services on current health topics with a special focus on wellness and prevention activities. Like most Native Americans, the Navajo face many health care services challenges, since much of the population lives in remote areas where access to health care services is difficult. Many tribal members, especially the elderly, do not speak English, which can make communications with non-native health care providers more difficult. The Community Health Representatives help all of these tribal members.
As full-time paid employees of the Navajo Nation government, the CHRs help meet the needs for increased basic health care and health information in Navajo homes and communities. Sometimes serving as “change agents” in their own communities, the CHRs foster greater community involvement in their own tribe’s health programs and more participation by tribal members in the identification and solving of their health problems. Since all CHRs are Navajo and most are fluent speakers of the Navajo language, this also aids in enhancing the effectiveness of clinic-based health care providers, most of whom are employees of the Navajo Area Indian Health Service.
Left to right, front: Dr. Ed Garrison, Diné College; Jolanta Billey, Anita David,
and Meria Miller-Castillo, Diné College students who received CHR Certificates;
Dr. Doug Taren, UA-MEZCOPH. Second row: Mark C. Bauer, PhD, Diné College;
Jacqueline Jim-Shorty, Diné College Student; Mae-Gilene Begay, Program Director,
CHR/Outreach Program, Navajo Nation Division of Health; and Dr. Madan Poudel,
of the Navajo Nation Division of Health. Photo: Ed McCombs, Diné College
Why have a CHR program?
Indian Health Service personnel provide most clinical health care in the Navajo Nation and are extremely busy, with one of the highest patient-to-provider ratios in the U.S., an example of the many health disparities that the Navajo people face. There is little time or manpower to provide services directly to patients out in the community. In fact, it would be an inefficient use of resources to send doctors and nurses out into the community since there is already a provider shortage in the hospitals and clinics. CHRs step in as “widely recognized and widely appreciated personnel whose function is to extend the health care knowledge and education out into the community,” said Edward R. Garrison, PhD, MPH, a member of the faculty at Diné College since 1983. Dr. Garrison led the development of the public health academic program at Diné College along with his colleague Mark C.Bauer, PhD, with whom he has collaborated in a wide variety of health and biomedical projects and programs for more than twenty years, and Kelly M. Burke, MPH, who did much of the technical work in developing the academic program at Diné College under Dr. Garrison’s supervision.
Dr. Garrison pointed out that one important role for CHRs is as para-professional health personnel who stay up-to-date on public health issues that affect the Navajo. As an example, with the current swine flu cases spreading, he pointed out that the CHRs are out in the Navajo community explaining what is happening and what the people can expect, and are teaching them how to protect themselves. “CHRs are the first-line responders,” said Dr. Garrison, “whether it’s swine flu, a weather emergency, or a forest fire. They are the ones out there in the community, knowing what is going on and what people are thinking and feeling.” CHRs function as the “eyes and ears for the Indian Health Service, tribal health system, and Navajo Nation government,” educating the tribal members about health care issues and also communicating health monitoring and surveillance information from the tribal communities to their own government.
Who are the Navajo Community Health Representatives (CHRs)?
As pointed out above, Native American communities have unique needs and multiple health disparities in health care, including a higher incidence of diabetes, lower rates of cancer screening, fewer doctors and nurses per capita than the general population, and they live in remote areas which are typically far removed from health care services. In addition, many Navajo people do not speak English. Community Health Representatives live and work with members of the tribe in their own communities to help overcome these health disparities and disadvantages in health care.
The Navajo Nation has 110 chapters, which are similar to “counties” in state governments. Each chapter has its own CHR, and a few of the most populous chapters have more than one. The entire Navajo CHR/Outreach program at this time has about 160 people working to build and maintain bridges between the Navajo people and the public health and health care systems that serve their needs and interests. The CHR/Outreach program includes CHRs and personnel in the Social Hygiene and Tuberculosis (TB) Control program, and is the only overall program that combines Community Health Representatives with Sexually Transmitted Diseases (STD) and tuberculosis prevention/education programs.
A Community Health Representative in the Navajo Nation typically has hands-on public health work experience or experience in a health care field, and less often the applicant has academic credits such as a bachelor degree or two-year associate degree. CHRs have been effective for years without academic credit, so some may wonder, why require it now? Standardizing the education needed to be a CHR and creating a certificate program helps to recognize their achievements and to provide college credits which may lead to promotions and salary increases.
History of the Joint Certificate and Degree Program
The Indian Health Service developed a basic description and national program for Community Health Representatives in the 1960s. Since then, many Indian tribes have contracted to run the programs in their own communities. Over the years, the Navajo Nation has worked with Diné College (and indirectly with the University of Arizona Mel and Enid Zuckerman College of Public Health) to develop academic credentials for the program including a two-year Associate of Science degree program in Public Health, and more recently the “Certificate in Public Health.”
The Associate of Science degree program in Public Health has been part of the Diné College curriculum since 2004. Headquartered in Tsaile, Arizona, Diné College is a public institution of higher education chartered by the Navajo Nation. It serves the residents of the 26,000 square-mile Navajo Nation which is spread over parts of Arizona, New Mexico and Utah. The first of 36 tribal colleges, Diné College has two main campuses and six community campus centers serving approximately 2,000 students. Diné is the word that members of the Navajo Nation use to describe themselves as a people.
In 2002, the Navajo Nation received a NARCH (Native American Research Center for Health) federal grant, which provided subcontracts to Diné College and The University of Arizona Mel and Enid Zuckerman College of Public Health (MEZCOPH).
Working together, both Diné College and MEZCOPH created the 12-credit certificate program in addition to the associate of science degree program. This is due to the fact that many CHRs don’t have the time they need to finish an associate degree due to family or other commitments, so the “Certificate in Public Health” serves as a credentials “stepping stone” that provides core academic instruction in public health.
In 2006, MEZCOPH approved the joint certificate with Diné College, and in 2006 and 2007 the UA Zuckerman College of Public Health offered the certificate for the first time to students at Diné College. 17 Navajo students were awarded the certificate in 2006 and 12 more received the certificate in 2007. Two of those who received certificate in 2007 were regular Diné College students rather than CHRs already working in the public health field which was typical for the rest of those receiving the certificate.
This year, the “Certificate in Public Health” was approved by Diné College, so this was the first year that the certificates were jointly awarded from the UA Zuckerman College of Public Health and Diné College.
The instructional program ensures that all the CHRs have the same knowledge base and that they all have had an overview of the basic concepts and principles of public health. These highly skilled community members now have the opportunity to integrate all of their health care experience into a public health perspective. This particular joint certificate program is specifically tailored to the public health needs and concerns of the Navajo Nation. Presenting this information in a culturally appropriate way is part of the mission and work of Diné College in the Navajo community.
In addition, the Arizona Center for Public Health Preparedness (AzCPHP) at the UA Zuckerman College of Public Health offers a Basic Certificate Program (BCP), a three-part series delivered through online training modules, seminars and workshops. This free program is designed to provide students and professionals with a practical foundation in public health preparedness to strengthen the public health workforce and the public health infrastructure. Diné College’s academic program in public health has incorporated a culturally adapted and expanded version of the AzCPHP Basic Certificate Program into its curriculum.
All Navajo CHR/Outreach Program Employees To Obtain Certificates
Every employee in the Navajo CHR/Outreach program – from the director and supervisors to the office assistants to the CHRs – is now required to complete this 12-credit “Certificate in Public Health" jointly awarded by Diné College and the UA Zuckerman College of Public Health. Why? As an example, at times the supervisors and CHRs may be out of the office working in the community, and the office assistant will be the only one there when a client comes in for services. If the office assistant has had basic instruction in public health, she can provide guidance when others of the program are out. Personnel are expected to obtain their public health certificate in a timely manner and to make satisfactory progress toward the certificate to maintain continued employment. This applies also to those employees who work in the Outreach program components providing services in tuberculosis, HIV/AIDS and sexually transmitted diseases services.
The relationship between MEZCOPH and Diné College is unique. “Other tribes in New Mexico, Oklahoma, and especially Montana are very interested in what we are doing,” Dr. Garrison said. Montana’s state health department is working with their state universities, tribal colleges and tribal health departments on developing collaborations, which may lead to a program somewhat different from the Diné College/MEZCOPH/Navajo Nation collaboration since the Arizona state health department is not involved. Each tribe “will do what’s right for themselves and their tribes,” said Dr. Garrison. “Their academic programs may be similar to ours, or they may be very different, depending on the needs of their own tribal communities in Montana.”
Web Links
- Harmony, Not War: Diné College Public Health Degree Focuses upon Hózhó, by Marjane Ambler. Reports on the creation of a public health degree at Diné College in Shiprock, New Mexico, the first degree of its kind at a "tribal college". Review of the work of the American Indian Higher Education Consortium and the Centers for Disease Control, who developed the degree with the goal of increasing the number of American Indians in health professions and improving the health status of American Indians. Comments from Edward Garrison, head of the Biology and Health Curriculum at Diné College. Publisher: Tribal College Journal of American Indian Higher Education. P.O. Box 720, Mancos, CO 81328. Tel: 888-899-6693; Fax: 970-533-9145; Web site: http://www.tribalcollegejournal.org
News Media Information
This article was written by Loretta McKibben with contributions from Ed Garrison, Mae-Gilene Begay, Ed McCombs and Doug Taren. Special thanks to Dr. Ed Garrison.
Please send comments, questions, or errors in this article to
Loretta McKibben, mckibben@email.arizona.edu.
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