Sky Lee M, Day A, Camplain C, Papini N, Smith M, Compton-Gore K, and Gardner J. The “who” and the “how” when working with tribal communities. Harvard Public Health Review. 2021; 30.
Our Context: The Response to COVID- 19 in the Southwest
As doctoral students studying in the field of public health and working with tribal communities, we have had the opportunity to witness the unfolding effects of COVID-19 on diverse populations alongside our public health coursework steeped in theory and research. While in our classes, we examined COVID-19 through different social determinants of health lenses (Marmot & Allen, 2014). For example, the outbreak of COVID-19 necessitated an urgent response from public health officials, for which messages of social distancing and hand washing, among others, emerged. While this response was informed by public health officials, these messages were often detached from the complexity of social and environmental factors that are particularly germane to tribal communities. As a group of future public health leaders, we have observed this disconnect and believe the field of public health can strive to better recognize the social determinants of health relevant to tribal communities, including understanding “who” the communities are and “how” to work with communities towards public health solutions.
Incidence of infection and mortality from COVID-19 in tribal communities has been considerably higher than other groups (Arrazola et al., 2020; Doshi et al., 2020) with current estimates likely being an underestimation due to poor data representation in data. At the start of the pandemic, two core tenants of COVID-19 public health campaigns included social distancing (e.g., staying home) and hand washing (Center for Disease Control, 2020). However, tribal communities often live in mutigenerational housing. With more than 15% of tribal homes being overcrowded for this reason (National Congress of American Indian, 2017), effective social distancing or quarantine is unrealistic. Other COVID-19 mitigation focuses on washing hands often with soap and water (Center for Disease Control, 2020). Given the lack of running water in some tribal communities, hand washing may be challenging at best and a potential source of disease transmission at worst since communal washing bowls are common in homes where clean or running water is scarce (National Congress of American Indian, 2017). While messages of “stay home” and “wash your hands” seem benign, they may be out of touch with the resources of many tribal communities.
While the effects of COVID-19 have been tragic, the pandemic has also provided public health professionals and students an opportunity to understand how we can be better prepared to work with tribal communities during public health emergencies. This paper presents examples of how tribal communities have led public health messaging efforts around COVID-19 and provides an explanation of how public health training can better support tribal communities.
Examples of Tribal Communities Leading Public Health Messaging
Since the pandemic, many tribal communities have adapted and preserved by creating and delivering their own culturally relevant messages around COVID-19 that resonate with their communities. One author’s tribe requested community participation in creating a music video communicating COVID-19 messaging. The music video was chosen through a contest and was disseminated throughout the community. Integrated into this music video, were messages on the importance of protecting elders by social distancing and regular hand washing. Relevant imagery specific to tribal communities also used as a strategy to communicate COVID-19 messaging. For example, on the Navajo reservation, billboards displaying two sheep in-between two individuals was used to provide an appropriate reference for staying six feet apart (Daley & Dietz, 2021). Other strategies use to communicate COVID-19 messaging included incorporating phrases in Native languages (John Hopkins Center for American Indian Health, 2020). Many of these resources stress the importance of adhering to COVID-19 recommendations to protect their loved ones, elders, and traditions.
On the Navajo Nation, CHWs helped carry out tribal mandates, deliver medicine and food, translate COVID-19 health directives and related materials, and connect community members to support resources (Rosenthal et al., 2020). CHWs are trusted individuals who often share similar lived experiences with the community. Training community members to be (CHWs) is another strategy in helping communities develop their own public health leaders that can be used for various situations such as public health crises (Peretz et al., 2020). Individuals in positions of power in tribal communities’ such as elected officials also assisted with leading COVID-19 efforts. Tribal leaders such as the Navajo Nation President, had his photograph taken while he received his COVID-19 vaccine attempting to build confidence in the vaccine among his community. Tribal communities do not need outsiders to create and deliver on behalf of their community. However, ongoing equitable partnerships between tribal communities and public health workers and researchers could provide tribal communities with much needed additional resources where community infrastructures are lacking. These partnerships should be driven by the needs and wants of tribal community members. As we move forward in our public health training, we must strive to understand best practices in developing these partnerships.
How Can Public Health Training Support Tribal Communities?
Traditionally, public health training focused on the “what” and “when” of understanding the disease or health condition and learning when it is best to intervene was emphasized (Koh, 2014). In other words, traditional public health training was not centered on how to effectively bring about necessary behavior change while considering the identity of tribal communities along with their rich histories, diverse beliefs, and intersecting identities. As public health programs evolve, training should include teaching students about the “who” and “how.” Providing applied experiences where students can work with communities teaches students these concepts. Often non-community members with training may consider themselves the health experts, though we must acknowledge that community members’ expertise on their own context is important for much of our work. Often, we do not belong to the tribal communities we work with, so we must recognize and seek out expert knowledge of tribal members.
Learning about the communities we want to work with (the “who”) requires prioritizing reciprocity and trust building. A common theme in understanding the “who” is building trust via a thorough understanding of community perspectives and establishing relationships through acknowledgement of personal and institutional histories. Without this context, and without trust, it becomes difficult to understand the broader context of a health concern (Israel et al., 2012). This trust is essential given the negative experiences many tribal communities have had with academic institutions, which have a long history of taking advantage of these communities for their own research agendas. In 2010, Arizona State University used blood collected from the Havasupai Tribe across for multiple studies, despite only receiving their consent for one of these studies (Mello & Wolf, 2010). The resulting and well-known legal battle resulted in many tribal communities to be hesitant to work with academic institutions. Given this history and our experiences, building trust in these relationships takes time and patience from both the tribal communities and researcher.
Participatory approaches (e.g., community based participatory research (CBPR), community engaged research) include the people who are directly related to the problem of interest and allow us to understand “how” to incorporate best practices for public health so that they maximize benefit to communities. Participatory principles also include building on the strengths of the community, empowering community members, and facilitating collaborative partnerships in all phases of the work (Israel et al., 2012). One tenant of CBPR emphasizes fostering co-learning. When tribal communities and public health researchers work together, tribal communities can learn about research (e.g., research design, data collection, data interpretation) while public health researchers can learn skills related to working with the community (e.g., how to translate the research findings into action strategies that will benefit the community). This exchange educates public health researchers and allows tribal community members to feel empowered to navigate their communities in solving public health concerns. In learning participatory approaches, we can work with communities in meaningful ways as we seek to mend power imbalances and acknowledge the importance of involving the community. By seeking out opportunities to work with communities, we aim for a greater understanding of contexts, concepts, designs, and approaches that ensure public health solutions are appropriate and applicable to communities.
Given the severity of COVID-19, public health messaging around best practices needed to be created quickly to respond to the urgent need. However, the messages that were created were not practical for many tribal communities, despite our awareness and training in understanding the many factors that impact an individual’s ability to act upon public health messages. It could be speculated that public health officials neglected to recognize the “who” and the “how,” and many already vulnerable communities suffered as a result. As future public health professionals, we have a responsibility to consider the complexity of adhering to public health recommendations such as community contexts and infrastructure. We must learn from this experience and work together with tribal community members to create appropriate public health responses for tribal communities. We are hopeful that students studying public health, including this group of authors, will rise as leaders in their communities to lead this type of work.