Community Asthma Program on Navajo Nation Increases Care-Seeking for Children with Asthma

DENVER - The Navajo Community Asthma Program (CAP) was designed to reduce asthma exacerbations among Diné (Navajo) children living on the 27,000-square-mile Navajo Nation, which spans Arizona, New Mexico, Utah and Colorado. Asthma rates among American Indian and Alaska Native children are among the highest in the United States, and a 2020 assessment found that about 21% of Diné adolescents on the Navajo Nation had been told by a health care provider they have asthma.

“Families on the Navajo Nation face a unique combination of environmental exposures, economic hardship and limited access to specialty care that can make asthma especially difficult to manage,” said Bruce Bender, PhD, neuropsychologist at National Jewish Health and lead author of the study. “CAP was designed with Navajo partners to build capacity in local communities, so children can get timely, culturally respectful asthma care where they live and go to school.”

After a year of community engagement meetings, CAP launched a seven-year, stepped-wedge study in three communities, each anchored by its own Indian Health Service (IHS) medical center and school system: Tuba City, Chinle and Ft. Defiance/Window Rock.

The program trained 439 health care and school staff, including 176 health care providers (physicians, nurses, pharmacists, respiratory therapists and others) and 263 school staff and community health representatives (CHRs).

Key components of CAP included:

“From the beginning, this work was guided by Navajo leaders, families and local staff,” Dr. Bender said. “Our goal was not to bring in a temporary team, but to help strengthen the skills, tools and infrastructure already present in these communities.”

The program launched just before the COVID-19 pandemic, which hit the Navajo Nation especially hard and led to some of the highest per-capita infection and mortality rates in the country. In March 2020, the Navajo Nation declared a public health emergency and instituted curfews, weekend lockdowns, masking and vaccine requirements for government employees.

These changes had major implications for both care and data collection. Like the rest of the United States and many countries worldwide, the Navajo Nation saw a dramatic drop in asthma exacerbations during the early phases of the pandemic, likely due to reduced exposure to respiratory infections, less travel and school contact, and some families’ reluctance to seek in-person care.

Because all non-urgent care was routed through emergency departments, the study team conducted both the planned primary analysis and a secondary analysis using a broader definition of asthma exacerbations based on ICD-10 codes across all care settings, to better reflect changing patterns of care during the pandemic.

While the rate of exacerbations among children who had at least one event did not significantly decrease, the combination of increased exacerbation coding and increased routine care visits suggests that families were more likely to seek care and that providers were more likely to recognize and code asthma exacerbations after the program.

“On the surface, it might seem concerning to see more exacerbations documented after the program,” Dr. Bender said. “But in the context of a pandemic that was keeping many people away from clinics, seeing more families come in and seeing more precise documentation actually suggests increased awareness, trust and engagement with the health care system.”

CAP is one of the few large-scale asthma implementation studies conducted on tribal lands.

“This program underscores that effective asthma care on tribal lands must be rooted in partnership, cultural respect and long-term commitment,” Dr. Bender said. “Future studies can build on this foundation to further reduce disparities and support the health of Native children.”