A Tribal Health Care Model That Works

The way Samantha Sabo, Dr.P.H., M.P.H., sees it, community health workers in Arizona and community health representatives in tribal communities move mountains. Throughout the pandemic, they helped thousands of residents, including many American Indian community members, access health resources – including COVID-19 vaccines.

“To us, they are the center of the universe,” said Sabo, an associate professor in both the Department of Health Sciences and the Center for Health Equity Research at Northern Arizona University. “They are the ones that link people to systems that are essential in getting them the information they need to make decisions about their health.”

Of the 22 tribes in Arizona, 19 operate a community health representative (CHR) program. CHRs make up 30% of the total community health worker workforce in the state and to the delight of researchers, like Sabo, are leading vaccine rollout efforts. “They do this through creative, culturally-relevant, and efficient means – meeting tribal members where they are in ways that work best for their clients,” she said. 

“Community health representatives are the trusted people who have a unique understanding of their community’s experiences during the COVID-19 pandemic, including fears, barriers, concerns about prevention and vaccines, and they know how to overcome these issues and support members to make the best decision for their health and for the well-being of their family,” said Arizona CEAL taskforce member Kim Russell, executive director of the Arizona Advisory Council on American Indian Healthcare.

"The first step always starts with meeting people where they are."

Ruby Meraz, M.P.H.

Training Center Director, AzCHOW

By July, half of American Indian and Alaskan Native residents living in Arizona had gotten a vaccine – much like the national average. And in Maricopa County, home to Phoenix and half of Arizona residents, the vaccination rate for American Indian and Alaskan Natives is 74% – higher than for any other racial or ethnic group.

To support these trends, the Arizona Community Health Workers Association (AzCHOW), which has been part of the community for 20 years, hosts free COVID-19 trainings for community health workers. Ruby Meraz, M.P.H., AzCHOW's training center director and a community health education specialist, said the goal is to “send them off with tricks and tips that they could pull out of their back pocket to talk about the vaccine.”

One of the best strategies, Sabo said, has been helping these essential health workers get vaccinated first, so they can share that message and their experience with others. While many members of tribal communities view vaccines as important, Sabo explained, they still need support to get their shot. This may include health workers printing out information for people living in areas without Wi-Fi, answering questions about new vaccines and variants, transporting family members to appointments, or making a visit to a homebound elder.

Their goal is to make information available and accessible, which sometimes requires extra translation. It also requires that they stay in touch with key people in the community. If they have questions they aren’t sure how to answer, for example, the health worker can reach out to a researcher or doctor, or to AzCHOW.

Many medical experts have also met with the community, where tribal leaders feel comfortable asking questions: What’s in a vaccine? What are the benefits? What happens after you get vaccinated? These leaders, often respected elders, appreciate the ability to have interactions in safe spaces, Sabo explained. Ultimately, the conversations help them make decisions and shape what information they share with their community, which can have an impact.

Another factor that helps is seeing COVID-19 rates among American Indian and Alaskan Native communities get closer to zero. In January in Arizona, more than 600 per 100,000 people in Indigenous communities had the disease, according to data from the Centers for Disease Control and Prevention. Seven months later, weekly case rates fell below 3 per 100,000 people.

“Any way that we can promote how COVID rates are changing really seems to be working for people to get motivated to get the vaccine,” Sabo said. “Folks are very well up to date on the COVID case counts in their communities.”

To continue to help tribal communities respond to COVID-19, community health workers will soon share resources designed to support the mental health and emotional well-being of residents, Meraz said. The goal is to help those who suffered throughout the pandemic, such as if they lost a loved one, were hospitalized, or felt isolated. 

Meraz said, “The first step always starts with meeting people where they are.”