Volume 2 Number 2
May 1962

Paul R. Mico, M.P.H.

The Navaho Health Education Project has been a two-phase field operation of the University of California School of Public Health under an agreement with the United States Public Health Service, Division of Indian Health. Phase One was in existence from July 1, 1955 to August 31, 1959, and was headquartered at Window Rock, Arizona, which is the central administrative field office of the Division of Indian Health for the reservation. It had as its purposes the development of a reservation-wide program of health education activities. This included the recruiting and training of professional-level community workers (health) and sub-professional community health education aides, who were then placed on duty at various health centers throughout the reservation. The Phase One staff was composed of two public health educators throughout its operation and a social anthropologist who served during Fiscal Year 1959.

Phase Two was set up as a three-year operation, beginning on September 1, 1959, and ending on June 30, 1962, at which time the Navaho Health Education Project formally closed its operations. Its purpose has been to construct a framework of highly-intensified health education activities, performed at the local level, that would contribute to the goals of the division as well as to the health education program and research interests of the School of Public Health. Its headquarters was relocated from the Window Rock field office to the Tuba City service unit. This is comparable, in a sense, to moving from a state to a county level.

The Tuba City service unit is one of eight on the reservation. It occupies 4,404 square miles of the western-most part of the reservation and has a population estimated at 9,000, although estimates from other sources vary from 6,000 to 15,000. There is a 75-bed general medical care hospital, which is accredited, and a field health program with dental, health education, and sanitation services. The majority of the adult Navaho population has had little or no formal education and cannot speak English.

The Phase Two project has been service-oriented. The health education activities were developed as an integral part of the health and medical services offered to the Navaho. Research was conducted concurrently, along lines that would increase understanding of Navaho health behavior and bring to light the factors which may facilitate or block the acceptance of the health and medical services. Three focal points were identified for study. One was the hospital, in which the health education opportunities in an Indian hospital could be explored. Another was health opinion leadership, on the premise that individuals, Navaho or non-Navaho, who influence the Navaho with respect to health attitudes, motivation and behavior, can be identified and consequently educated to contribute significantly to the goals of the program. And the third was the Navaho community, on the assumption that Navaho people, who have an adequate understanding of the preventable factors contributing to their disease and disability problems, and of the resources available to them, would develop desirable individual practices and participate in group activities in order to prevent disease and maintain a higher level of personal health.

The health education staff of the Tuba City service unit has been composed of two cooperating groups: the project's (see Note 1) public health educator and social anthropologist; and the division's permanent employees, who are a community worker (health) and a hospital health education aide. Both of the latter were recruited and trained by the Phase Two project, which was responsible for the development and original demonstration of the hospital health education aide position.

By and large, Phase Two has been carried out as planned, with no changes in either staffs to disrupt continuity. This long term study, conducted on a local level where activities could be initiated and carried through to completion, has been very productive in terms of our criteria.

Some Relevant Conclusions. An attempt will be made here to report on some of the Phase Two conclusions, which are relevant to Indian education. No thought has been given to their placement in terms of importance.

1. Causation of Disease. We, like many others, find that the Navaho's conception of health and disease is very different from that which most non-Indians and public health workers have (3: 15). For him, health is part of a correct relationship between man and his supernatural environment, the world around him, and his fellow man. A precise, prescribed behaviour must be followed if the correct relationship is to be maintained, which in turn guarantees spiritual, social and physical well-being insofar as possible in the Navaho's complex and dangerous universe (7: 2-3). "Well-being" infers "good and beauty, or harmony," which describes the balance and perfect functioning of all parts plus the exalted feeling which accompanies this desired state. Whatever is not in this desired state may be called sickness, whether it is disease in the physical or mental sense or is a disturbance in the physical or social environment. Thus it can be seen that disease is viewed by the Navaho as a state of disharmony caused by a transgression of the prescribed behavior or by witchcraft. The specific diagnosis is made by a native diagnostician, or hand-trembler, who suggests the kind of "sing" or ceremony that must be performed if the patient is to be cured. The family then contracts for the services of the "singer," or medicine man, who knows how to perform the required ceremony.

This is vastly different from the concept of "disease caused by bacterial or viral infection" as held by non-Indians. It is difficult to teach the Navaho the "germ theory." One reason is that there are no corresponding concepts, words, or phrases in the Navaho language to adequately describe "germs" in that language. Another reason is that it is difficult for the Navaho to perceive that disease and death can be caused by something so small as to be invisible to the naked eye. or of the Navaho with respect to, personal

Changes made in the behavior of the Navajo with respect to personal hygiene, environmental sanitation, food preparation, infant care, and home nursing appear to be accomplished more on the basis of a desire for quality living than of an adequate understanding of the germ theory.

2. Motivation for the utilization of medical care. Levy reports a significant motivational characteristic of the traditional Navaho (7: 4): he comes to the hospital or clinic not to be cured but to obtain relief from painful symptoms. The curing of the individual's illness can only be effected by an elaborate healing ritual performed by the medicine man, or singer; symptomatic relief of pain or discomfort, pending the ceremonial cure, may be obtained from Anglo medical practitioners (see Note 2), Navaho herbalists, Hopi medicine men and even Christian faith-healers—all are perceived as having equal role and function, that of providing relief from painful symptoms.

The implications of this factor are obvious. The physician who is for fortunate in having patients whose diseases can be cured or whose symptoms can be alleviated by one "shot" or so, is regarded as a good doctor. On the other hand, the physician who must treat a patient on the basis of several visits in order to achieve a cure, or the patient who has a chronic disease which cannot be cured without long term treatment, if at all, faces problems. The patient may not continue to take his medicine or return for follow-up visits once he begins to feel good. Also, he may become disgruntled and go to another source for symptomatic relief, thereby breaking the continuity of a treatment program.

Problems are created by hospitalized patients, frequently in serious condition, who want to go home to have a "sing" performed at a time when the interruption of medical care may be fatal. Unless the problems are resolved satisfactorily, the patients may leave the hospital against medical advice.

Shots and X-rays are seen by almost all Navahos as guaranteed to give relief to symptoms, and the physician who is new to the reservation often has a hard time remaining calm in the face of the frequent demands for these services, whether they are needed or not.

3. Perception. Perception is the process of being consciously or sub-consciously aware of the objects and events which enter into the experience field of the individual, reorganized mentally to meet his social and emotional needs (8: 4). Knutson says, "Our perceptions are our sole means for maintaining an awareness of ourselves and other things (9: 1706). They serve us in filtering out things of immediate importance to us, and bringing them into meaningful focus. What seems unimportant or unchanged tends to be ignored."

Needless to say, there are significant differences in perception relating to health and medicine existing between the Navaho and the Anglo. These differences result all too frequently in the creation of imposing barriers to the Navaho's utilization of health resources, as well as in a breakdown of services provided effectively by public health workers.

The Navaho perceptual field is dominant, dynamic and culture-bound. There is being introduced into this field the strange and foreign symbolism of another culture—the public health and medical concepts of the Anglo culture. The people are encouraged to seek immunizations, attend prenatal and postnatal clinics, bring infants to well-baby clinics, learn to make sterile formulas for infants, make changes in their diet, build European-style houses in place of the hogan, build and use toilets, eliminate garbage and refuse by burial, understand how germs transmit disease, use water only from safe sources, purchase individual home water storage units, come to the hospital or clinic only during working hours when it is usually necessary to wait the longest before being seen, come for treatment in the earliest stages of sickness, continue to take medicines as prescribed even after the symptoms are relieved, return for medical check-ups even though the illness seems to have gone, and follow many other health practices. These practices are perceived by non-Indians as ways of prevent by non-Indians as ways of preventing disease and promoting good health.

The Navaho, as pointed out before, perceives health and religion as one and the same, in which well-being is the existence of a correct relationship between man and his natural and supernatural environment. Sickness is caused by a disturbance of this delicate balance. An exactly prescribed Navaho ritual must be performed to cure the sickness and restore the harmony. If physical pain and discomfort persist, symptomatic relief may be obtained wherever it can be had. One of these source is the Indian Health hospital or clinic, known to the Navaho as "white man's medicine." Shots and X-rays are regarded as the most effective of "white man's medicine" in relieving symptoms.

In essence then, the Anglo culture, through Public health is forcing changes in the Navaho's traditional way of looking at things. Hartley and Hartley say that these changes introduced from outside of the traditional culture, makes the traditional perception inadequate and therefore produces a state of discomfort which lasts until a new adjustment can be made (10: 257-258).

Suffice it to say that a state of discomfort has been produced in the Navaho perceptual field which is far from being resolved. This is because the changes being introduced are frequently not based on the genuine needs of the people who are to be changed and are not adapted to fit into their existing behavioral practices and perceptual framework.

4. Discussion-decision processes (11: 78-80). A major understanding necessary for the practice of good health education is that of the methods and processes by which people make decisions, with the decisions so binding as to motivate the follow—through behavior necessary on the part of the people involved.

While much about this factor of human behavior has been documented as it pertains to the general non-Indian society of the United States, a great deal needs to be known as it pertains to cross-cultural situations. Both the project educator and the anthropologist gathered data in this area from their respective viewpoints. Many joint and separate experiences in the hospital and in the field, in formal and informal settings, have been documented. Two generalizations can be made which will be of vital significance to those who would work more effectively with the Navaho.

5. Roles. Navaho employees of public health were studied to determine what kind of a role they played in influencing others around them, either at home or in the community, in matters of health. The Navaho-speaking employee is not seen as a health opinion leader within his or her family unit or community unless he or she occupies a leadership role otherwise. The impression of the project field staff is that few Navaho employees have enough knowledge about any one program to be able to satisfy the need for information on the part of the requesting family or community group. This is due partly to the cross-cultural breakdown in communications which exists, and partly to the role played by the usual Navaho employee in the public health organizational structure. The usual role played is one of a sub-professional worker, because of the lack of education and training necessary for higher level positions. Therefore, these employees are rarely involved in program planning and administration. As discussed before, both adequate information and adequate discussion are necessary if the Navaho group is to make desired decisions and carry them into action. Therefore, the Navaho employee who does not possess the information needed is either reluctant to play the role of the resource person or is apt to play the role of blocking constructive action, if he is negatively inclined.

Implications for Indian Education. The conclusions discussed above were selected from many because they contain within them certain significant implications for Indian Education in general. They are as follows:

Attention must be paid to the fact that the level of Indian health today is at a point where the non-Indian population was 20 to 30 years ago. It is a serious problem and if the long range goal of raising the level to that of the non-Indian population is to be achieved the present and future generations of Indian children and youth, who are in our schools today, will have to be prepared more effectively for healthful living.

2. Course content. Other agencies in the past have reported to this Conference on the problems of teaching the "germ theory" to Indian people. We wish to add our emphasis to this need. An adequate understanding of this concept is vital if preventive health practices are to be adopted because they are understood.

Children and youth should leave school with an understanding of human physical, mental, and emotional development. They should have an appreciation of personal health, which includes a knowledge of anatomy and physiology, nutrition, first aid and safety, stimulants and narcotics, periodical medical and dental care, and family life. They should also have an understanding of community health programs and problems, and the health resources available to them as citizens of the community.

Understandings of these subjects will help make for a smoother adjustment in the perceptual field of the Indian who is experiencing change. The causes of disease will be better understood, which in turn will help change the reasons which motivate him to seek Anglo health and medical care.

3. School health program. Every school child and youth deserves to benefit from an adequate school health program. This includes a program of effective instruction at all grade levels, whether formal or informal; school health medical services, to provide him with health and medical supervision throughout his school years; and a safe and sanitary school health environment.

These aspects of the program will provide for the meaningful, health learning experiences of the school child which are necessary in developing desirable attitudes and practices in adulthood.

4. Health career development. If the role of the Indian is to have greater meaning in the planning and development of public health programs among Indian peoples, more Indians will have to be motivated and trained for the varied professional medical and para-medical positions which are available, career-wise. This involves both the creating of the opportunity to learn about the various health careers, as well as the necessary academic preparation at the secondary level for admittance into the collegiate level program desired.

5. Problem-solving activities. One of the most effective methods of education is the group discussion-decision approach, wherein the group helps identify a problem for solution and carries through with the activity until the problem has been resolved. Experiences of this nature are seen as having great carry-over value and cannot be emphasized too strongly. If community groups are to be successful in solving their problems they must learn how to work together in groups.

Beasley reported to this conference last year on some successful experiences in problem-solving (2:74-75) among Navaho children. Orata, to mention another, writes about a successful experience in problem solving among Indian children which involved the interest and support of parents also (13:207-211).

One factor is usually evident to public health educators who work in Indian health programs. There are few voluntary groups composed of Indian members who are donating their time and efforts to help solve their own tribal health problems, like the many health-and-welfare-oriented groups who besiege us in non-Indian communities. Where these groups are being organized, though, they are effective. Keneally (see Note 3) has reported on several of these experiences in the past. Bronson, one of his community workers (health) describes the success of 14 Apache women who make up the voluntary San Carlos Apache Hospital Auxiliary (14). They help at wellbaby clinics, help orient new public health personnel, encourage people to attend special clinics, raise funds for health improvements, and are now involved in projects to help improve housing in the community as well as provide teenage girls with a constructive program of summer activities. It is very gratifying to see this kind of development.

Havighurst and Neugarten reported on a study which has some implications for understanding the motivational drives of Indian children (15:195). This may be of some interest to the members of this conference because of the concern expressed during the past two years about the lack of proper motivation among the children and youth.

The study involved Papago, Hopi, Zuni, Zia, Navaho and Sioux Indians, compared to the white children of "Midwest," a small midwestern city with a surrounding rural trading area which was supposedly "representative of the kind of community most frequently found in the middle-western part of the United States."

Part of the study was concerned with determining whether the children were "self-centered" or "other-centered" in terms of needs and interests. It was found that the Navaho children and the children of Midwest were "highly self-centered," with the criteria of "self-centeredness" being: Individual achievement, self-restraint, self-gratification, competence, and personal virtues. The three Pueblo societies of Hopi, Zuni and Zia were found to be "highly other-centered," with the criteria of "other-centeredness" being: Regard for others, service, smooth personal relations, relations with authority, discipline and authority for others, aggression toward peers, and aggression by others. The Papago were found to be even in terms of "centered" trends.

6. In-service education of teachers. Health education is not always recognized as a discipline of its own and given its rightful place in the program of the teacher training institutions (12:8). The curriculum and course content are usually inadequate, there is a lack of qualified instructors and appropriate resources and, generally, teachers leave college not equipped to teach health effectively to students.

Because there is usually a genuine need and interest in a better school health program on the part of the students and teachers alike, teachers soon turn to in-service education programs to develop a higher level of skill in health education. Numerous resources are available to schools and teachers who are interested in in-service training. Among these are universities and colleges, state departments of education and public health, regional offices of Indian Health and the Public Health Service, and voluntary health agencies.

Attention is called to A Syllabus for Teachers in Navaho Health, developed by the Cornell University group at Manyfarms (16). This is a good resource manual which would be of value to those who teach health to Navaho children and youth.

7. Research. Obviously, there is need for the continued support of this conference and for formal contributions from its members in the area of school health and health education. Specifically, there is need for the study of the methods of health education which are effective with Indian students, and for the development of better teaching materials and audio-visual aids and assessing their effectiveness. Studies are needed in the health attitudes, motivation and behavior of Indian students, with comparative data on their parents and tribal groups. The continuity of health teaching at various grade levels needs to be developed also. Pilot projects should be developed in schools, communities and teacher training institutions to promote better health education.

These are only a few of the research needs. The social sciences of psychology, sociology and anthropology should be looked to by educators as valuable resources to be considered in bringing to the solution of the health education problems the constructive viewpoints and contributions of related disciplines.

Summary. This paper has attempted to describe the Navaho Health Education Project and the problem and needs which led to its development. A few basic conclusions were presented which are relevant to the needs of Indian education in general, and the implications of these were discussed briefly.

In conclusion, health education in schools should be based on the health needs and interests of children and youth, which are to be met by the home, the community and the school working co-operatively. This must be an important part of the total health and medical program of Indians if the long range objectives of the Division of Indian Health and our Anglo-American society are to be realized.

2. Members of the Public Health Service, missionaries, and private practitioners who are of the dominant Anglo culture.