Navajo Nation Home to Region’s Highest HPV Vaccination Rate

CHINLE, Ariz. – The Association of American Cancer Institutes (AACI), in partnership with the Centers for Disease Control and Prevention (CDC) and the American Cancer Society, recognized 10 pediatric practices across the nation for exceptionally high rates of human papillomavirus (HPV) vaccination. In the U.S. Department of Health and Human Services’ Region 9, which encompasses California, Arizona, Nevada, Hawaii and U.S. territories in the Pacific, the honor went to the Navajo Area Indian Health Service Unit in Chinle. Their HPV vaccination completion rate was 82.7 percent, giving the Chinle Service Unit one of the highest vaccination rates of all 10 honorees nationwide.

HPV is transmitted by skin-to-skin sexual contact and causes virtually all cervical cancers, and can also cause cancers of the throat, anus, vagina, vulva, penis and rectum. Depending on the age of the recipient, two to three doses of the HPV vaccine are recommended for preteens and teens. The vaccine has led to declines in HPV infections and is projected to reduce rates of HPV-associated cancers.

Chinle has been continuously inhabited for more than five millennia, and the Chinle Service Unit serves 35,000 people in the geographical heart of the Navajo Nation. Their vaccination rate of nearly 83 percent is especially remarkable given how low uptake is across the country. According to the CDC, in 2016, only 50 percent of Arizonans 13–17 years of age received two or more doses of the HPV vaccine. Rates for American Indians and Alaska Natives nationwide are similar, with nearly 47 percent in this age range receiving two or more doses.

UA Cancer Center honors Chinle’s accomplishments

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Margaret Briehl, PhD (left) presents award to Jill Moses, MD, MPH (right) (photo: Ryan F. Goldtooth)

The AACI enlisted the University of Arizona Cancer Center to present the award to Chinle Service Unit staff. On March 28, Margaret Briehl, PhD, professor of pathology at the UA College of Medicine – Tucson and leader of the training core for the Partnership for Native American Cancer Prevention (NACP), and Tiffani Begay, MPH, NACP Training program coordinator, traveled to Chinle for the award ceremony.

“We left at 6:30 in the morning,” recalls Dr. Briehl. “The trip from Tucson is a six-and-a-half hour drive, to the very northeast corner of the state. It really is beautiful country.”

The ceremony, followed by a reception, was attended by about 20 people. Dr. Briehl presented the award to Jill Moses, MD, MPH, the director of the Chinle Service Unit’s Division of Public Health.

“The award was a beautiful glass plaque,” says Dr. Briehl. “Dr. Moses thanked everyone for the work they had done, talking about the great team.”

“It was an honor to receive the award for Chinle Service Unit,” says Annie R. Moon, MPH, MSN, nurse practitioner for the Chinle Service Unit’s Department of Adolescent and School Health. “The award was beautiful and is proudly displayed in our Public Health building. This is definitely a group effort with the teen clinic and pediatric department.”

“Being able to see all their hard work and how proud they were of each other — that was what I took away the most,” says Begay. “It’s a small community and they all came together and made this so successful.”

Before presenting the award, attendants introduced themselves to one another.

“One of the things among Navajos is an introduction. When you introduce yourself in Navajo you are telling them who you are and who you are born for,” explains Begay, referring to the naming of one’s maternal and paternal clans. “From that introduction you have a connection.”

One such connection was uncovered during the introductions, when Dr. Briehl realized she had known Dr. Moses’ father, Harold (Hal) Moses, MD, a renowned cancer researcher who at one time was an adviser to the NACP.

“That connection meant even more to us, that we could present [the award] to her, and Margaret knew her father,” says Begay.

Fighting HPV and cervical cancer on the Navajo Nation

HPV infection among Native Americans is not well-studied, but a 2011 study found that, compared to other racial and ethnic groups, Native women were just as likely to be infected with HPV-16 and HPV-18, the strains of the virus that are covered by all versions of the HPV vaccine.

However, compared to the general population, American Indians and Alaska Natives are more likely to die from cervical cancer. The higher mortality rate indicates their cervical cancers are detected at a later stage, when they are more difficult to treat. According to the CDC, in 2015, Native women were the least likely of all racial groups to have been screened for cervical cancer in the previous three years.

While screening is important, widespread HPV vaccination can also help address disparities in cervical cancer deaths by preventing potentially fatal HPV infections. According to Moon, there is not much resistance to HPV vaccination in the population she serves.

“Some of the parents think their kids are too young to receive the vaccine, but after explaining the benefits, most of them agree,” says Moon. “I tell parents that the earlier they get the vaccine, the better — especially before they become sexually active.”

Chinle Service Unit staff wove HPV vaccination into Navajo culture by connecting it to coming-of-age ceremonies that observe the transition into adulthood. A ceremony called Kinaaldá celebrates a girl’s first period, while a sweat lodge ceremony called Táchééh marks the time when a boy’s voice changes.

“These are about the ages when they should be getting their first HPV vaccine,” says Moon, explaining the connection. “It would be great for parents to realize that when their child reaches puberty, they also need their HPV vaccines.”

The Indian Health Service is charged with providing health care to members of federally recognized tribes, and strives to do so in a culturally appropriate way.

“The Chinle Indian Health Service has incorporated traditional healers into their medical practice,” says Dr. Briehl. “The HPV vaccine is a good example of a health intervention that came out of Western medicine, which needed to be culturally adapted to the community to which that help was being delivered.”

Tools like the HPV vaccine have tremendous potential for changing the face of health care across the world, including here on the Navajo Nation.

“I believe that cervical cancer can be eradicated through immunizations, just like we eradicated polio,” says Moon. “This will be challenging, but it can be done. Even if we do not eradicate cervical cancer, we can substantially reduce the numbers of cancers in both Navajo men and women — I’ll take that!”

Promoting cultural competence to improve health

The Partnership for Native American Cancer Prevention (NACP) is run jointly with Northern Arizona University with funding from the National Cancer Institute. Its mission is to improve the health of Native Americans in the U.S. Southwest, where Natives generally suffer higher cancer rates than the general population.

The NACP was chosen to present the award to the Chinle Service Unit on behalf of the UA Cancer Center because of the work they do to increase Native representation and cultural competency in the health sciences. The Chinle Service Unit’s culturally appropriate approach to integrating HPV vaccination within Navajo traditions is an example of the types of strategies NACP promotes.

“One of the things we’re trying to do at the NACP is help non-Native researchers better understand the communities with which they’re working,” says Dr. Briehl, adding that research must be done “with” the people rather than “on” the people. “To do respectful work in communities, it has to be a partnership.”

The NACP supports cultural competency among researchers by hosting educational workshops.

“We invite our non-Native research mentors to participate so they can hear not only from the Navajo community, but also from the Pascua Yaqui and Tohono O’odham community, about cultural sensitivity and what they should look out for,” says Begay. “Little things make a difference when you’re working with the Native community.”

Just as it is important for researchers to be culturally competent, so too is it important for health-care workers to understand the cultural context in which they work.

“On the Navajo Nation, in most cases, elders only speak and understand Navajo, and know very little English,” Begay explains. “When grandparents go in [the IHS facilities], they go in knowing what they are there for and are then asked questions about specific health concerns and current medications, which sometimes they do not know anything about. In return, the grandparents will agree because they do not understand, and don’t ask questions because they don’t know what to ask.”

Begay describes her experience taking her own grandmother to see IHS health-care providers.

“When the physician is talking to her, she looks to me to explain it to her,” says Begay. However, “when the Navajo nurse comes in, these walls fall. The nurse will explain what the doctor’s saying. She’ll ask questions and the nurse will recite it to the doctor.”

The NACP also connects Native students to mentors to help them launch careers in cancer research, other biomedical research or the health-care professions. Begay, an NACP alumna herself, says that watching students successfully complete the program is her favorite part of the job.

“It’s rewarding, seeing the student’s progress from knowing the basics of science to then reiterating their research at a professional level,” says Begay. “And then to see them graduate and matriculate into a graduate program — I absolutely love it.”