Introduction

On March 17, 2020, the first confirmed case of COVID-19 was reported on the Navajo Nation and subsequently linked to a church gathering attended by individuals from over half a dozen communities from across the Navajo Nation [1,2]. Within the first several months of local transmission in the United States (US), the Navajo Nation became a COVID-19 hotspot with per-capita infection rates far outpacing more densely populated areas in the US such as New York City and Los Angeles [1,3,4]. The Centers for Disease Control and Prevention (CDC) estimated that COVID-19 infection rates among American Indian and Alaska Natives AI/ANs was 3.5 (95% CI 1.2–10.1) times that of the non-Hispanic white population [5]. Additionally, case fatality rates (~4%) for the Nation were twice what was reported for neighboring Arizona and New Mexico, 2.0% and 2.1% respectively, during the same period [6].

The disproportionate burden of COVID-19 infection and mortality among the Navajo or Diné people, as well as other AI/AN communities in US, are legacies of centuries of broken treaties, structural racism, and settler colonialization [5,7,8]. The Snyder Act of 1921 and Indian Health Care Improvement Act of 1976 ordered treaty rights for quality healthcare for AI/AN nations in the US, treaties that remain unfulfilled to this day [8]. Decades of underfunding of public health infrastructure and the Indian Health Service have contributed to the higher prevalence of chronic disease including cancer, diabetes, hypertension, heart disease and kidney disease among the Navajo population – all of which are comorbid conditions linked to adverse COVID-19 clinical outcomes [9–11]. In fact, these additional burdens and the excessive transmission rates and their impact on our community health partners of the Navajo Healthy Stomach Project that brought this project into existence.

Likewise, settler colonial structures and forces designed for control of land and resources have created socioeconomic conditions and frayed infrastructure have made many households and communities on the Navajo Nation vulnerable to COVID-19 infection [8,12–14]. The Navajo Nation spans 27,000 miles and three states (Arizona, New Mexico, and Utah) in the Four Corners area of the US. It is home to approximately 400,000 people. However, in an area roughly the size of West Virginia, Diné citizens have access to only 13 grocery stores (driving an average of three hours for groceries) and just 13 health care facilities (12 on-reservation and one located off-reservation) [8,14]. Food insecurity and poor access to health care services have been linked to increased COVID-19 infection and mortality among other rural and minoritized populations in the US [15,16]. Moreover, along with high rates of unemployment and poverty, nearly 30% of the population does not have access to running water [14,17]. These conditions increased the difficulty for Navajo residents to adhere to COVID-19 mitigation advice including frequent handwashing.

Furthermore, until the passage of the American Indian Religious Freedom Act in 1978, AI/ANs were prohibited from and often punished for visiting sacred sites, performing religious dances, and conducting ceremonies and other traditional medicine practices [18]. However, despite these efforts, a 1998 study estimated that 39% of Navajo (Diné) patients at an Indian Health Services clinic reported being regular users of traditional medicine or native healers [19]. In Diné culture, traditional medicine (DTM) “sees a person not simply, as a body but as a whole being with body, mind, and spirit seen to be connected to other people, to families, to communities, and even to the planet and universe.” [20–23]. Indigenous health and well-being encompass more than simply the absence of disease or physical health but includes emotional, mental, and spiritual elements of life and extends beyond the individual to incorporate land, animals, family, and community [24]. On the Navajo Nation, the Diné Hataałii Association is a 501I(3) nonprofit organization established in the 1970s comprised of medicine men and women from across the Nation to protect, preserve and promote Diné traditional cultural wisdom, ceremony, and herbal healing knowledge [25]. The organization is comprised of spiritual leaders and cultural wisdom keepers that include but are not limited to Hataałii (medicine men and chanters), herbalists, diagnosticians, and singers.

At the height of the COVID-19 pandemic on Navajo Nation, leaders implemented nightly curfews and 57-hour weekend lockdowns from 8:00 pm on Friday through 5:00 am on Monday [26]. Residents were ordered to remain at home, with exceptions for certain essential workers, first responders, and health care personnel [27]. To address concerns raised by community health partners of our Navajo Healthy Stomach Project regarding the impact of COVID-19 mitigation strategies on Diné people’s access and utilization of allopathic medical care and DTM, we developed a 1-year multimethod study to explore the impact of the COVID-19 pandemic on Navajo community members’ livelihood including healthcare access (allopathic and DTM) and personal well-being, using online and in-person surveys and focus group discussions. Results from our primary analyses describing risk factors associated with COVID-19, utilization and access to allopathic health care during the pandemic and mechanisms of resilience among Navajo adults are described elsewhere [28].

In recognition that health is more than accessing allopathic medicine, this investigation sought to examine community members’ perceptions of the impact of the COVID-19 pandemic on access, utilization, and perceived quality of DTM on the Navajo Nation. Additionally, we characterize individuals who sought or used DTM during the COVID-19 pandemic, including their personal and psychosocial wellbeing. This work adds to our understanding of DTM use, especially during times of crisis.

Methods

We recruited participants from 18 May to 12 October 2021 to complete a survey designed to explore community members’ perceptions of COVID-19 impacts on access, utilization, and quality of health care (allopathic and DTM) on the Navajo Nation. The surveys were conducted online or in-person.

Study participants and data collection

Participants were recruited for the study using five convenience sampling methods: 1) a two-hour radio forum on Navajo Nation’s KTNN 600 AM radio station in May 2021, 2) recruitment flyers emailed to Navajo Nation chapters, 3) the research team’s website, and 4) social media, specifically Facebook and Instagram. Following the end of 57-hour stay-at-home lockdowns on Navajo Nation in July 2021, subjects were also recruited from in-person tabling at four outdoor chapter flea markets (July 2021 – September 2021). Participants were eligible to participate if they were at least 18 years of age and self-identified as Navajo.

Participants completed the COVID-19 Impact Survey which assessed a) COVID-19 exposure, symptoms, testing, and vaccination, b) impact on cancer care seeking, c) barriers to (allopathic) health care, including barriers introduced due to lockdown restrictions, d) barriers to Diné Traditional Medicine care, including barriers introduced due to lockdown restrictions and e) COVID-19 Well-being including psychosocial impact, f) resilience and coping, and g) employment and financial impact. Additionally, housing, living and community demographic questions were asked to understand the influence of these factors on care-seeking capacity. The questionnaire was reviewed by CAC members and the Diné Hataałii Association and edited according to feedback. A copy of the questionnaire is available in Supplemental material.

Surveys were administered through REDCap (Research Electronic Data Capture) electronic data capture tools hosted at the University of Arizona, which permitted secure data entry and met privacy requirements for research studies [31,32]. Additionally, a small team of University of Arizona and Northern Arizona University staff and students administered in-person surveys to participants recruited at the four outdoor chapter flea markets (July 2021 – September 2021). These surveys were then entered into REDCap by the research team.

Of the initial 190 participants recruited, 169 (89%) consented to participate in the survey. Most of the survey responses were entered by the research team from the paper forms (n = 127), with fewer respondents (n = 27) directly entering into the online forms. Only individuals that completed the entire survey (n = 153 or 81% of recruited participants) were included in this analysis. The survey allowed for participant non-response or refusal and these responses were coded as missing. Thus, missingness was observed in our final analytic sample, see Table 1.

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Table 1. Characteristics of Navajo survey participants in the COVID-19 Impact Study (N = 153) by Diné Traditional Medicine (DTM) Use.

https://doi.org/10.1371/journal.pone.0337427.t001

Results

The characteristics of Navajo participants in the COVID-19 Impact Survey are shown in Table 1. Most of the survey participants (66.9%) were recruited in-person at flea markets, followed by friends and family (27.4%), newsletters/fliers (11.9%) and social media (10.7%). Age was not reported for 51 participants or one-third (33.3%) of our survey participants, reported age ranged from 18–90 (mean = 44.65, SD = 15.76). Survey participants were mostly female (66.4%) and had at least a high school diploma or GED (84.1%). Most participants lived in modern houses or trailers (46.1% and 31.6%, respectively), with a mean household size of 3.49 persons (SD = 1.78). Participants lived mostly (43.7%) in rural communities and less than 15 minutes driving distance to grocery shopping (30.5%).

Barriers and access to diné traditional medicine and healing

Table 2 shows the scores for barriers or issues encountered in seeking DTM pre- and mid-pandemic among the 74 participants who reported use of Diné traditional medical care and healing. Overall, median scores remained unchanged from pre-pandemic to mid-pandemic for all barriers or issues except for ‘availability or child or elder care’. The median score for ‘availability of child or elder care’ was higher mid-pandemic than pre-pandemic, but this was not a statistically significant difference.

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Table 2. Comparison of pre-pandemic and mid-pandemic scores for barriers or issues encountered in Diné traditional medical care and healing.

https://doi.org/10.1371/journal.pone.0337427.t002

Of the participants that sought DTM during the pandemic, most indicated that traditional practitioners/healers had implemented measures to address COVID-19 (58.1% with 33.8% strongly agreed and 24.3% agreed). Over half (n = 41) either strongly agreed or agreed (25.7% and 29.7%, respectively) that social distancing guidelines had disrupted or delayed their traditional medicine and healing experiences. Likewise, most participants (25.7% strongly agreed and 30.7% agreed) indicated that Navajo Nation lockdown restrictions had also disrupted or delayed their traditional medical care.

Diné traditional medicine and healing use and COVID-19 well-being

Comparisons of median scores and standard deviations for all COVID-19 PPE subscales and summary scales between DTM use groups are shown in Table 3. Scores for health care disruption, satisfaction with provider response, disruption to daily and social activities, and financial hardship were uniform between DTM users and non-users. DTM users had slightly higher scores for perceived benefits, social support, and perceived stress management (3.17 (SD = 0.70), 2.89 (SD = 0.96), and 2.76 (SD = 0.80), respectively) but these were not statistically significant. In contrast, significant differences were observed for anxiety and depression scores. DTM users reported higher anxiety symptoms (2.66, SD = 1.06) and depression symptoms (2.47, SD = 1.15) than non-users (2.15 (SD = 1.10) and 1.89 (SD = 1.11), respectively). Both summary scores, risk factors and protective factors, were higher among DTM users than non-users (2.34 vs. 2.00 and 2.90 vs. 2.73, respectively). However, only the risk factors summary score was significantly different (p < 0.05).

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Table 3. COVID-19 Psychosocial & Practical Experiences (COVID-PPE) Subscales and Summary Scores for Navajo community members by Dine Traditional Medicine and Healing Use.

https://doi.org/10.1371/journal.pone.0337427.t003

Discussion

This study was conducted in response to concerns from the Navajo community about the impact of the COVID-19 pandemic including social distancing and lockdown restrictions enacted by the Navajo Nation to reduce transmissions on Diné people’s access, use, and quality of health care including Diné traditional medicine [27]. In this study, we found that nearly half (n = 74, 48.7%) of the study sample reported use of Diné traditional medicine (DTM) or healing during the COVID-19 pandemic. While not directly comparable, a 1998 survey of Navajo Indian Health Service patients found 62% reported ever seeking DTM and 39% reported being regular users [19]. With limited data on current, general population users, it is difficult to interpret our 48.7% during a time of crisis as either an increase of regular users or a decrease of ever users. Nevertheless, DTM users in our sample indicated that the COVID-19 pandemic had minimal impact on the barriers or issues they faced in receiving DTM care or healing and reported higher levels of anxiety, depression, and risk factors than non-users. We cannot know from our analysis whether the observed association between DTM use and mood-related symptoms was because DTM was perceived as a safe and comfortable space during the high anxiety COVID times or if DTM users generally experience more anxiety and depression.

Although several ecological studies have been conducted to describe the factors and vulnerabilities contributing to the increased burden of COVID-19 infection and mortality on the Navajo Nation and other Indigenous communities [12,36–40], these studies were not designed to assess and understand the personal impact of this increased COVID-19 burden on Diné communities. Results from this study contribute to the limited examination of lived experiences and impact of the pandemic from the Indigenous communities’ perspective [41,42].

At the beginning of the pandemic, the Navajo Nation empowered by tribal sovereignty and governance, implemented some of the strictest mitigation strategies in the United States, including mask mandates, restricting social gathering, closing of schools to in-person instruction, weeknight curfews and lockdown restrictions for its citizens [1,26,27]. Social gathering restrictions also extended to in-person traditional ceremonies and other Diné traditional medicine (DTM). Our study findings indicate that these mitigation strategies did not deter Diné people from seeking and receiving Diné traditional medicine and healing. Due to colonization, discrimination, and marginalization, the AI/AN peoples of the US have always faced significant barriers preserving and practicing their culture including the use of traditional Indigenous medicine [18,20,43,44]. Thus, it is likely that the fortitude and adaptability that the Diné people have developed to navigate daily life may have been useful in navigating the pandemic-induced hardships in the pursuit of DTM. For example, members of the Diné Hataałii Association (DHA) adopted technology-based modalities, including phone and online conferencing, in lieu of in-person or home-to-home visits (either within the patient’s or practitioner’s home) for conducting ceremonies and healing practices [25,44,45]. In addition, the DHA shifted member meetings from in-person to online, collected and distributed masks to DHA members across the Navajo Nation, and developed a proclamation informed by Centers for Disease Control and Prevention (CDC) infection control guidelines outlining how to safely proceed in the protection, promotion, and preservation of Diné cultural wisdom and language during the pandemic, despite mitigation restrictions [46]. The Navajo concept of K’é, or family kinship ties, was supportive in the protection of families, communities, elders and cultural keepers facilitating early adoption of masking and social distancing while still taking care of one another.

In contrast to previous studies characterizing users of Indigenous medicine and healing as older and with lower education levels, DTM users in our study were young (56.2% aged 18–45 years old) and had higher levels of education (76.0% reported postsecondary education) [20,43,47]. These findings could be indicative of the resurgence and reclaiming of cultural traditions in younger generations [48–50]. As rebuttal to decades of assimilation and denial of cultural identity, Indigenous communities and tribal nations have identified culture, language, traditional knowledge including traditional medicine as necessary tenets of Indigenous health and well-being [20,48–52]. Although DTM users in our study reported higher levels of anxiety and depression than non-users, they also reported higher levels of protective factors (satisfaction with provider response, perceived benefits, social support, and perceived stress management ability) than non-users. These findings perhaps reflect the emphasis on holistic well-being in Diné culture, wherein shortfalls in mental and emotional health are mitigated through strengthening connections to family, community, nature and non-human kin, and other aspects of life [21–23,53].

This study had several limitations. First, the responses collected are limited by small sample size and potential selection bias. Our sample was slightly older (44.7 y.o. vs 34.6 y.o.), more female (66.4% vs 51%), more educated (84% vs 80% high school diploma or greater) and had higher unemployment (31% vs 15%) compared to the Navajo Nation [54]. While we attempted to reach people throughout the Navajo Nation through the radio and social media most of the respondents were recruited from flea markets in two Navajo communities (Shiprock and Tuba City). These communities are the two most populous on the Navajo Nation, have an economic infrastructure that supports health care and shopping facilities within the community boundaries and have a lower percentage of the population aged 65 and older compared to the overall Navajo Nation (Shiprock: 9%, Tuba City: 12%, Navajo Nation: 14%), thus survey participants may not be representative of the on-reservation Navajo population [54]. Additionally, experiences and perceptions of those that were able to complete surveys (i.e., had internet access or were mobile enough to be recruited at local flea markets) may be different than those that did not participate. Second, our cross-sectional study only captured COVID-19 experiences and perceptions at a single-point in time. Responses were collected between August to October 2021, a period when high vaccination rates and decreased COVID-19 levels on the Navajo Nation had enabled loosening of restrictions on in-person activities and gathering limits. Lastly, our study was primarily focused on examining the influence of proximal factors on individual experiences of the COVID-19 pandemic and may have underestimated the effects of structural vulnerabilities from historical racism and colonialism on these participant’s COVID-19 experiences. Deschine Parkhurst, Huyser and Yellow Horse [40], found ZIP code level COVID-19 incidence among AI/ANs in New Mexico had a stronger association with indices that included measurement of historically embedded vulnerabilities from environmental racism, specifically proximity to abandoned uranium mines compared to current social vulnerability indices that measure the aggregate of specific social, economic, and demographic conditions that place certain populations at risk for hazards (vulnerability) but do not include measures of potential drivers of these vulnerabilities [40].

Future research should explore a diverse range of methods including social media, radio, and community gatherings to recruit and consent Navajo participants from a broad range of backgrounds to examine their perceptions and experiences, during the COVID-19 pandemic. Additionally, future studies could examine assets and resources of Navajo community and participants in contrast to barriers and vulnerabilities to understand how individuals and communities were able to mitigate worsening COVID-19 pandemic conditions.

Conclusion

In summary, despite significant challenges imposed by the COVID-19 pandemic, this investigation highlighted the incredible resilience of the Diné people and the importance that Diné traditional medicine and healing contributes to overall health and well-being of the Diné people.

Supporting information

Acknowledgments

We would like to acknowledge and thank the Diné Hataałii Association for their feedback during development of our study questionnaire and approval of this study. We would also like to thank and acknowledge the Navajo Nation Human Research Review Board for approving this study. This manuscript is part of PhD doctoral dissertation work.