Practicing Tribal Sovereignty Through a Tribal Health Policy: Implementation of the Healthy Diné Nation Act on the Navajo Nation.
Regina Eddie, Caleigh Curley, Del Yazzie, Simental Francisco, Ramona Antone-Nez, Gloria Ann Begay, Priscilla R Sanderson, Carmen George, Sonya Shin, Shirleen Jumbo-Rintila, Nicolette Teufel-Shone, Julie Baldwin, Hendrik Dirk de Heer
Author Information
Regina Eddie: School of Nursing, Northern Arizona University, 202 E Pine Knoll Dr, Flagstaff, AZ 86011. Email: Regina.Eddie@nau.edu.
Caleigh Curley: Department of Health Sciences, Northern Arizona University, Flagstaff, Arizona.
Del Yazzie: Navajo Epidemiology Center, Navajo Department of Health, Window Rock, Arizona.
Simental Francisco: Navajo Epidemiology Center, Navajo Department of Health, Window Rock, Arizona.
Ramona Antone-Nez: Navajo Epidemiology Center, Navajo Department of Health, Window Rock, Arizona.
Gloria Ann Begay: Diné Food Sovereignty Alliance, Gallup, New Mexico.
Priscilla R Sanderson: Department of Health Sciences, Northern Arizona University, Flagstaff, Arizona.
Carmen George: Brigham and Women's Hospital, Boston, Massachusetts.
Sonya Shin: Brigham and Women's Hospital, Boston, Massachusetts.
Shirleen Jumbo-Rintila: Navajo Division of Community Development, Window Rock, Arizona.
Nicolette Teufel-Shone: Department of Health Sciences, Northern Arizona University, Flagstaff, Arizona.
Julie Baldwin: Department of Health Sciences, Northern Arizona University, Flagstaff, Arizona.
Hendrik Dirk de Heer: Department of Health Sciences, Northern Arizona University, Flagstaff, Arizona.
INTRODUCTION: The Navajo Nation is a large sovereign tribal nation. After several years of grassroots efforts and overcoming an initial presidential veto, the Navajo Nation passed the Healthy Diné Nation Act (HDNA) in 2014 to promote healthy behaviors in Navajo communities. This was the first such policy in the US and in any sovereign tribal nation worldwide. PURPOSE AND OBJECTIVES: The objective of this study was to describe the process, implementation, and evaluation of the HDNA passage and its 2020 reauthorization and the potential for using existing and tribal-specific data to inform tribal policy making. INTERVENTION APPROACH: The HDNA included a 2% tax on unhealthy foods sold on the Navajo Nation and waived a 6% sales tax on healthy foods. HDNA-generated funds were allocated to 110 local communities for wellness projects. No funds were allocated for enforcement or compliance. EVALUATION METHODS: We assessed HDNA tax revenue and tax-funded wellness projects in 110 chapters over time, by region and community size. The food store environment was assessed for fidelity of HDNA implementation, price changes since pretax levels, and shopper behaviors. HDNA revenue was cross-matched with baseline nutrition behaviors and health status through a Navajo-specific Behavioral Risk Factor Surveillance System survey. RESULTS: HDNA revenue decreased modestly annually, and 99% of revenue was disbursed to local chapters, mostly for the built recreational environment, education, equipment, and social events. Stores implemented the 2% tax accurately, and the food store environment improved modestly. Regions with high tax revenue also had high rates of diabetes, but not other chronic conditions. The HDNA was reauthorized in 2020. IMPLICATIONS FOR PUBLIC HEALTH: Sovereign tribal nations can drive their own health policy. Program evaluation can use existing data sources, tailored data collection efforts, and tribal-specific surveys to gain insight into feasibility, implementation, and impact.
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