Centering Diné (Navajo) Voices: Barriers, Facilitators, and Perceptions of Cardiac Care Among Patients With Heart Failure in Rural Navajo Nation.

Background: The American Indian population in the United States experiences marked cardiovascular health disparities. American Indian patients, particularly those receiving care rurally through the Indian Health Service (IHS), face unique challenges to accessing appropriate cardiovascular care. However, there are no studies in the current era characterizing these challenges from the patient perspective. Therefore, the aim of this study was to characterize the barriers, facilitators, and perceptions of cardiac care among Diné (Navajo) patients with heart failure receiving care through the IHS, as well as to determine patient-designed solutions to improve access to quality cardiovascular care.

Methods: We performed semi-structured interviews and surveys of Diné patients (n=30) living with heart failure and receiving care at two IHS sites in rural Navajo Nation. The participants were 27% female and 30% Navajo speaking with a median age of 59 (interquartile range 53, 67) years. Interviews were guided by the Consolidation Framework for Implementation Research to describe patient experiences with receiving cardiac care. Interviews were audio recorded and transcribed for thematic analysis.

Results: Several themes emerged reflecting barriers and facilitators to accessing cardiac care, as well as perspectives regarding heart failure care and advanced therapies. Primary barriers included lack of specialists locally, transportation-related and financial barriers to traveling long distances to urban centers for care, complicated IHS referral processes, and mistrust of providers outside of the IHS. Facilitators included trust of local IHS care; community and family support; and exceptional patient and caregiver resiliency and activation. Most patients felt that Traditional Medicine was important for their cardiovascular health and desired more of its integration into Western treatment. There was heterogeneity in cultural beliefs regarding heart transplantation, but the majority felt that it was acceptable if needed. Proposed solutions for improving cardiovascular care included making more services available locally, increased telehealth options, and assistance for social determinants of health, especially access to healthier food and transportation-related costs for referral care.

Conclusions: As the first qualitative study of American Indian patients with heart failure in the current era, these results highlight unique care challenges, which can inform community-designed strategies to improve access to care.