The Water is K’é program was developed to increase water consumption and decrease consumption of sugar-sweetened beverages for young children and caregivers. The pilot program was successfully delivered by three Family and Child Education (FACE) programs on the Navajo Nation using a culturally centered curriculum between 2020 to 2022. The purpose of this research was to understand teacher and caregiver perspectives of program feasibility, acceptability, impact, and other factors influencing beverage behaviors due to the pilot program. Nine caregivers and teachers were interviewed between June 2022 and December 2022, and a study team of four, including three who self-identified as Navajo, analyzed the data using inductive thematic analysis and consensus building to agree on codes. Five themes emerged, including feasibility, acceptability, impact, suggestions for future use of the program, and external factors that influenced water consumption. The analysis showed stakeholders’ strong approval for continuing the program based on impact and acceptability, and identified factors that promote the program and barriers that can be addressed to make the program sustainable. Overall, the Water is K’é program and staff overcame many challenges during the COVID-19 pandemic to support healthy behavior change that had a rippled influence among children, caregivers, teachers, and many others.

Background: Family-level interventions can promote early child health. Partnering with community stakeholders, we co-developed Water is K’é, a culturally grounded family intervention delivered in early childhood education settings to promote healthy beverage choices and wellbeing among Navajo. (Diné) children ages two to seven. This manuscript describes the rationale, design, and methods of the study. Aim: To evaluate the impact of Water is K’é on beverage behaviors among children and families, and on family cohesion and cultural connectedness. Methods: Diné and non-Diné researchers and community advisors developed the intervention and study design using community engagement methods. In this cluster-randomized crossover trial, early childhood education sites on Navajo Nation will be enrolled and randomly assigned to begin the intervention in year one or serve as a waitlist control until year two. Child-caregiver dyads will be enrolled at the start of the school year, with optional participation from other family members. The intervention strengthens the cultural connection to water, encourages behavior change, and addresses water access through 4 monthly lesson plans, social media content, and tailored strategies to increase children's access to drinking water throughout the day. Primary endpoints include beverage habits and family cohesion. Collected data includes surveys, optional health measures, and qualitative interviews. Summary: Water is K’é is a multilevel, community-designed intervention emphasizing Navajo language and culture. Innovative features include participant choice of health measures and family member enrollment. If successful, the program could be scaled across Navajo Nation and adapted for other early childhood programs.

Background. Unhealthy food and beverage taxes are gaining global momentum, but implementation complexities at the retailer level are poorly understood. The only such policy in the United States, a 2014 Navajo Nation legislation, applies a 2% tax to unhealthy foods and beverages, while exempting healthy foods and beverages from their 6% Navajo sales tax. In 2019, approximately half of small stores had not implemented both taxes correctly, primarily the tax exemption. Therefore, this study aimed to provide culturally-informed promotional materials to enhance implementation accuracy in these stores and test the impact. Methods. Stores ( N = 20) were randomly assigned to receive early promotional materials versus a waitlist group. Three to 6 months later, we visited all stores to purchase healthy and less healthy items, at which time waitlist stores received materials. Implementation accuracy of the junk food tax and exemption were tracked and compared. Results. Overall implementation accuracy of both taxes increased from 0% to 20% at follow-up ( p = .013). Tax waiver accuracy increased from 5% to 30% ( p = .065). Comparing intervention versus waitlist stores, we observed no difference in implementation of tax exemption and a non-significant increase in accuracy of added tax on unhealthy foods and beverages (90% vs. 70%, p = .284). The study process revealed strengths and barriers to impactful store outreach. Discussion. Grounded in community partnership, we explored a promotional outreach strategy to enhance accurate implementation of Navajo Nation food and beverage taxes. Our findings suggest store outreach and promotional materials could address confusion issues, while barriers related to store capacity merit further exploration.