Collaboration Among Tribal and State Maternal and Child Health (MCH) Organizations

1. Collaboration Among Tribal and State Maternal and Child Health (MCH) Organizations CATSO Project University of Alabama at Birmingham (UAB) Association of Maternal and Child Health Programs (AMCHP) National Indian Health Board (NIHB)

2. Acknowledgements This project was generously funded by a grant from the Robert Wood Johnson Foundation (ID: 67623) We also wish to acknowledge the Maternal and Child Health Training Grant (ID: T75MC00008) funded by the Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration (HRSA)

3. Background • Working collaboratively has been shown to produce desired public health outcomes (Institute of Medicine, 2005) • Programs funded by the Health Services and Research Administration (HRSA) and Title V of the Social Security Act through the Maternal and Child Health (MCH) Block Grant exist in all states to serve the MCH population • Higher levels of collaboration between organizations may lead to improved relationships to better serve the MCH population broadly

4. Objectives To explore the association between levels of collaboration and stages of interorganizational relationships (IORs) To identify effective models of collaboration within and between State Title V and American Indian/Alaskan Native (AI/AN) MCH entities To identify the characteristics present in these collaborative models from which best practices can emerge and be shared

5. Study Design • Mixed-methods, two-stage sequential cross-sectional • Year 1/Study Phase I - quantitative data collection and analysis • Year 2/Study Phase II - qualitative data collection and analysis • Study Area • 34 states with federally recognized tribes in 2010 • Participants • State HRSA Title V Maternal and Child Health(MCH) and Children with Special Health Care Needs (CSHCN) directors in the study area • Personnel working in American Indian/Alaska Native (AI/AN) organizations serving the MCH population in the study area

6. Mixed Methods Design for This Study

7. Study Phase I – Examining Phases of Network Formation

8. Intensity and Density of Interorganizational Collaboration • Intensity — the “how often?” dimension; the mean frequencies of different levels of interaction • Density—the “how many?” dimension; the relative number of collaborators for an agency in comparison to the average number of collaborators overall • Density is measured on a normal distribution from low density (few relative to the mean, producing negative scores) to high density (many relative to the mean, producing positive scores)

9. Network Phases, Density & Intensity of Collaboration Adapted from: Singer HH & Kegler MC. 2004. Assessing interorganizational networks as a dimension of community capacity: Illustrations from a community intervention to prevent lead poisoning. Health Educ Behav, 31(6):808-821.

10. Results from Study Phase I The participants examined primarily discuss and exchange ideas and information with their collaborators The respondents largely do not set mutual goals, take collective action, or enter into formal agreements

11. From Surveys to Interviews The surveysindicated that the participants were not involved in higher levels of collaborative action with their working partners We wanted to understand WHY and HOW various levels of collaboration occurred Interviews were conducted to shed more light on the survey responses and better understand unique collaborative relationships between state Title V and AI/AN MCH entities

12. Study Phase II – Participant Interviews From the pool of participants in Study Phase I, we identified 5 states with respondents from both a Title V and an AI/AN organization/agency We identified “pairs” to understand the point of view of the Title V and the AI/AN participants working on MCH issues in the same geographic area

13. Interview Content • These pairs were asked questions regarding: • What collaboration means to them • Perceived barriers to collaboration • Enabling factors to promote collaboration • Strategies utilized to enhance collaborative efforts • How collaboration was maintained, enhanced, and facilitated • The responses helped to better understand collaboration as the participants viewed it

14. Barriers to Collaboration as Identified by CATSO Participants

15. Barriers #1 • Organizational Issues • Varying definition of collaboration • Organizational structure and style differences • Trust issues • Unwilling to collaborate • Lack of openness • Non-commitment on a personal level

16. Barriers #2 • Tribal Issues • Limited recognition and understanding of tribal sovereignty • Doing lip service to sovereignty • Disagreement on legal language (contracts, etc.) that accounts for tribal sovereignty in states • Lack of general understanding of treaty obligations and laws

17. Barriers #3 • Establishing and Maintaining Relationships • Feelings of being an outsider from either side • Outsiders not willing or not knowing how to work with grass-roots folks • Infrequent or no contact around mutually relevant MCH issues • Lack of trust and openness in contacts and relationships

18. Barriers #4 • Mutual Understandings • Misconceptions about non-natives • Limited exposure to non-tribal world • Tribal reluctance to initiate communication and contact • Understanding of cultural competency • Inability to adhere to all ideals of cultural competency

19. Barriers #5 • Financial Constraints • Differing financial contracting structures • Funding constraints • State budget constraints

20. Barriers #6 • Data Issues • Access to data • Data collection differences between AI/AN region vs. state Title V organizations • Differences in data reporting structures

21. Hallmarks of Successful Collaboration Between State Title V and AI/AN MCH-serving agencies

22. Hallmarks of Successful Collaboration • Commonality of Goals and Direction • Invested and focused on the same outcome • Mutual benefit and understanding • Willingness to Work Together • Working and deciding things together • Working together and combining resources • Wanting to be involved • Collaboration as a core value

23. Hallmarks of Successful Collaboration • Open Communication • Regularly informing each other • Utilizing liaisons • Having Common Goals • Focusing on the outcome • Goals are mutually beneficial and necessary • Understanding each other’s perspective • Addressing identified needs of each community • Goals need to be approved by both parties

24. Hallmarks of Successful Collaboration • Multi-Cultural Competency • Cultural competency is a priority for all partners • Willingness to learn about each other’s culture • Meaningful Inclusion of Stakeholders and Partners • Being invited • Nurturing relationships • Involving all • All partners have equal “authority” • Being patient

25. Hallmarks of Successful Collaboration • On-going Long-term Relationships • On-going initiatives to maintain collaborative efforts • Reaching out to each other • Maintaining trust in relationship • Open, Voluntary, Committed Relationships • Having open and respectful partnerships • Being accessible to potential partners

26. Hallmarks of a Successful Collaboration • Respecting Tribal Sovereignty • Understanding what tribal sovereignty means • Acknowledging tribal sovereignty • Learning about each individual tribe • Relying on the tribal community for advice • Being community-driven

27. Best Practices and Action Strategies to Enhance Collaboration between Tribal and Non-Tribal Maternal and Child Health Organizations

28. Best Practice #1: Organizational Culture Openly Values a Collaborative Working Style • Action Strategies • Clearly communicate regarding a collaborative process • Openly create a culture of collaboration as a core value • Establish mutually beneficial common goals • Gain trust and credibility with tribal and non-tribal groups • Tribes involve state collaborators; state personnel engage, reach out, visit tribal communities • Include and invite all relevant parties on both sides

29. Best Practice #2: Increase Mutual Understanding of Each Other’s Cultures and Values • Action Strategies: • Establish a clear understanding of cultural competency as a priority • Provide cultural competency forums, workshops, and meetings in which barriers and solutions can be addressed • Acknowledge and respect cultural differences

30. Best Practice #3: Understand and Respect Tribal Sovereignty • Action Strategies: • Acknowledge, understand, and be respectful of tribal sovereignty • Create dialogue to increase understanding of what tribal sovereignty means to individual tribes in different states • Assure tribal membership on committees, task forces, councils, etc. • Seek out advice, viewpoints, and opinions from tribal leaders and communities on pertinent matters

31. Best Practice #4: Reach Out and Establish Relevant and Appropriate Relationships • Action Strategies: • Involve all relevant individuals and groups on a regular basis • Identify appropriate tribal and non-tribal contacts to assure correct person(s) participate • Establish and maintain trust through transparency and openness • Respond promptly to communication efforts

32. Study Limitations • The perceptions represented in this study are those of a limited number of respondents to surveys and interviews • The data in this study should be considered pilot or preliminary data because a. a small number of participants b. the uniqueness of the attempt to explain the nature of a tribal and non-tribal interorganizational relationship

33. For more information, please contact: • The UAB Investigative Team: • Beverly Mulvihill (PI) – bmulvihi@uab.edu • Martha Wingate (C0-PI) – mslay@uab.edu • Nataliya Ivankova (Investigator) – nivankov@uab.edu • Andrew Rucks (Investigator) – arucks@uab.edu • Su Jin Jeong (Graduate Assistant) – sjeong@uab.edu • Association of Maternal and Child Health Programs (AMCHP): • Sharron Corle – scorle@amchp.org • National Indian Health Board (NIHB): • Paul Allis – pallis@nihb.org • Black Harper – bharper@nihb.org