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)
Acknowledgements
2
 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)
Background
3
 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
Objectives
4
 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
Study Design
5
 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
Mixed Methods Design for This Study
6
Year 1
Visual Model Of Mixed Methods Procedures for Study
Phase
Quantitative Data
Collection
Procedure
·
·
·
Mixed mode survey
N = 68
IOR Survey and ICAT
·
Descriptive statistics of health
indicators
k-means cluster analysis (IOR Survey
Data)
Multi-dimensional scaling (MDS)
(ICAT data)
Multiple regression analysis (IOR
Survey data and health status
indicators)
SPSS v. 17, SAS
·
Quantitative Data
Analysis
·
·
·
Year 2
·
Case Selection
·
·
Qualitative Data
Collection
·
·
·
·
Qualitative Data
Analysis
Define Policy Findings
·
·
·
·
Product
·
Numeric data
·
·
·
·
Descriptive statistical analysis
appropriate to data
IOR clusters
IOR-domain relationships
IOR-health status indicator
associations
Maximal variation sampling
(purposefully selecting 1-5 cases)
Developing interview protocol
·
·
Cases (1-5)
Interview protocol
Individual in-depth telephone
interviews select participants
Documents
Secondary sources
·
Text data (interview transcripts,
documents)
Supplemental numeric data
·
Coding and thematic analysis
Within-case and across-case theme
development
Cross-thematic analysis
Credibility procedures
NVivo 8 software
Interpretation and explanation of
quantitative and qualitative results
·
·
·
·
·
Visual model of multiple case analysis
Codes and themes
Similar and different themes and
categories
Cross-thematic matrix
Peer-reviewed meeting presentations and
journal articles
Study Phase I – Examining Phases of Network Formation
7
Phase 1
Exchange Network
Information sharing
Phase 2
Action Network
Mutual goal setting &
collective action
Phase 3
Systemic Network
Long-term formal
linkages
Adapted from: Alter C, Hage J. Organizations working together. Newbury Park (CA): Sage Publications; 1993.
Intensity and Density of
Interorganizational Collaboration
8
 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)
Network Phases, Density & Intensity of
Collaboration
9
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.
Results from Study Phase I
10
 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
From Surveys to Interviews
11
 The surveys indicated 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
Study Phase II – Participant Interviews
12
 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
Interview Content
13
 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
Barriers to Collaboration as
Identified by CATSO Participants
Barriers #1
15
 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
Barriers #2
16
 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
Barriers #3
17
 Establishing and Maintaining Relationships
 Feelings of being an outsider from either side
 Outsiders not willing or not knowing how to work with grassroots folks
 Infrequent or no contact around mutually relevant MCH issues
 Lack of trust and openness in contacts and relationships
Barriers #4
18
 Mutual Understandings
o Misconceptions about non-natives
o Limited exposure to non-tribal world
o Tribal reluctance to initiate communication and contact
o Understanding of cultural competency
o Inability to adhere to all ideals of cultural competency
Barriers #5
19
 Financial Constraints
 Differing financial contracting structures
 Funding constraints
 State budget constraints
Barriers #6
20
 Data Issues
 Access to data
 Data collection differences between AI/AN region vs. state
Title V organizations
 Differences in data reporting structures
Hallmarks of Successful
Collaboration Between State Title V
and AI/AN MCH-serving agencies
Hallmarks of Successful Collaboration
22
 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
Hallmarks of Successful Collaboration
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 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
Hallmarks of Successful Collaboration
24
 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
Hallmarks of Successful Collaboration
25
 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
Hallmarks of a Successful Collaboration
26
 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
Best Practices and Action Strategies
to Enhance Collaboration between
Tribal and Non-Tribal Maternal and
Child Health Organizations
Best Practice #1: Organizational Culture Openly Values
a Collaborative Working Style
28
 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
Best Practice #2: Increase Mutual Understanding of
Each Other’s Cultures and Values
29
 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
Best Practice #3: Understand and Respect
Tribal Sovereignty
30
 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
Best Practice #4: Reach Out and Establish Relevant
and Appropriate Relationships
31
 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
Study Limitations
32
 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
For more information, please contact:
33
 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