CATSO PROJECT

UNIVERSITY OF ALABAMA AT BIRMINGHAM (UAB)ASSOCIATION OF MATERNAL AND CHILD HEALTH

PROGRAMS (AMCHP)NATIONAL INDIAN HEALTH BOARD (NIHB)

Collaboration Among Tribal and State Maternal and Child

Health (MCH) Organizations

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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)

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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

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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

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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

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Mixed Methods Design for This Study

Visual Model Of Mixed Methods Procedures for Study

Yea

r 1

Yea

r 2

Procedure ProductPhase

Quantitative Data Collection

· Mixed mode survey· N = 68· IOR Survey and ICAT

· Numeric data

Quantitative Data Analysis

· 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

· 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

· Visual model of multiple case analysis· Codes and themes· Similar and different themes and

categories· Cross-thematic matrix

· Interpretation and explanation of quantitative and qualitative results

· Peer-reviewed meeting presentations and journal articles

Case Selection

Qualitative Data Collection

Qualitative Data Analysis

Define Policy Findings

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Study Phase I – Examining Phases of Network Formation

Phase 1Exchange NetworkInformation sharing

Phase 2Action Network

Mutual goal setting &collective action

Phase 3Systemic NetworkLong-term formal

linkages

Adapted from: Alter C, Hage J. Organizations working together. Newbury Park (CA): Sage Publications; 1993.

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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)

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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.

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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

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From Surveys to Interviews

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

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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

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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

Barriers to Collaboration as Identified by CATSO

Participants

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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

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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

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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

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Barriers #4

Mutual Understandingso Misconceptions about non-nativeso Limited exposure to non-tribal worldo Tribal reluctance to initiate communication and

contact o Understanding of cultural competencyo Inability to adhere to all ideals of cultural competency

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Barriers #5

Financial Constraints Differing financial contracting structures Funding constraints State budget constraints

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Barriers #6

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

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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

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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

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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

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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

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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

Best Practices and Action Strategies

to Enhance Collaboration between Tribal and Non-Tribal Maternal and Child Health Organizations

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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

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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

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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

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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

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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

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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