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Evaluating Inclusiveness in
 Multi‐Sector
 Community Health Networks: The Case of Tribal Organizations

Research ObjectiveThere is growing evidence that strong multi‐sector networks of community organizations can reduce health risks and improve outcomes for historically marginalized and underserved populations. Multiple studies of community networks document the advantages of membership inclusiveness and diversity. Over 70% of American Indian and Alaska Native (AIAN) U.S. residents live in urban areas that are not part of tribal lands. Community health networks serving these areas have the potential to engage with tribal organizations in order to better serve AIAN residents, however, the prevalence of tribal organization engagement in these networks is unknown. This study is the first to quantify variation in network inclusiveness regarding tribal organizations across a large national sample of communities, and to identify predictors of inclusion.Study DesignWe used 2018 National Longitudinal Survey of Public Health Systems (NALSYS) data, a nationally‐representative cohort of U.S. public health systems. Tribal engagement was measured as a binary indicator for whether the local public health official reported tribal organization involvement in at least one of 19 essential public health activities. NALSYS data were linked to the American Community Survey, NACCHO's profile survey, Indian Health Services and Tribal Epidemiology Center facility data, and U.S. Census Bureau reservation land data. Social network analysis measures were computed to indicate the extent of tribal organization participation in community networks and to identify what sectors and social services were most likely to engage with tribal organizations. Linear probability models were used to estimate predictors of tribal engagement. Covariates included county‐level variables for AIAN population, distance from a reservation land, presence of a tribal‐serving health facility, and multiple socioeconomic and demographic variables.Population StudiedA stratified random sample of local public health agencies was surveyed with a 71% response rate, yielding 731 respondents that serve approximately 70% of the US population. To account for agencies serving multiple counties (10% of respondents), we disaggregated data to the county‐level (n = 1051).Principal FindingsLocal health officials in 15.7% of counties reported that their networks included tribal organization engagement in at least one public health activity. Among counties with a tribal‐serving health facility located in the region (n = 329), 30.7% of networks included tribal organization engagement. Top activities for engagement with tribal organizations included assessing and prioritizing community health needs, maintaining communication networks, and investigating adverse health events. Tribal organizations had strongest ties with hospitals and community health centers, and organizations that provide housing services, and services for Veterans and people with disabilities. The likelihood of tribal engagement increased significantly with the size of the AIAN population in urban communities (6.2 percentage points, p < 0.001), presence of a tribal‐serving health facility in the region (12.4 percentage points, p < 0.001), and geographic proximity to reservation land (p < 0.05).ConclusionsThe vast majority of community health networks do not report engagement with tribal organizations. Even when tribal‐serving health facilities are present, reported engagement with tribal organizations remains low.Implications for Policy or PracticeLocal public health agencies and their community partners must prioritize efforts to include tribal organizations in their collaborative networks, in order to address persistent AIAN health disparities and emerging health threats such as COVID‐19.Primary Funding SourceThe Robert Wood Johnson Foundation.