Cross-Sector Responses to Obesity: Models for Change: Workshop Summary (2015)

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Sault Ste. Marie Tribe of Chippewa Indians Cross-Sector Case Study

Submitted by presenters
Jeff Holt, Shannon Laing, and Donna Norkoli¹

DESCRIPTION OF CROSS-SECTOR MODEL USED

The Sault Tribe Community Transformation cross-sector work follows the Community Coalition Action Theory model (Butterfoss and Kegler, 2008), and is characterized by a network of action-oriented coalition partnerships focused on accomplishing a broad set of common goals, one of which is reducing obesity. This collaborative health improvement initiative began over 10 years prior to the Centers for Disease Control and Prevention’s (CDC’s) Community Transformation Grant (CTG) and has been evolving over time. As the lead convening agency, the Sault Tribe Community Health Department began this work focusing on just one community in 2006. A strategic approach, including analyzing the problem; gathering data and assessing need; developing an action plan with identified solutions; implementing solutions; achieving outcomes; and creating social change was used to address selected priority health issues. Using the momentum generated through participation in a CDC-supported community health promotion program, Sault Tribe expanded this model to four of its communities in 2008. At this time, Sault Tribe staff and coalition leaders strategically fostered partnerships and built upon programmatic successes to move toward using strategies that would maximize population-wide health improvement, such as policy, systems, and environmental changes that support healthy lifestyles. With the award of the CDC CTG cooperative agreement in 2011, Sault Tribe strategically expanded the initiative again

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¹Reprinted as submitted by the presenters.

into a network of coalitions covering the Tribe’s entire seven-county service area. Sault Tribe Community Transformation has invested significant time and effort into coalition building over the lifespan of the initiative, with dedicated staff to work on recruiting and mobilizing members, establishing structure, building capacity, planning and implementing strategies, evaluating outcomes, and supporting institutionalization of strategies. Contextual factors, such as the sociocultural and political environment, geography, history of collaborative work, and social norms have heavily influenced the success of the initiative.

The Sault Tribe Community Transformation initiative is overseen by a tribal Leadership Team that steers the direction of the initiative and action planning that covers the entire tribal service area. In addition, Sault Tribe facilitates a Tribal Food Sovereignty Collaborative and five local coalitions in communities across the service area. Finally, Sault Tribe Community Health partners with various other local community coalitions to promote shared goals among initiatives.

SECTORS INCLUDED

Sault Tribe Community Transformation coalition partners represent diverse sectors, organizations, and constituencies. Sectors represented on the Leadership Team include: tribal transportation, tribal housing, tribal enterprise (i.e., casinos), tribal insurance department, tribal government, tribal health system (health care, public health, and rural health program), tribal economic development and planning, tribal early childhood programs, tribal elders, and tribal youth programs. In addition, tribal nutrition programs, tribal U.S. Department of Agriculture food program, tribal farmers and growers, tribal elders program, and Michigan State University Extension are represented on the Sault Tribe Food Sovereignty Collaborative.

Sectors included in the local community coalitions include: local transportation, local government, higher education institutions and cooperative extension, school districts, farmers and growers, Food Hubs, downtown development authorities, local health departments, local hospitals, county commissioners, YMCA, early childhood advocates (i.e., Great Start Collaboratives), local media outlets, regional planning and development commissions, food co-ops, area agencies on aging, community economic development, parks and recreation departments and others.

LESSONS LEARNED FROM THE INITIATIVE

• Health equity:
  • The Sault Tribe now has a “place at the table” with local government and in decision-making processes that affect tribal members (who live in non-tribal community settings); tribal staff serve on committees and advisory roles; local government includes tribal issues on meeting agendas for ongoing collaboration.
  • Our coalitions used a balance of evidence-based strategies, community wisdom, and innovative interventions that addressed the root causes of health disparities as determined through community assessment.
• Sustainability:
  • Each sector contributes what they are able since all partners have a stake in the game.
  • Inclusive of shared priorities: there is a shared focus on creating healthier communities, and conditions that support health. These coalitions don’t focus only on obesity. This broad focus gets more people involved, creates more shared benefits and brings more resources to the table to support obesity work. Partners capitalize on anything and everything partners can bring to the table.
  • The Sault Tribe CTG Project has implemented cross-cutting strategies: Safe Routes to School, Complete Streets, and Non-motorized Transportation Planning to bring cross-sector partners together. This maximizes impact and shared benefits, increases support for each other’s efforts, and increases the ability to leverage funds for partners from a variety of sources.
  • The Project uses social support strategies and concrete supports (funds, signage, staff, etc.) in combination with policy, systems, and environmental changes to promote and sustain positive changes in community environment and to bring about lasting changes in community norms.
• Leadership:
  • The Sault Tribe CTG Project developed a strong Leadership Team and used staff with expertise in coalition building, strategic planning and implementation of policy, systems, and environmental change to facilitate coalition functioning, pooling of resources and engagement of community partners.
  • The project fostered shared leadership and bridge building between coalition members and the community.

• Measurement:
  • Good-quality, tribal-level population health data empower Sault Tribe to tailor the strategies in their action plans to priority groups and sub-populations.
  • Community assessment data show positive increases in measures of the physical and built environment and the nutrition environment.

BARRIERS TO ESTABLISHING THE INITIATIVE

• Health equity:
  • The Sault Tribe has not traditionally been a partner with local government or schools and there was a “trust” barrier to overcome on both sides.
• Sustainability:
  • Changes in federal funding (end of Strategic Alliance for Health, sequestration) delay progress or decimate infrastructure to sustain staff support and coordination of coalition activities.
  • Staff turnover and need for training of new staff to develop community organizing skills has been a barrier to sustainability of the initiative.
• Leadership:
  • Turf issues have arisen. Why is health involved in or trying to lead a (business, transportation, human resources, etc.) issue?
• Measurement:
  • There was no existing population-level data on obesity-related health measures for tribal members.
  • Sharing data publically has historically been a concern for Tribes due to misperceptions and misuse or abuse of data by external stakeholders. Data-sharing agreements, internal capacity, and models for appropriate data use and management were limited.
  • Evidence of population-level outcomes from this cross-sector work was limited for a number of reasons; the most obvious being that population change may take years or even generations to occur. Although they frequently require them, funding streams traditionally were not designed to support measurement of outcomes over this length of time, and priorities for data collection focused solely on meeting requirements. A flexible vision for long-term strategic planning and investment in evaluation and population-level health surveillance (aligned with changing funding requirements) was needed.

WHAT IS NEEDED TO ACCELERATE MOVEMENT FORWARD IN YOUR CROSS-SECTOR WORK?

• Health equity:
  • Organizational and personal relationships need to continue to be strengthened and stand the test of time for real equity to be achieved.
  • Assessment, evaluation, and surveillance data collection needs to be culturally sensitive and rigorous to identify subpopulation disparities for prioritization.
• Sustainability:
  • Funding for initiatives needs to come from a variety of sources to reduce dependency on one source of funding.
• Leadership:
  • Leadership needs to engage partners in assessments, prioritization of needs, and decisions regarding implementation of strategies to address the needs. Shared responsibility creates greater buy-in.
• Measurement:
  • Adequate resources to support rigorous local (tribal-specific) data collection and continued focus and priority on high-quality, population-based data for assessment and evaluation.

WHAT ARE THE CORE FEATURES OR ELEMENTS OF YOUR INITIATIVE THAT ARE NECESSARY FOR SCALE AND SPREAD; WHAT ARE THE FEATURES THAT NEED TO REMAIN FLEXIBLE TO ALLOW FOR LOCAL ADAPTATION?

Core Features Necessary for Scale and Spread

• The creation of infrastructure and capacity building at the local level is critical to ensure sustainability and successful pilot projects that can be replicated across communities.
• Partnerships are most effective when technical assistance and support are available to provide guidance, resources, and expertise to community leaders. This is especially true when coalitions are conducting key processes and activities during the implementation phase.

Core Features to Remain Flexible

• The strategies and initiatives selected may differ in each local community so we must let the local partners decide the need and move

• forward. For example, the CTG project had allocated funding for sub-awards to local municipalities to develop non-motorized transportation plans. In one community the local leaders met with CTG staff and explained that in their small community they had a non-motorized section in their recreation plan so could they use the funding to implement one of the priorities from their plan, which was creation and promotion of a historic walking route through the town.

Additional information about Sault Tribe Community Transformation is available at: http://www.up4health.org.