Status Report:

Tribal Connections Phase 3: Community-based Health Information Outreach

June 23, 2003
Pacific Northwest Regional Medical Library
University of Washington

1.  Project Description

Tribal Connections Phase 3 (TC3) was designed to increase the use of Internet-based information resources about health, medical and wellness among three selected tribal communities in the Pacific Northwest Region (PNR). The major goals of the project are:

• To enhance the capacity of the selected tribal communities to internally promote and use health information resources from the National Library of Medicine (NLM) and other sources.


• To provide information to the National Network of Libraries of Medicine (NNLM) program that will allow it to assist network members in undertaking successful outreach projects in American Indian, Alaska Native, Native Hawaiian, and possibly other underserved communities.

The Samish Tribe (Anacortes, Washington), the Confederated Tribes of Umatilla (Pendleton, Oregon) and the Nez Perce Tribe (Lapwai, Idaho) were invited to participate in the TC3 project. Each of these tribes had previously participated in the Tribal Connections Phase 1 (TC1) project, which was designed to enhance the technology infrastructure and Internet connectivity of 16 tribal communities in the PNR. Six sites were initially recruited for TC3 before the final three participants were selected. The full set of criteria for choosing TC3 partners included:

• Having successfully participated in the TC1 project.


• Having a minimum level of technological capacity, i.e., good Internet access; a public access computer workstation(s); some capacity to provide group computer training (preferable).


• Having a Wellness Committee and/or Tribal Health Program.


• Enough diversity among the three sites to allow project managers to assess different modes of delivering TC3.


• A different northwest state for each project site (preferable).


• A strong interest by the tribal community in continuing to work with TC3 and the RML.

The three participating tribes were invited to choose projects based on their respective needs. Each tribal community was to receive a $5,000 incentive award to assist in the implementation of its project. Tribal partners were expected to provide on-site activities, coordinate meetings with tribal members and staff and to advocate for health education and promotion within their communities.

TC3 Resource Teams from the Pacific Northwest Regional Medical Library (RML) were formed to liaise with the sites and to provide training and assistance in developing each tribal project. These Resource Teams were composed of a Project Manager, a Librarian and an Evaluator. The Project Manager was responsible for recruiting the sites, guiding project development for each site and for logistical arrangements between teams and tribal partners. Librarians were responsible for developing curriculum, delivering training and other resource development activities, and for providing expert advice on accessing and applying health and medical information. The Evaluators assess each stage of the project, document how tribes use the incentive award, interview participants, and assess project outcomes.

Resource Teams met with their respective communities to work out the project plan and logistics for each site. The assistance provided by TC3 Resource teams was to include: on-site visits and Internet search skills training to tribal staff and/or community members; continuing support on resource development and project planning; other materials and resources as were appropriate for tribal needs within the scope of the budget and project duration. Librarians were initially scheduled to work with their respective project sites through May of 2003, with evaluations to follow.

2.  Project Implementation

October – December 2001
During this initial phase, PNR Regional Medical Library staff discussed how the TC3 project would be implemented. It was decided that the project would be limited to three tribal communities drawn from the pool of 16 TC1 participants, with selection based on readiness factors, their willingness to participate and other criteria. A logic model was drafted to help begin internal discussions about PNR's thinking regarding overall goals, desired outcomes, and possible strategies to reach them. It was also suggested that advisors be drawn from each tribal community. An incentive funding amount of $5,000 was proposed for each project, and guidelines established for how the money would be spent. It was decided that the money should help provide:

• Health committee leadership, events and other activities


• Technical support and specialist referrals


• Computer skills training with an added information resources component

January – March 2002
TC3 staff developed criteria to determine the qualifications, duties and job description for the Project Evaluator position. Candidate interviews were conducted, and Joan LaFrance was hired to fill the Project Evaluator position. Susan Usitalo, a public health evaluation specialist, was also retained to assist with project evaluations.

Following discussions with Project Manager Roy Sahali and tribal community representatives, the Samish, Umatilla and Nez Perce tribes were invited to participate in TC3.

It was decided that each Resource Team would be comprised of Project Manager Roy Sahali, a PNRML Librarian (a different Librarian was selected for each tribal community) and Project Evaluator Joan LaFrance (or her assistant).

April – June 2002
Samish

The TC3 Resource Team, with Librarian Susan Barnes, made a site visit to the Samish Tribe in Anacortes, Washington. Discussions with the tribal Wellness Committee revealed that the community’s greatest need was for assistance in developing the tribe’s 10-year health plan. Evaluator LaFrance suggested that this was an opportunity to explore the "relationship between health planning and health promotion" within the tribe. It was decided that Librarian Barnes would:

• Assist with development of the health plan.


• Develop a health page for the tribal Web site.


• Participate in the annual tribal meeting and demonstrate tribal Web site and online health information resources.


• Distribute a short questionnaire to obtain input from the tribe about their health needs.


• Explore opportunities for health information skills training.

It was also decided that Project Manager Sahali would provide technical assistance to Scott Cooper in the Information Technology (IT) department in enhancing the tribe’s telephone and computer network.

Umatilla

Project Manager Roy Sahali, Evaluator Joan LaFrance and Librarian Maryanne Blake made an initial visit to the Umatilla site in Pendleton, Oregon. In discussion with tribal contacts, a number of project goals were established. These included:

• Investigate options for a more user-friendly interface with the Indian Health Service RPMS patient record management system.


• Encourage and support tribal community health representatives and elders to explore health topics that would generate sustained interest and benefit the group.


• Facilitate the transition from using a dial-up to an on-demand Internet connection.


• Work with the tribal health educator and the youth group program on nutrition and diabetes prevention.


• Help to establish and organize a health library for professional and public use. Need to establish end points and criteria for success.

Nez Perce

Project Manager Roy Sahali, Librarian Linda Milgrom and Evaluation Assistant Susan Usitalo comprised the Resource Team assigned to the Nez Perce tribe of Lapwai, Idaho. Initial contacts with the tribe did not yield specific, identifiable health information needs. There was a concern that tribal staff would be too busy to allot the necessary time to devote to the project. It was also noted that there was some lack of communication between the three clinics serving the reservation population, which included the Lapwai, the Kamiai and the Orofino.

The Resource Team was later contacted by Julie Keller, the tribal nutritionist, about the possibility of producing several health related videos that could also be used to promote awareness of NLM products and PNR services. Roy will assist Antonio Smith, editor of Ta’c Tito’oqan News, with the details for this.

July – September 2002
Van Chase replaced Susan Usitalo as Evaluation Assistant for the Nez Perce project site.

In an August strategic planning session, Evaluator LaFrance and TC3 team members drafted a set of questions to be used as the basis for pre-program interviews of project participants in each tribal community; the questions were deemed modifiable for each project site. These questions are appended as part of this report.

Evaluator LaFrance made several summary observations about the progress of the projects up to that point. In suggesting that "We are not bringing a program so much as bringing you as resources to tribes", she concluded that:

• It might be necessary to reorganize RML staff and to approach the project more as a partnership.
  
• Expectations might need to be modified, that RML staff needed to "start where people are at, not where you are at or where you want them to be."

October – December 2002
Samish

• Three site visits to date have been made by the Resource Team; Librarian Barnes and Evaluator Assistant Chase have conducted interviews with primary contacts.


• Health promotion and education goals have been incorporated into the tribal health plan; this is tied to health information resources; content and resources for the health plan will be provided by Librarian Barnes.


• It was suggested that training for members of the Health Planning Committee and other activities would perhaps take place following the completion of the health plan.


• It was suggested that the project evaluation take note of the plan to use the incentive funds to improve Internet connectivity in one of the tribal buildings.

Umatilla

• A second site visit was made in October 2002; interviews were conducted by Cathy Burroughs and Evaluator LaFrance.


• Librarian Maryanne Blake will develop a training class for the tribe’s community health representatives.


• The observation has been made that there is good computer use, support and availability among project participants and tribal contacts.


• The project is focusing attention on the tribal Health Department – the Yellow Hawk Clinic.


• Plans are made to work with the tribal elders group.

Nez Perce

• A Memorandum of Agreement (MOA) was drafted, reviewed and agreed to.


• The Wellness Committee decided to use the TC3 project participation to create a series of health education videos using tribal members as actors. The videos would highlight relevant online health information resources; sponsorship credit would be given to NLM and NN/LM.


• It was decided that program plan interviews would be conducted in the next quarter.

January – March 2003
Samish

• An MOA was drafted, delivered and reviewed by the tribal Health Committee and forwarded to the tribal council for signing.


• Librarian Barnes has developed a list of Internet resources focusing on links to information about disease management; these resources will be included in the health section on the Samish Internet Web site.


• Evaluator LaFrance and C. Burroughs will begin to draft specific evaluation questions for each site.

Umatilla

To date, there has been a frustrating lack of response on the part of tribal contacts; progress on project activities has been limited.

Nez Perce

• A site visit was conducted in early February; Evaluator LaFrance conducted five staff interviews.


• The primary contact for the tribe has requested that a training session be conducted.


• Librarian Milgrom and Project Manager Sahali have been asked to participate in a Men’s Wellness Conference in March.


• The MOA has been signed.

March – June 2003
Samish

• The TC3 project has been completed; Librarian Barnes has a few more activities to finish up.


• The tribal health plan has been completed.


• Project Manager Sahali reports that Internet connection for "community access" in tribal buildings has been enhanced; there is now one computer in the tribal administration building and three or four computers in the Long House. Part of the $5,000 project grant was used for hardware upgrade; the project also leveraged an additional $10,000 in funding from the Gates Foundation.

Umatilla

• This project is incomplete as of this time. Project Manager Sahali and C. Burroughs have discussed implementing a “crash intervention” plan within the next three months, although there is some question as to whether the project can be completed in that time. Contact with a tribal representative has been ongoing but infrequent. PM Sahali observes that no key tribal representative took the lead role in assuming responsibility for completing the project; the project also lost momentum because it was shifted between tribal departments. The initial incentive funds are unused.


• The project may have to be reassessed to determine its viability; stopping it without accomplishing objectives may have to be considered. Librarian Blake will have to decide what the next step needs to be. It is possible the project may proceed in a different direction than originally planned. PM Sahali suggests it may still be possible to complete installation of a computer in the tribal clinic before the project closes. It is agreed by RML staff that project should terminate by the end of August.

Nez Perce

• Librarian Milgrom participated in a Men’s Wellness Conference at the request of tribal representative Jim Pond, who wanted to add a health information component to the conference. The conference was attended by tribal elders and was held in Lewiston, Idaho. Librarian Milgrom delivered a presentation on MEDLINEplus. Project Manager Sahali participated in the conference as a PNR representative, noting opportunities to make the activity sustainable.


• Tina Bullock and Jim Pond, project contacts and leaders, were invited to participate in a 2-week internship at NLM by Specialized Information Services division of NLM. Although and honor and they were ultimately able to attend, the tribe struggled with how to replace their services during their absence. Tina is an IT/network specialist and Jim is a radiologic technician. The community went without these services while they were away.


• The health education videos proposed by the Wellness Committee were recently completed, according to Tribal Nutritionist Julie Keller. The five videos were written and produced by the tribe and used actors from the community. There was no direct PNR/RML team involvement although assistance was offered. NNLM and NLM are credited in the videos as the funding source and reference is made to MEDLINEplus. The videos deal with several aspects of diabetes care and management, and with tobacco use and smoking cessation. Copies of the videos will be made available to the RML and to NLM. A portion of each video will be web-streamed from the TC website, with a pointer to the Nez Perce health website for more information.


• Evaluator LaFrance suggested that she and C. Burroughs plan a post-program site visit for August to gather post-intervention interview data.


• The MOA has been signed and sent back.


• Progress on planning for a patient online information center in the clinic is incomplete and it’s not clear what will be done with this project component.

Evaluator LaFrance is developing final review plans for the Samish and Nez Perce projects.

The next TC3 project meeting will be in late August, for a final assessment of each project. Final project evaluation reports should be targeted for completion by the Fall.

3.   Project Logic Model

4.  Questions/Issues Regarding Designing Projects with Tribes

• How does the community describe its needs for health education and access to health information?


• Who in the community will be the official liaison to work with the TC3 Community Resource Coordinator?


• How does the community want to use the $5,000 incentive?


• What community programs or structures can be used for TC3?
  -   Wellness or Health Committees
  -   Health clinics
  -   Head Start and Schools
  -   Others


• What resources exist in the community?
  -   Computer access for public use
  -   Computer labs or other resources to train local
      people in use of online access to health information
  -   Naturally occurring training opportunities


• Who are the potential audiences for training?
  -   Health workers (outreach workers, clinic staff, etc.)
  -   Early childhood and school staff, students, parents
  -   Elder service and nutrition programs
  -   Others


• What opportunities exist for access to health education promotion activities?
  -   Wellness or other community events
  -   Powwows
  -   Newspapers or newsletters
  -   Other publicity or outreach opportunities


• How can the librarians best work with the community?
  -   To ensure that knowledge and capacity to access health information is left
       in the community
  -   To ensure work is integrated into existing tribal programs, events, and/or     communication systems
  
• What is the timing for delivery of TC3 services?
  -   When should the librarians visit the tribal site for training or other
      activities?
  -   Are there events or other opportunities that would benefit from materials that could be sent by librarians?


• How can the evaluation process benefit the Tribe?
  -   What do tribes want to learn from this project?
  -   Are there issues to work out for evaluation – permissions for interviewing
      participants, approval processes, etc.?

5.  Preliminary Project Observations

• Health information is a component of health education. The utility of health information on its own may not be readily apparent to community members. Embedded in the context of health education/promotion may increase receptivity.


• There is a desire by to see a documented before/after change in health information seeking behavior. However, we must document what we find. What are the barriers to using online health information in a particular community—technology, behavior, culture, literacy? We suspect that the desired behavior change is not realistic; not only given the limited timeframe and the lack of intensity, but also due to a more profound and fundamental issue. This issue is that in underserved communities, it can be difficult to convince community members that access to online health information is a priority issue. This is especially so when access to basic health services is inadequate and there are many more pressing, basic needs.


• We have a service that we try to figure out how to deliver in a given situation, to meet identified needs. It’s broad and malleable. That is both an opportunity and a challenge.


• The idea of this project was to integrate health information outreach with a community health promotion effort. Maybe it isn’t integrated enough.


• There should be more of an incentive for the tribe.


• There are not enough opportunities for frequent contact or maintaining a presence. Being able to drop by regularly is an important advantage.


• There is a need for an assessment/preparatory period to determine if project implementation is feasible.


• Resource Team support is crucial to the success of a project. Presence of RML staff to provide sustained time and attention is also critical in adding value to site projects, as suggested by the impact of the Tribal Health Connections project in the Four Corners area. Librarian Milgrom suggested that RML librarians have multiple duties to attend to which take away from the amount of dedicated time that can be given to intensive outreach projects.


• Project Manager Sahali suggested that in cases where projects appear to be losing momentum, having a tribal person who would be responsible to nudge and focus attention on, is a good strategy.