Objective To quantify variation in public health system engagement with tribal organizations across a national sample of communities and to identify predictors of engagement. Data Sources We used 2018 National Longitudinal Survey of Public Health Systems data, a nationally representative cohort of the US public health systems. Study Design Social network analysis measures were computed to indicate the extent of tribal organization participation in public health networks and to understand the sectors and social services that engage with tribal organizations in public health activities. Two‐part regression models estimated predictors of tribal engagement. Data Collection A stratified random sample of local public health agencies was surveyed, yielding 574 respondents. An additional cohort of oversampled respondents was also surveyed to include jurisdictions from the entire state upon the request of their respective state health departments (n = 154). Analyses were restricted to jurisdictions with a nearby American Indian and Alaska Native (AI/AN) serving health facility, yielding a final sample size of 258 local public health systems. Principal Findings When an AI/AN serving health facility was present in the region, tribal organizations participated in 28% of public health networks and 9% of implemented public health activities. Networks with tribal engagement were more comprehensive in terms of the breadth of sectors and social services participating in the network and the scope of public health activities implemented relative to networks without tribal engagement. The likelihood of tribal engagement increased significantly with the size of the AI/AN population, the presence of a tribal facility with Indian Health Service funding in the region, and geographic proximity to reservation land (p < 0.10). Conclusions The vast majority of public health networks do not report engagement with tribal organizations. Even when AI/AN serving health facilities are present, reported engagement of tribal organizations remains low.

Research Objective There 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 Design We 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 Studied A 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 Findings Local 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 ...