To support the individual and family change promoted by the HCSF childhood obesity intervention (6,8), university and tribal partners organized a CAB with each of the 3 tribes. The goal of each CAB was to reduce environmental barriers to healthy diet and exercise. By engaging tribal communities in forming their own CAB, our aim was to identify, prioritize, and create sustainable community interventions to reduce these barriers and ultimately improve community health. A university-based facilitator (non-AI) was hired to help launch and coordinate the CABs. CAB approval was obtained from each tribal council. We invited each CAB to review this manuscript and incorporated their comments.

Four outreach strategies were used to ensure community-wide representation, build membership, and increase community engagement in CAB activities. First, the facilitator approached standing tribal committees and invited members to participate in the CAB. The facilitator also asked these individuals to recommend and invite additional community members. Second, one-on-one networking and snowball techniques were used. The facilitator met with many individuals, resulting in an e-mail and address list of 70 to 95 contacts for each CAB. Third, the facilitator created “save the date” meeting notices with an open meeting invitation; these notices were disseminated by mail, on community bulletin boards, and in tribal newspapers. This approach brought various community members together, including those who traditionally did not participate in tribal meetings. Fourth, continued open invitations and member recruitment were used to enhance membership throughout CAB operation.

The composition of each CAB varied slightly and reflected the individual tribal community. We did not limit membership, although other research has shown that new partnerships should start small and involve a few highly regarded community-based organizations (10). We initially compiled a list of more than 100 occupations to be represented on the CABs but soon chose not to limit membership by livelihood. The university partners did not know nor want to presume the specific issues or outcomes that would be important to each CAB. From the onset, CAB membership included community, academic, and tribal partner stakeholders (11).

The facilitator (the same person for all 3 CABs) organized meetings, traveled to each site for monthly meetings, maintained e-mail lists, and spent considerable time connecting one-on-one with potential and current CAB members. Because the sites were 3 to 5.5 hours by car from the university, the facilitator scheduled meetings sequentially to avoid meeting conflicts and reduce total travel time. Over time, all of the partners found that facilitation by a non-AI, someone who had no tribal political affiliation, was important in encouraging open communication and political neutrality. That the facilitator was an academic partner also lent legitimacy and credibility to meetings.

Each CAB decided to make the meetings open, not pay people for participating, and not reimburse travel expenses. CAB meetings occurred at varied times of day to accommodate schedules and always included a healthy meal (sometimes incorporating traditional foods). The facilitator prepared an agenda for each meeting, but quorum was not required to proceed with business. At the start of each meeting, the facilitator gave a brief overview of the CAB’s history and mission to orient new members.

In advance of each meeting, CAB members or the facilitator met with new members to provide background, including information on activities and successes, a written synopsis of what had been accomplished so far, and the upcoming meeting’s agenda. Project funds paid for meeting costs and the facilitator’s travel costs.

A key component of CAB operations was planning for transition to local coordination before the end of the 5-year grant. At each site during the third and fourth years, the academic facilitator selected a community facilitator with the CAB’s help. The two then co-organized meetings, and at some meetings the academic facilitator was present by telephone only, to recognize the importance of the local leader.

A key activity of early meetings was to brainstorm to identify local environmental supports that made it easy for people to make healthy diet and physical activity choices and to identify environmental barriers that impeded healthy choices. Initial lists of supports and barriers were unique to each community but had numerous common themes. The Box details environmental supports noted by all CABs, including strong cultural identity, natural resources, family ties, and tribal agency services. Barriers to healthy nutrition included limited access to fresh fruits and vegetables, easily available processed foods, and alcohol and sugared drinks at local convenience stores. Barriers to physical activity included lack of sidewalks, loose dogs, and unsafe areas. Similar barriers were combined to simplify focus and then prioritized by perceived importance. Through this process, issues that could be influenced by interventions, both short-term and long-term, were moved to the top of the list and addressed.

Initially, we envisioned CAB work to be done in 3 phases (Figure 1). In Phase 1, CABs reviewed supports and barriers, prioritized barriers, and discussed potential intervention options. In Phase 2, CABs conducted community assessments of barriers, collecting data and expert opinions as needed, which led to action to address the barriers in Phase 3. The timeframe of this assessment and action cycle varied but, in all locations, moved to the intervention phase more quickly than anticipated. Phase 2 assessments were largely either already in place, not done, or done rapidly so the CAB could move quickly into action.

Invited experts helped the CABs understand the nature of environmental barriers in each community while clarifying options for intervention. Experts included academic specialists in nutrition and physical activity and community experts in gardening, nutrition, and law enforcement. CAB members gathered information on specific topics (such as current tribal policies, jurisdiction, and future guest experts) and reported back to the CAB. The CAB then designed interventions and took action steps to remove or reduce a barrier (sometimes through a designated subcommittee). Each year, this cycle was repeated many times with different barriers. To facilitate policy change, each CAB included members who were on various tribal committees (see Outcomes) and who shared information about CAB initiatives with other committee members. The facilitator and/or CAB members also reported on CAB activities annually to each tribal council.

CABs sustained momentum by regularly reviewing successes and selecting the next issues to address. Subcommittees took ownership of specific barriers. The facilitator tracked progress and shared ideas and successes with the other CABs. At each meeting, CABs decided whether the CAB was ready to move on to another barrier. With new participants joining longstanding members, each CAB’s focus continually shifted, as membership assessed, advised, and reprioritized initiatives. CAB members were surveyed annually to evaluate CAB function, engagement, and collaboration. Because of the high level of engagement measured at baseline, survey results did not change significantly over time.

Although a core group of members attended each CAB meeting from the onset, meeting attendance was fluid, totaling more than 1,070 regular and new members over 5 years for the 3 CABs and an average meeting attendance of 19 (Table 1). This was much greater than the partners’ prelaunch assumption that CABs would include 5 to 10 standing members.

Meetings were regularly attended by community members, academic experts, and individuals representing tribal planning, education, transportation, health clinics, nutrition and disease prevention programs, human resources, environmental services, commerce, housing, food distribution, and recreation. Other members represented tribal and county extension, Boys and Girls Clubs, local media, chambers of commerce, casino employees, and local colleges. Members represented various occupational, professional, political, familial, cultural, and personal perspectives and often represented multiple roles and types of expertise. CAB members who had not previously participated in tribal meetings reported that they appreciated being part of the process.

Each CAB completed varying numbers and types of interventions (Table 2). Timeline for intervention completion varied and often depended on who was in attendance when a barrier was identified; who made the barrier a personal project, brought new members to the CAB, or volunteered to lead the issue subcommittee; or who had the political power to make it an agency or tribal priority. One intervention was introduced and completed in 4 hours (police and animal rescue panel to address safety issues of wandering dogs). Another lasted 18 months from planning to completion (playground project [Figure 2] requiring academic team travel and assistance, numerous tribal agency and community volunteer person-hours, installation during inclement weather, and secondary reconfiguration). A third intervention is entering its sixth year of operation (community and individual gardening); this highly active subcommittee has a structured short and long-term vision for gardening in the community (Figure 3).

The CABs produced tangible results that require little cost to maintain, including a cultural playground, community and individual gardens, landscaped safe beach access, and gardening and canning workshops. In addition, policies related to food served at tribal meetings, Head Start, and school lunch rooms were changed to encourage more healthy options. Because of CAB interventions, the number of environmental supports in each community increased while environmental barriers decreased. CABs enabled community members and stakeholders to engage in regular intra-CAB networking, resulting in increased awareness and collaboration across agencies.

Tribes share similar histories, barriers to health (Box), and health risks. Thus inter-CAB networking was an important outcome of this work. If a barrier was identified (8) and successfully addressed by one CAB, the facilitator shared details of the issue, intervention design, and action with another CAB, if requested. Members from one CAB shared their expertise at meetings of other CABs.

National research results and grant opportunities were regularly shared at CAB meetings. For example, one of the CABs adopted findings from a national lunchroom design study detailing food and display placement affecting healthier selections. State and national funding opportunities introduced at CAB meetings were pursued, with several grants awarded and existing resources repurposed and leveraged to support CAB priorities. For example, one CAB was awarded a $50,000 grant from the Wisconsin Partnership Program to continue CAB work and develop a comprehensive data management and evaluation plan for youth obesity prevention. Members from each CAB represented the collaborative project at local and national forums to talk about process and results. Tribal and community newspapers regularly featured CAB work, and state media coverage increased awareness of the CABs (12).

Academic partners brought their expertise and university resources to the CABs. Once the CAB had identified environmental barriers, the academic partners helped develop plans for future research partnerships that were beneficial to both the university researchers and the tribe (13). For example, a University of Wisconsin (UW) faculty landscape architect and several UW students he recruited worked with tribal elders to design and install a culturally appropriate and environmentally friendly playground in Bad River with CAB members and volunteers from the community. Donations of natural resources (eg, acorns, shed antlers, sand, rocks, pinecones, logs, lumber) and equipment (eg, a canoe for harvesting wild rice, maple sugar pan, bird houses) were integrated into the project (Figure 2). CAB interventions also provided university students with internship opportunities in which they applied their knowledge and skills to work with the community.

A university researcher introduced his study at 2 CABs. The study logo was designed by a tribal member, and CAB members from the diabetes prevention program accompanied the researcher to tribal health committee meetings to gain approval. The CAB edited and simplified medical language for study recruitment and consent forms — an important CBPR milestone and an example of a CAB-enabled strategy that may increase trust and participation in future research.