The component model of infrastructure: a practical approach to understanding public health program infrastructure

Systems thinking in practice when implementing a national policy program for the improvement of women's healthcare

Introduction

Interest in applying systems thinking (ST) in public health and healthcare improvement has increased in the past decade, but its practical use is still unclear. ST has been found useful in addressing the complexity and dynamics of organizations and welfare systems during periods of change. Exploring how ST is used in practice in national policy programs addressing complex and ill-structured problems can increase the knowledge of the use and eventually the usefulness of ST during complex changes. In ST, a multi-level approach is suggested to coordinate interventions over individual, organizational, and community levels, but most attempts to operationalize ST focus on the individual level. This study aimed to investigate how ST is expressed in policy programs addressing wicked problems and describe the specific action strategies used in practice in a national program in Sweden, using a new conceptual framework comprising ST principles on the organizational level as an analytical tool. The program addresses several challenges and aims to achieve systems change within women's healthcare.

Methods

The case study used a rich set of qualitative, longitudinal data on individual, group, and organizational levels, collected during the implementation of the program. Deductive content analysis provided narrative descriptions of how the ST principles were expressed in actions, based on interviews, observations, and archival data.

Results

The results showed that the program management team used various strategies and activities corresponding to organizational level ST. The team convened numerous types of actors and used collaborative approaches and many different information sources in striving to create a joint and holistic understanding of the program and its context. Visualization tools and adaptive approaches were used to support regional contact persons and staff in their development work. Efforts were made to identify high-leverage solutions to problems influencing the quality and coordination of care before, during, and after childbirth, solutions adaptable to regional conditions.

Discussion/conclusions

The organizational level ST framework was useful for identifying ST in practice in the policy program, but to increase further understanding of how ST is applied within policy programs, we suggest a multi-dimensional model to identify ST on several levels.

Impact of COVID-19 on a Community Health Coalition and Its Residents in Allegheny County, Pennsylvania: Insights Into Adaptation From Focus Groups and Evaluation Reports

Live Well Allegheny: Lifting Wellness for African Americans (LWA2) is a coalition in Allegheny County, Pennsylvania, funded by the Centers for Disease Control and Prevention’s (CDC) Racial and Ethnic Approaches to Community Health (REACH) initiative. LWA2 consists of partner organizations addressing chronic disease prevention in six Black communities through nutrition, physical activity, and community–clinical linkage strategies. This analysis focuses on qualitative data exploring the influence of COVID-19 on coalition functioning and communities. We conducted focus groups with residents in REACH communities and collected evaluation reports from partner organizations. Three focus groups assessed awareness of and participation in the REACH initiative, feedback, and the impact of COVID-19 when applicable. An additional focus group included questions related to flu vaccine messaging and the COVID-19 vaccine. These data sources provided insight regarding how COVID-19 affected planned tasks. Evaluation team members analyzed focus groups and collated summaries as part of a larger comprehensive evaluation. Partner organizations experienced an increase in food stamp applications, delays in opening farmers’ markets, a shift to virtual preventive health programs, canceled in-person events, and programmatic interruptions that shifted long-term goals. Community resident concerns included difficulty accessing public transportation, decreased physical activity, fear of in-person interactions, and increased wait times for mental health services. Coalition members developed methods to continue functioning and sustaining program activities. Residents were able to engage differently with chronic illness prevention techniques. Reports from the ongoing analysis will be used to adapt coalition functioning.

From Practice to Publication: The Promise of Writing Workshops

Practitioners in health departments, university extension programs, and nonprofit organizations working in public health face varied challenges to publishing in the peer-reviewed literature. These practitioners may lack time, support, skills, and efficacy needed for manuscript submission, which keeps them from sharing their wisdom and experience-based evidence. This exclusion can contribute to literature gaps, a failure of evidence-based practice to inform future research, reduced ability to educate partners, and delays in advancing public health practice. Our article describes the writing workshops offered to Division of Nutrition, Physical Activity, and Obesity (DNPAO), Centers for Disease Control and Prevention (CDC) funded programs in 2021. This project consisted of three 60-minute introductory writing webinars open to all recipients, followed by a Writing for Publications workshop, an 8- to 9-week virtual learning/writing intensive for selected writing team applicants. The Society for Public Health Education staff, consultants, and CDC/DNPAO staff developed, refined, and presented the curriculum. The workshop for public health practitioner writing teams was offered to two cohorts and included extensive coaching and focused on potential submission to a Health Promotion Practice supplement, “Reducing Chronic Disease through Physical Activity and Nutrition: Public Health Practice in the Field” (see Supplemental Material), which was supported by CDC/DNPAO. We describe the webinars, the workshop design, modifications, evaluation methods and results.

Collaboration With African American Faith-Based Organizations to Promote Physical Activity: Lessons Learned From a Process Evaluation of a Shared-Use Agreements Program

Chronic diseases are disproportionately high among African Americans, often caused by social determinants of health (e.g., access to physical activity opportunities), as stated by the Centers for Disease Control and Prevention. Several studies have examined practices and policies of shared-use in school-based and other settings. There is still a gap in the literature regarding how faith-based shared-use programs, practices, and policies are implemented in a virtual or hybrid setting. This evaluation reviewed program activities and partnerships and assessed program needs for quality improvement. Focus groups ( n = 2) were conducted with program participants and site coordinators from five faith-based shared-use sites. A 12-question discussion guide was developed based on topics of interest predetermined by the project team to understand participant perceptions about participation, satisfaction, and recommendations. Focus group audio recordings were transcribed verbatim and reviewed using thematic analysis. The evaluators reviewed transcripts separately to confirm final coding and ensured intercoder reliability. The analysis yielded six themes and eight subthemes. Findings indicated that the program was rewarding and achievable, with suggestions for improvement. Social support was developed as a result of the program, health improvements were observed by participants, and networked partnerships were formed to promote health and wellness. The virtual platform presented limited access; therefore, adopting a hybrid approach could offer greater flexibility and reach broader audiences. It may be helpful for public health agencies to partner with faith-based organizations to jointly open their facilities. Agencies, like local health departments, may consider establishing agreements to expand shared-use to local faith-based settings.

Implementing Locally Tailored Strategies to Promote Redemption of Farmers' Market Nutrition Program Vouchers Among WIC Participants in Central Pennsylvania

The Pennsylvania Farmers' Market Nutrition Program (FMNP) provides vouchers to participants of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) to purchase locally grown fruits, vegetables (F&V), and herbs every year from June to November. Voucher redemption is suboptimal among WIC participants in Lebanon County, a community with high numbers of low-income and Hispanic families. Supported by a Racial and Ethnic Approaches to Community Health (REACH) award, our community-academic coalition partnered with the local WIC provider to implement locally tailored strategies to promote redemption of FMNP vouchers. In 2019, we surveyed FMNP participants (n = 100) to examine opportunities for improved voucher redemption. Increasing sites for voucher use (47%) and a larger variety of F&V (27%) were the most commonly selected improvements participants identified. Participants also supported improvements to increase awareness of available seasonal produce (14%), text/phone reminders to redeem vouchers (13%), and having recipes to cook meals with FMNP-approved F&V (12%). These findings led us to implement a weekly, Farm-to-WIC "grab bag" program in 2020/2021. We partnered with a local farmer to offer a variety of FMNP-approved produce in $3 and $6 grab bags at the local WIC provider. Each grab bag included healthy recipes using the included produce. In 2021, we launched a text/phone reminder intervention to encourage voucher redemption among FMNP participants (n = 57). Our work demonstrates the value of community-academic partnerships to identify and implement feasible strategies that are responsive to local needs as well as supporting existing programs providing greater access to affordable produce.

Empty Houses, Loose Dogs, and Engaged Citizens: Lessons Learned From Community Participatory Data Collection in Rural Areas

Rural surveys tend to oversample easy to reach populations, which can misrepresent community health needs. To achieve baseline data reflective of the communities served by the high obesity program (HOP), an innovative evaluation plan was created to prioritize equity and reflect the whole community. Principles of Community-Based Participatory Research (CBPR) were used to guide instrument development, research protocols, and data collection. A random sample of addresses created with United States Postal Service records provided a representative list of addresses in three HOP counties in Louisiana. Local data collectors were recruited to go door to door at the selected addresses to collect in-person surveys (N = 682; response rate of 84%). Over a quarter of participants reported using the charitable food system and walking for transportation at least weekly. Collecting door to door data in rural communities presents unique challenges, including abandoned properties, inaccurate address records, loose dogs, and at times, racial tensions and houses far removed from public roads. Lessons learned include the importance of local knowledge, adapting protocols to fit local conditions, and community awareness of the survey. Health practitioners need confidence when they are making data-based decisions about interventions, and one way to provide this confidence is to collect data from a true cross-section of the community. With a plan and in partnership with community members, a probability sample is feasible to collect in rural communities.

Healthy Here: A Promising Referral System Model for Community–Clinical Linkages to Prevent Chronic Disease

Linking clinical services to community-based resources is a promising strategy for assisting patients with chronic disease prevention and management. However, there remains a gap in understanding how to effectively develop and implement community–clinical linkages (CCLs), especially in communities of color. The Healthy Here initiative used Stage Theory of organizational change to implement a centralized wellness referral system, linking primary care clinics to community organizations in majority Hispanic/Latinx and Native American communities. Data were collected using a standardized referral form. Facilitators and challenges were identified through semi-structured discussions with partner organizations. Between 2016 and 2021, 43 clinics and 497 health care providers made 7,465 referrals, the majority of which were from the focus populations. The average proportion of patients referred by clinic champions decreased significantly over time, reflecting diffusion of the intervention within clinics. Facilitators to system success included building on existing networked partnerships, utilizing a centralized referral center, leveraging funding, sharing data, addressing challenges collectively, incorporating multilevel leadership, and co-developing and testing a standardized referral form and process with a single clinic and provider before scaling up. Challenges included funding restrictions, decreasing referrals within clinics over time, changing availability of resources and programs, and the COVID-19 pandemic. This innovative initiative demonstrates that CCLs can be developed and implemented to successfully reach Hispanic/Latinx and Native American communities and provides strategies for overcoming challenges.

Creating a Culture of Breastfeeding Support and Continuity of Care in Central Illinois

Central Illinois breastfeeding rates fall short of the recommendation to breastfeed exclusively through 6 months, and Black, low-income, and rural families disproportionately experience low rates. A continuity of care framework, which emphasizes interdisciplinary coordination from the prenatal period through weaning, can support breastfeeding. This case study describes an innovative practice model informed by the Collective Impact Model (CIM) designed to promote breastfeeding continuity of care and community support in Central Illinois. Development and maintenance of the Central Illinois Breastfeeding Professional Network (CIBPN), a network of diverse public health practitioners, leveraged CIM principles. The CIBPN began with influential Breastfeeding Champions, identified through the Illinois State Physical Activity and Nutrition program. Champions convened Central Illinois breastfeeding allies and led the CIBPN to coalesce around a common agenda and engage in mutually reinforcing activities. Linked breastfeeding data for families giving birth at a Central Illinois hospital and receiving postnatal care at a health center were analyzed as a snapshot of CIBPN initiatives. The CIBPN engaged at least 135 practitioners and more than 27 organizations. At least 33 people received advanced breastfeeding training, and many professional development opportunities were offered. Numerous breastfeeding support improvements were made at and between CIBPN sites. Breastfeeding rates at the birthing hospital and health center were stable, including during the COVID-19 pandemic. This article contributes to the practice-based evidence for breastfeeding support by strengthening continuity of care through a successful application of the CIM by public health practitioners.

Differences in Rural Built Environment Perceptions Across Demographic and Social Environment Characteristics

The benefits of physical activity to health and obesity prevention are well established. However, attributes of the built environment influence participation in physical activity. The purpose of this study is to assess differences in perceptions of neighborhood walkability across demographic characteristics and social environment factors among rural residents. In a telephone survey, adult respondents (N = 448) across nine rural counties in a southeastern state answered questions about perceived neighborhood walkability, demographic characteristics, and their neighborhood social environment. Study recruitment for a convenience sample occurred through collaborations with local community organizations. Prevalence of destinations and barriers were estimated according to demographic and neighborhood social environment characteristics. Multiple logistic regression models assessed the association of demographic and neighborhood social environment characteristics with neighborhood walkability and calculated adjusted prevalence. Relaxing places to walk were the most often reported destinations (62.0%), followed by retail destinations (45.7%), and communal destinations (42.6%). Traffic was the most reported barrier to safe walking (40.4%), followed by animals (37.5%), and crime (30.5%). Perceptions of retail and communal destinations varied by age and race. Perceptions of traffic and crime as barriers varied by race, weight status, and income. Community belonging and social cohesion were associated with lower perceptions of barriers. Study findings present demographic characteristics and social environment attributes as key factors that shape perceived neighborhood walkability. Findings can help inform programmatic efforts and environmental change strategies to improve walking in rural areas.

Navajo Nation Stores Show Resilience During COVID-19 Pandemic

On April 8, 2020, the Navajo Nation issued an administrative order limiting business operations. Facing high coronavirus disease 2019 (COVID-19) rates and limited food infrastructure, a survey was conducted among Navajo Nation store managers to assess: (1) COVID-19 adaptations; (2) challenges; (3) changes in customer volume and purchasing; and (4) suggestions for additional support. Purposive sampling identified 29 stores in Navajo communities. Representatives from 20 stores (19 store managers/owners, 1 other; 7 grocery, and 13 convenience/other stores) were interviewed by phone or in-person to reach saturation (new information threshold < 5%). Responses were coded using frequencies and inductive thematic analysis. All 20 stores implemented COVID-19 guidelines (Centers for Disease Control and Prevention [CDC]/Navajo Nation) and most received orientation/support from local chapters, community organizations, or health centers. Stores implemented staff policies (50%, handwashing, vaccinations, protective personal equipment (PPE), sick leave, temperature checks), environmental changes (50%, hand sanitizer, checkout dividers), customer protocols (40%, limit customers, mask requirements, closed restrooms), and deep cleaning (40%). Most stores (65%) reported challenges including stress/anxiety, changing guidelines, supply chain and customer compliance; 30% reported infection or loss of staff. Weekday customer volume was slightly higher vs. pre-COVID, but weekend lower. Stores reported consistent or more healthy food purchases (50%), more nonfood essentials (20%), or shelf-stable foods (10%). Desired support included further orientation (30%), leadership support (20%), overtime/time to learn guidelines (20%), and signage/handouts (15%). Despite a high COVID-19 burden and limited food store infrastructure, Navajo Nation stores adapted by implementing staff, environmental and customer policies. Local support, staffing, and small store offerings were key factors in healthy food access.

Alaska's Play Every Day Campaign Encourages Parents to Serve Healthy Drinks to Young Children

BACKGROUND

Sugary drink consumption by young children is a public health concern. The State of Alaska, partnering with the Alaska Native Tribal Health Consortium, implemented the Play Every Day social marketing campaign in 2019-2021 to encourage parents to serve healthy drinks to young children. The campaign's intended audience was parents who experience disproportionately poor nutrition outcomes: Alaska Native people, those living in rural communities, and those with low incomes and/or educational attainment. We described campaign development, implementation, and performance.

METHOD

Parents from the identified disproportionately affected populations participated in formative research. Campaign awareness and engagement questions were added to Alaska's child health surveillance system. Regression models assessed associations between campaign exposure and outcomes.

RESULTS

The sample included 476 Alaska mothers of 3-year-old children. Of the 34% who reported seeing the campaign, 21% said they changed drinks served to their child because of the campaign. Campaign awareness, engagement, and reported changes in drinks given to children because of the campaign were greater among Alaska Native mothers than White mothers. Among all mothers, those who said the campaign gave them new information or that they shared the campaign had 7 to 8 times greater odds for reporting changes in behavior than those not engaged with the campaign.

IMPLICATIONS FOR PRACTICE

Social marketing campaigns that encourage parents to serve healthy drinks to young children may change behavior. Resources should be systematically dedicated to research, implementation, and evaluation focused on specific populations. Partnering with trusted community-serving organizations likely improves outcomes in disproportionately affected populations.

A Proactive, Systematic Approach to Building the Capacity of Technical Assistance Providers

Technical assistance (TA) is a major capacity building strategy used by the government sector to promote health outcomes in the United States. However, there is minimal literature about how to develop TA provider capacities. This article describes a systematic and proactive approach for developing TA provider capacity, referred to as Technical Assistance for Technical Assistance Providers (TAFTAP), which draws on three implementation science frameworks (Interactive Systems Framework for Dissemination and Implementation, Getting To Outcomes, and R = MC²). We present an application of TAFTAP within a federal agency providing a readiness-informed TA approach to health departments of states, territories, and tribal areas implementing comprehensive tobacco prevention control programs. Pilot data suggest that TAFTAP is a promising approach for improving the quality of TA delivery. At the end of the 2-year project period, TAFTAP recipients provided generally positive qualitative feedback about the support they received. They chose to sustain the readiness-informed TA by incorporating it into a future funding announcement. Downstream state-level TA grantee recipients reported positive outcomes (e.g., accelerated progress, enjoying more one-on-one time with TA providers) from receiving the TA innovation from TAFTAP recipients. We suggest that funding agencies and training and TA centers consider this approach to bolster the capacity and motivation of TA providers for downstream benefit to health and human services staff and their clients. Practical steps for employing TAFTAP to advance health outcomes are included in this article.

Impact of Entrepreneurship on the Quality of Public Health Sector Institutions and Policies

The purpose of this paper is to investigate whether public health entrepreneurship principles implementation in the public health sector are alternative ways of promoting an immediate improvement of healthcare infrastructure. To contribute to the literature on the impact of public health entrepreneurship on public healthcare infrastructure, we estimate two empirical models, with the first model having institutions and the second model having public healthcare policies as the dependent variable. Our empirical analysis is based on the WHO international health regulation data for all WHO member countries (in order to achieve a balanced panel, we decided to retain 192 of them), covering the period from 2010 through to 2019. The main results obtained using a Poisson panel regression indicate a positive relationship between employing more entrepreneurship within public healthcare and the quality of public healthcare infrastructure represented through institutions and policies. This study produces several contributions to the stream of research on public health entrepreneurship. First, it makes a theoretical contribution in the way that it fills the lacking literature on the relationship between entrepreneurship within the public health sector and efficiency of country-specific public healthcare infrastructure. Second, it offers an empirical quantitative analysis of entrepreneurship that is generally lacking. Concerning policy implications, the third contribution of this paper is the provision of evidence showing alternative ways to improve healthcare infrastructure other than traditionally observed investments in physical infrastructure.

R = MC2 readiness building process: A practical approach to support implementation in local, state, and national settings

Effective implementation of evidence-based interventions is a persistent challenge across community settings. Organizational readiness - or, the motivation and collective capacity of an entity to adopt and sustain an innovation - is important to facilitate implementation. Drawing on the R = MC² readiness framework, we developed a readiness building process to tailor support for implementation. The process is composed of the following stages: assessment, feedback and prioritization, and strategize. In this article, we describe the application of the readiness building process through three case examples representing interventions at different ecological levels: local, state, and national. The case examples illuminate challenges and practical considerations for using the readiness building process, including the significance of on-going leadership engagement and collaboration between support system and delivery system staff. To further the research and practice of implementation readiness, we suggest examining the impact of readiness building on implementation outcomes and developing an empirically-informed repository of change management strategies matched to readiness constructs.

Special Report from the CDC: Readiness to surge: State health departments' workforce infrastructure during the opioid crisis

INTRODUCTION

As part of scaling up the response to the opioid overdose epidemic, there is an opportunity to examine how state public health departments addressed workforce and other infrastructure needs to implement a large-scale opioid overdose prevention program. Understanding how this was done-and any lessons learned from the process-can inform future workforce development and capital improvement efforts.

METHODS

Administrative data from the Centers for Disease Control and Prevention (CDC) Prescription Drug Overdose Prevention for States (PfS) program were analyzed to understand how states adapted to this emerging public health priority.

RESULTS

Six months into the first year of funding, 6 of the 16 state health departments had filled all anticipated staffing positions. States faced challenges obtaining timely expenditure authority and hiring staff. However, states were able to overcome these challenges by strategically reassigning staff, hiring from within, and utilizing existing contract mechanisms.

CONCLUSION

Our analysis revealed how planning, using existing infrastructure, and maintaining a prepared workforce are critical to ensure that public health agencies have the ability to surge to meet emerging challenges and effectively utilize resources to achieve program goals. practical applications: Greater attention should be directed toward strategically addressing known barriers and timelines in work plans and budgets during the application and selection process to ensure implementation readiness.

A systemic approach to achieving population-level impact in injury and violence prevention

The contemporary public health model for injury and violence prevention is a four-step process, which has been difficult to fully actualize in real-world contexts. This difficulty results from challenges in bridging science to practice and developing and applying population-level approaches. Prevention programmes and policies are embedded within and impacted by a range of system-level factors, which must be considered and actively managed when addressing complex public health challenges involving multiple sectors and stakeholders. To address these concerns, a systemic approach to population-level injury and violence prevention is being developed and explored by the Division of Analysis, Research, and Practice Integration in the National Center for Injury Prevention and Control at the Centers for Disease Control and Prevention. This article makes the case for and provides a high-level overview of this systemic approach, its various components, and how it is being applied in one governmental unit.

Capacity Building for and Implementation of Policy, Systems, and Environmental Change: Results from a Survey of the National Comprehensive Cancer Control Program

Policy, systems, and environmental (PSE) approaches are commonly used to improve population health. Cancer-related examples include providing data and education to stakeholders about policies that support healthy living, or health systems changes such as universal reminders about recommended cancer screening. The National Comprehensive Cancer Control Program (NCCCP) funds health departments to form cancer coalitions that develop and implement cancer plans. NCCCP initiated a demonstration program in 13 of 65 funded grantees to determine whether skilled, dedicated staffing and using a strategic process to examine data, form a workgroup, and develop an agenda would enhance their capacity to implement PSE approaches, recruit new partners, and provide data and education to stakeholders. The objective of this study was to compare demonstration program grantees to other NCCCP grantees on their ability to develop and implement PSE strategies, and the short-term results that were achieved. Program directors (PDs) from each NCCCP-funded jurisdiction completed web surveys at 2 time points during implementation to assess changes in their capacity for PSE approaches, identify implementation activities, and document short-term outcomes. Responses from demonstration program PDs and other PDs at both time points were compared in a descriptive analysis. Demonstration program grantees experienced greater increases in skills and capacity to address PSE approaches, engaged in necessary implementation activities more often, and achieved greater improvements in stakeholder and decision maker awareness and support for PSE strategies, compared to nonparticipating NCCCP grantees. These findings support continued implementation of PSE approaches for sustainable cancer prevention and control.

Race/Ethnic Variations in Quitline Use Among US Adult Tobacco Users in 45 States, 2011-2013

Introduction

State quitlines provide free telephone-based cessation services and are available in all states. However, quitlines presently reach 1% of US cigarette smokers. We assessed variations in quitline reach by race/ethnicity across 45 US states included in the National Quitline Data Warehouse, a repository on non-identifiable data reported by state quitlines.

Methods

During 2011 to 2013, we analyzed 1 220 171 records from the National Quitline Data Warehouse. Annual quitline reach was defined as the proportion of cigarette smokers and smokeless tobacco users who utilized quitline services during each year, and was calculated by dividing the number of state-specific quitline registrants in each year by the number of adult cigarette smokers and smokeless tobacco users in the state.

Results

Average annual reach ranged from: 0.08% (Tennessee) to 3.42% (Hawaii) among non-Hispanic whites; 0.17% (Tennessee) to 3.85% (Delaware) among non-Hispanic blacks; 0.27% (Nevada) to 9.98% (Delaware) among non-Hispanic American Indians/Alaska Native; 0.03% (Alabama) to 2.43% (Hawaii) among non-Hispanic Asian/Pacific Islanders; and from 0.08% (Tennessee) to 3.18% (Maine) among Hispanics. Average annual reach was highest among non-Hispanic American Indians/Alaska Native in 27 states, non-Hispanic blacks in 14 states, and non-Hispanic whites in four states.

Conclusions

Quitlines appear to be reaching minority populations; however, overall reach remains low and variations in quitline reach exist by race/ethnicity. Opportunities exist to increase the utilization of quitlines and other effective cessation treatments among racial/ethnic minority populations.

Implications

Some studies have assessed quitline reach across demographic groups in individual states; however, no studies have provided multistate data about quitline reach across race/ethnic groups. Ongoing monitoring of the use of state quitlines can help guide targeted outreach to particular race/ethnic groups with the goal of increasing the overall proportion and number of tobacco users that use quitlines. These efforts should be complemented by comprehensive tobacco control initiatives that increase cessation including mass media campaigns, smoke-free policies, increased tobacco prices, expansion of health insurance coverage, and health systems change.

State tobacco control expenditures and tax paid cigarette sales

This research is the first nationally representative study to examine the relationship between actual state-level tobacco control spending in each of the 5 CDC's Best Practices for Comprehensive Tobacco Control Program categories and cigarette sales. We employed several alternative two-way fixed-effects regression techniques to estimate the determinants of cigarette sales in the United States for the years 2008-2012. State spending on tobacco control was found to have a negative and significant impact on cigarette sales in all models that were estimated. Spending in the areas of cessation interventions, health communication interventions, and state and community interventions were found to have a negative impact on cigarette sales in all models that were estimated, whereas spending in the areas of surveillance and evaluation, and administration and management were found to have negative effects on cigarette sales in only some models. Our models predict that states that spend up to seven times their current levels could still see significant reductions in cigarette sales. The findings from this research could help inform further investments in state tobacco control programs.

Development of a Comprehensive and Interactive Tool to Inform State Violence and Injury Prevention Plans

CONTEXT

The Center of Disease Control and Prevention's Core State Violence and Injury Prevention Program (Core SVIPP) provides an opportunity for states to engage with their partners to implement, evaluate, and disseminate strategies that lead to the reduction and prevention of injury and violence. Core SVIPP requires awardees to develop or update their state injury and violence plans. Currently, literature informing state planning efforts is limited, especially regarding materials related to injury and violence. Presumably, plans that are higher quality result in having a greater impact on preventing injury and violence, and literature to improve quality would benefit prevention programming.

OBJECTIVE

(1) To create a comprehensive injury-specific index to aid in the development and revision of state injury and violence prevention plans, and (2) to assess the reliability and utility of this index.

DESIGN

Through an iterative development process, a workgroup of subject matter experts created the Violence and Injury Prevention: Comprehensive Index Tool (VIP:CIT). The tool was pilot tested on 3 state injury and violence prevention plans and assessed for initial usability. Following revisions to the tool (ie, a rubric was developed to further delineate consistent criteria for rating; items were added and clarified), the same state plans were reassessed to test interrater reliability and tool utility.

RESULTS

For the second assessment, reliability of the VIP:CIT improved, indicating that the rubric was a useful addition. Qualitative feedback from states suggested that the tool significantly helped guide plan development and communicate about planning processes.

CONCLUSION

The final VIP:CIT is a tool that can help increase plan quality, decrease the research-to-practice gap, and increase connectivity to emerging public health paradigms. The tool provides an example of tailoring guidance materials to reflect academic literature, and it can be easily adapted to other topic areas to promote quality of strategic plans for numerous outcomes.

How Health Department Contextual Factors Affect Public Health Preparedness (PHP) and Perceptions of the 15 PHP Capabilities

OBJECTIVES

To assess how health department contextual factors influence perceptions of the 15 Public Health Preparedness Capabilities, developed by the Centers for Disease Control and Prevention (CDC) to provide guidance on organizing preparedness activities.

METHODS

We conducted an online survey and focus group between September 2015 and May 2016 with directors of preparedness programs in state, metropolitan, and territorial jurisdictions funded by CDC's Public Health Emergency Preparedness (PHEP) cooperative agreement. The survey collected demographic information and data on contextual factors including leadership, partnerships, organizational structure, resources and structural capacity, and data and evaluation.

RESULTS

Seventy-seven percent (48 of 62) of PHEP directors completed the survey and 8 participated in the focus group. Respondents were experienced directors (mean = 10.6 years), and 58% led 7 or more emergency responses. Leadership, partnerships, and access to fiscal and human resources were associated with perception and use of the capabilities.

CONCLUSIONS

Despite some deficiencies, PHEP awardees believe the capabilities provide useful guidance and a flexible framework for organizing their work. Contextual factors affect perceptions of the capabilities and possibly the effectiveness of their use. Public Health Implications. The capabilities can be used to address challenges in preparedness, including identifying evidence-based practices, developing performance measures, and improving responses.

Using a Theory of Change to Guide Grant Monitoring and Grantmaking

Charitable foundations play a significant role in advancing public health, funding billions of dollars in health grants each year. Evaluation is an important accountability tool for foundations and helps ensure that philanthropic investments contribute to the broader public health evidence base. While commitment to evaluation has increased among foundations over the past few decades, effective use of evaluation findings remains challenging. To facilitate use of evaluation findings among philanthropic organizations, evaluators can incorporate the foundation's theory of change-an illustration of the presumed causal pathways between a program's activities and its intended outcomes-into user-friendly products that summarize evaluation findings and recommendations. Using examples from the evaluation of the Kansas Health Foundation's Healthy Living Focus Area, we present a mapping technique that can be applied to assess and graphically depict alignment between program theory and program reality, refine the theory of change, and inform grantmaking.

State Tobacco Control Program Implementation Strategies for Smoke-Free Multiunit Housing

Multiunit housing residents are at risk of secondhand smoke exposure from adjoining units and common areas. We developed this case study to document state-level strategies undertaken to address this risk. We explored program documents to identify facilitators, barriers, and outcomes. Three states (Montana, Michigan, and Nebraska) provided detailed information on multiunit housing efforts in the study time frame. We conducted a qualitative analysis using inductive coding to develop themes. Several facilitators relating to existing infrastructure included traditional and nontraditional partnerships, leadership and champions, collecting and using data, efficient use of resources, and strategic plans. We also report external catalysts, barriers, and outcomes. Significant state leadership and effort were required to provide local-level technical assistance to engage traditional and nontraditional partners. Information needs were identified and varied by stakeholder type (i.e., health vs. housing). States recommend starting with public housing authorities, so they can become resources for affordable and subsidized housing. These lessons and resources can be used to inform smoke-free multiunit housing initiatives in other states and localities.

Measuring infrastructure: A key step in program evaluation and planning

State tobacco prevention and control programs (TCPs) require a fully functioning infrastructure to respond effectively to the Surgeon General's call for accelerating the national reduction in tobacco use. The literature describes common elements of infrastructure; however, a lack of valid and reliable measures has made it difficult for program planners to monitor relevant infrastructure indicators and address observed deficiencies, or for evaluators to determine the association among infrastructure, program efforts, and program outcomes. The Component Model of Infrastructure (CMI) is a comprehensive, evidence-based framework that facilitates TCP program planning efforts to develop and maintain their infrastructure. Measures of CMI components were needed to evaluate the model's utility and predictive capability for assessing infrastructure. This paper describes the development of CMI measures and results of a pilot test with nine state TCP managers. Pilot test findings indicate that the tool has good face validity and is clear and easy to follow. The CMI tool yields data that can enhance public health efforts in a funding-constrained environment and provides insight into program sustainability. Ultimately, the CMI measurement tool could facilitate better evaluation and program planning across public health programs.

Sustainability of physical activity promoting environments and influences on sustainability following a structural intervention in residential children's homes

Research examining sustainability of health promotion programs within organizational settings is limited. The Environmental Interventions in Residential Children's Homes (ENRICH) was a structural intervention that trained Wellness Teams (WTs) within residential children's homes (RCH) to target environmental changes that promote physical activity (PA) among residential youth. This study examines the sustainability of PA promoting environments and influences on sustainability within RCHs. A sustainability survey was administered to 14 RCHs 2 years after receiving ENRICH. Variables included sustainability of PA promoting environments, Organizational Influences, perceived organizational and individual benefits, and implementation of PA and general (i.e. Global) wellness activities. Activities reported as sustained and barriers were used descriptively to inform sustainability. Path analyses explained the relationship between sustainability influences and sustainability of PA promoting environments. Sustainability was found in 8 of 14 (57%) RCHs. Sustained activities reflected greater Global versus PA implementation. Global implementation mediated the relationship between Organizational Influences and sustainability, which may have been more easily achieved since Global activities were most likely controlled by WTs and did not require extensive organizational support from RCH administrators. Results highlight the importance of defining and assessing different implementation types when measuring sustainability and influences on sustainability within RCHs organizations.

A Customizable Model for Chronic Disease Coordination: Lessons Learned From the Coordinated Chronic Disease Program

In 2012, the Centers for Disease Control and Prevention provided funding and technical assistance to all states and territories to implement the Coordinated Chronic Disease Program, marking the first time that all state health departments had federal resources to coordinate chronic disease prevention and control programs. This article describes lessons learned from this initiative and identifies key elements of a coordinated approach. We analyzed 80 programmatic documents from 21 states and conducted semistructured interviews with 7 chronic disease directors. Six overarching themes emerged: 1) focused agenda, 2) identification of functions, 3) comprehensive planning, 4) collaborative leadership and expertise, 5) managed resources, and 6) relationship building. These elements supported 4 essential activities: 1) evidence-based interventions, 2) strategic use of staff, 3) consistent communication, and 4) strong program infrastructure. On the basis of these elements and activities, we propose a conceptual model that frames overarching concepts, skills, and strategies needed to coordinate state chronic disease prevention and control programs.

Strategies to Support Tobacco Cessation and Tobacco-Free Environments in Mental Health and Substance Abuse Facilities

We identified and described strategies for promoting smoking cessation and smoke-free environments that were implemented in Oregon and Utah in treatment centers for mental illness and substance abuse. We reviewed final evaluation reports submitted by state tobacco control programs (TCPs) to the Centers for Disease Control and Prevention and transcripts from a call study evaluation. The TCPs described factors that assisted in implementing strategies: being ready for opportunity, having a sound infrastructure, and having a branded initiative. These strategies could be used by other programs serving high-need populations for whom evidence-based interventions are still being developed.

Mental illness, mass shootings, and the politics of American firearms

Four assumptions frequently arise in the aftermath of mass shootings in the United States: (1) that mental illness causes gun violence, (2) that psychiatric diagnosis can predict gun crime, (3) that shootings represent the deranged acts of mentally ill loners, and (4) that gun control "won't prevent" another Newtown (Connecticut school mass shooting). Each of these statements is certainly true in particular instances. Yet, as we show, notions of mental illness that emerge in relation to mass shootings frequently reflect larger cultural stereotypes and anxieties about matters such as race/ethnicity, social class, and politics. These issues become obscured when mass shootings come to stand in for all gun crime, and when "mentally ill" ceases to be a medical designation and becomes a sign of violent threat.