Infrastructure—more than platforms for moving vehicles! Kim Snyder, ICF International René Lavinghouze, CDC’s Office on Smoking and Health Patricia Rieker, Boston University and Harvard Medical School The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.

“DHHS should develop a comprehensive investment plan for a strong public health infrastructure at all levels with a timetable, clear performance measures, and regular progress reports to the public.” IOM’s recommendations on infrastructure…

Tobacco Institute Tobacco Institute. Overview of state ASSIST programs. Bates #: TI Accessed May 4,

Infrastructure through a tobacco control lens

We have outcome measures and know where we are going…

…Best Practices tell us how to get there…

…But do we consider the foundation for achieving outcomes?

InputsActivitiesOutputs Targeted to populations with tobacco- related disparities Short-termIntermediateLong-term Outcomes Reduced tobacco-related morbidity and mortality 9 Decreased tobacco-related disparities 10 Reduced exposure to secondhand smoke 7 Reduced tobacco consumption 8 Increased knowledge of, improved attitudes toward, and increased support for the creation and active enforcement of tobacco-free policies 3 Creation of tobacco-free policies 4 Enforcement of tobacco-free public policies 5 Compliance with tobacco-free policies 6 Completed activities to disseminate information about secondhand smoke and tobacco-free policies 1 Completed activities to create and enforce tobacco-free policies 2 Counter- Marketing Community mobilization Policy and regulatory action State health department and partners Eliminating Nonsmokers’ Exposure to Secondhand Smoke What are we really saying about infrastructure or the “inputs” box…

“The original implementation plan for this action item was intended to generate referrals to Quitline [state] through a pilot project with [name] Hospital in [state]. …The [hospital name] pharmacy would refer each client to Quitline [state] when they received the medication. The partnership with [hospital name] was not realized. This was primarily due to the lack of alignment of timing and priorities and the project simply not getting started.”

What’s Missing?

Ecological Model of Infrastructure

Evaluation Questions What is the definition of public health program infrastructure? Is the EMI and its components applicable across public health programs? How is the EMI a practical and actionable model of infrastructure? Is there a connection between infrastructure, outcomes and sustainability?

Methods Literature review (n= 25) Case studies, literature reviews, scientific presentations, white papers and national reports Coding independently by two scientists Context, engaged data, leadership, managed resources, outcomes, partnership, state plans, strategic understanding, sustainability, tactical action

Methods Documents selected: English language Focus on interventions with health outcomes Directly report on: Infrastructure Capacity building Sustainability

Topic Areas of Documents Included in Literature Review Adolescent Reproductive HealthPrevention Programs Asthma (n=3)Racial Health Disparities Communities, CDC SymposiumSexual Violence Community BuildingState Health Departments (n=2) Community Health (n=3)Substance Abuse Prevention Services DiabetesTobacco Control and Prevention (n=4) Non-profit Performance USAID, Developing Country Health Systems Oral HealthYouth Services Physical Activity

Essential Elements

the foundation or platform that supports capacity, implementation, and sustainability of program initiatives

Inputs/ Infrastructure ActivitiesOutputsOutcomes Sustainability Capacity

Reconstructing infrastructure: from model to measurement tool René Lavinghouze, CDC’s Office on Smoking and Health Kim Snyder, ICF International Patricia Rieker, Boston University and Harvard Medical School The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Building the Evidence-Based Model

OSH CPPW Evaluation Questions What does success look like that drives policy and environmental change? What is the foundation for effective tobacco control programs?

Methods Data from state tobacco control programs (n=18) – CPPW case study (n= 4) – CPPW call study (n= 9) – CPPW site visits (n=5)

OSH CPPW Evaluation Sites

All studies – Document review Case and call studies – In-depth theme discussions related to TCP infrastructure and achievements TA site visits – Discussions of progress, hurdles and infrastructure Data Collection

Inductive and deductive coding Analytic techniques: – Theme analysis – Memoing – Network diagrams – Triangulation of data Data Analysis

Component Model of Infrastructure Outcomes Managed Resources Engaged Data Multi-Level Leadership Networked Partnerships Responsive Plans/ Planning Continued Support Capacity Lavinghouze, S. Rene, Snyder, Kim, and Rieker, Pat

Multi-Level Leadership Connected to a vision, plan or direction Includes champions Ownership of programs at multiple levels Succession planning Formal and informal leadership People and their expertise Dynamic process Selected examples of defining characteristics Managed Resources Engaged Data Multi-Level Leadership Networked Partnerships Responsive Plans/ Planning

Managed Resources Diversified funding streams Leveraging Integration Coordination Staff expertise Technical assistance Training Selected examples of defining characteristics Managed Resources Engaged Data Multi-Level Leadership Networked Partnerships Responsive Plans/ Planning

Engaged Data Use of data Increase program visibility Attract partners Secure and manage scarce resources Ready communication Igniting passion Facilitates evolution of initiatives and overall sustainability Knowledge management Selected examples of defining characteristics Managed Resources Engaged Data Multi-Level Leadership Networked Partnerships Responsive Plans/ Planning

Healthy People 2020 A Resource for Promoting Health and Preventing Disease Throughout the Nation

Responsive Plans/Planning Dynamic Evolving Responsive Flexible Shared ownership Direction/roadmap Used, doesn't sit on a shelf Education and recruitment tool Progress yardstick Living document(s) Specific goals, objectives, actions, time frames, and resources Evidence-based and context appropriate Selected examples of defining characteristics Managed Resources Engaged Data Multi-Level Leadership Networked Partnerships Responsive Plans/ Planning

Networked Partnerships Diversity Extend reach of program Fit program needs, structure, and political context Relationships take time to mature Nurtured beyond "fundee“ All levels with multiple types of organizations, content areas & groups Multiply the work program can accomplish Fill different roles Selected examples of defining characteristics Managed Resources Engaged Data Multi-Level Leadership Networked Partnerships Responsive Plans/ Planning

Component Model of Infrastructure Outcomes Managed Resources Engaged Data Multi-Level Leadership Networked Partnerships Responsive Plans/ Planning Continued Support Capacity Lavinghouze, S. Rene, Snyder, Kim, and Rieker, Pat

Translating the CMI into a Measurement Tool

Valid Reliable Feasible Culturally appropriate Accessible Measurement Considerations

Interactive Maps State Highlight, Comparison and Trend Reports Fact Sheets Reporting Infrastructure Data

Component Model of Infrastructure Outcomes Managed Resources Engaged Data Multi-Level Leadership Networked Partnerships Responsive Plans/ Planning Continued Support Capacity Lavinghouze, S. Rene, Snyder, Kim, and Rieker, Pat

What’s Next?

Questions? Comments?