Action planning for building public health program sustainability: results from a group-randomized trial.

BACKGROUND: Public health programs are charged with implementing evidence-based interventions to support public health improvement; however, to achieve long-term population-based benefits, these interventions must be sustained. Empirical evidence suggests that program sustainability can be improved through training and technical assistance, but few resources are available to support public health programs in building capacity for sustainability. METHODS: This study sought to build capacity for sustainability among state tobacco control programs through a multiyear, group-randomized trial that developed, tested, and evaluated a novel Program Sustainability Action Planning Model and Training Curricula. Using Kolb's experiential learning theory, we developed this action-oriented training model to address the program-related domains proven to impact capacity for sustainability as outlined in the Program Sustainability Framework. We evaluated the intervention using a longitudinal mixed-effects model using Program Sustainability Assessment (PSAT) scores from three time points. The main predictors in our model included group (control vs intervention) and type of dosage (active and passive). Covariates included state-level American Lung Association Score (proxy for tobacco control policy environment) and percent of CDC-recommended funding (proxy for program resources). RESULTS: Twenty-three of the 24 state tobacco control programs were included in the analyses: 11 received the training intervention and 12 were control. Results of the longitudinal mixed-effects linear regression model, where the annual PSAT score was the outcome, showed that states in the intervention condition reported significantly higher PSAT scores. The effects of CDC-recommended funding and American Lung Association smoke-free scores (proxy for policy environment) were small but statistically significant. CONCLUSION: This study found that the Program Sustainability Action Planning Model and Training Curricula was effective in building capacity for sustainability. The training was most beneficial for programs that had made less policy progress than others, implying that tailored training may be most appropriate for programs possibly struggling to make progress. Finally, while funding had a small, statistically significant effect on our model, it virtually made no difference for the average program in our study. This suggests that other factors may be more or equally important as the level of funding a program receives. CLINICALTRIALS: gov, NCT03598114. Registered on July 26, 2018.

Barriers and Facilitators to Program Sustainability Among State Tobacco Control Programs.

Public health programs, particularly tobacco control programs (TCPs) in state health departments, face numerous barriers and facilitators to sustainability, which affect delivery and, consequently, health outcomes achieved. We used the Program Sustainability Framework to review and analyze qualitative interview data from states that received training and technical assistance during the Plans, Actions, and Capacity to Sustain Tobacco Control (PACT) study to better understand the barriers and facilitators to sustainability capacity that these public health programs face at the state level. The PACT study was a multiyear, randomized controlled trial to assess the effectiveness of an action planning workshop and technical assistance in improving capacity for sustainability among 11 intervention and 12 control TCPs. Technical assistance calls focused on the progress and barriers of implementing the sustainability action plan created during the in-person workshops. Calls were audio recorded and professionally transcribed. Thematic analysis focused on the codes describing barriers and facilitators faced by TCPs in increasing their capacity for sustainability. Barriers were reported in the Organization Capacity, Environmental Support, Partnerships, Communication, and Funding Stability domains of the Program Sustainability Framework. Facilitators to action planning and building capacity for program sustainability were primarily in the Strategic Planning, Program Evaluation, Program Adaptation, and Partnership domains. Our study is the first to identify barriers and facilitators to increasing the capacity of program sustainability in TCPs. This work advances the understanding of program sustainability capacity and technical assistance for public health programs.

A qualitative study examining the impact of COVID-19 on capacity for sustainability of tobacco control programs.

BACKGROUND: The coronavirus (COVID-19) pandemic presented a significant stressor on the public health system in the United States. While we know the immediate effects of the pandemic on public health programming, no literature has examined the resultant long-term impact on programmatic capacity for sustainability. This paper aims to identify the impact that the COVID-19 pandemic had on state tobacco control program's capacity for sustainability. METHODS: From December 2018 to January 2022, we conducted 46 technical assistance calls with tobacco control program employees from 11 states. Calls were audio recorded and professionally transcribed. We analyzed calls (n = 20) that took place during the COVID-19 pandemic. Thematic analysis focused on the impact the COVID-19 pandemic had on tobacco control program's capacity for sustainability. RESULTS: We identified six domains of sustainability that were impacted by COVID-19: (1) funding stability; (2) organizational capacity; (3) partnerships; (4) communication; (5) strategic planning; and (6) program adaptation. CONCLUSIONS: Our study is the first to identify the impact of the pandemic on capacity for sustainability of tobacco control programs. Having an understanding of COVID-19's influence on these sustainability domains could help with future public health programming during significant public health events and emergency preparedness. GOV IDENTIFIER: NCT03598114. REGISTRATION DATE: Retrospectively registered 02-07-2018.

Action Planning for Building Program Sustainability: Results from a Group-Randomized Trial.

Background: Public health programs are charged with implementing evidence-based interventions to support public health improvement, however, to achieve long term population based benefit these interventions must be sustained. Empirical evidence suggests that program sustainability can be improved through training and technical assistance, but few resources are available to support public health programs in building capacity for sustainability. Methods: This study sought to build capacity for sustainability among state tobacco control programs through a multiyear, group-randomized trial that developed, tested, and evaluated a novel Program Sustainability Action Planning Model and Training Curricula. Using Kolb's experiential learning theory, we developed this action-oriented training model to address the program-related domains proven to impact capacity for sustainability as outlined in the Program Sustainability Framework. We evaluated the intervention using a longitudinal mixed-effects model using Program Sustainability Assessment (PSAT) scores from three time points. The main predictors in our model included group (control vs intervention) and type of dosage (active and passive). Covariates included state level American Lung Association score (proxy for tobacco control policy environment) and percent of CDC-recommended funding (proxy for program resources). Results: Twenty-three of the 24 state tobacco control programs were included in the analyses: 11 received the training intervention and 12 were control. Results of the longitudinal mixed-effects linear regression model, where the annual PSAT score was the outcome, showed that states in the intervention condition reported significantly higher PSAT scores. The effects for CDC-recommended funding and American Lung Association smoke-free scores (proxy for policy environment) were small but statistically significant. Conclusion: This study found that the Program Sustainability Action Planning Model and Training Curricula was effective in building capacity for sustainability. The training was most beneficial for programs that had made less policy progress than others, implying that tailored training may be most appropriate for programs possibly struggling to make progress. Finally, while funding had a small, statistically significant effect in our model, it virtually made no difference for the average program in our study. This suggests that other factors may be more or equally important as the level of funding a program receives. Trial registration: NCT03598114, Registered on July 26, 2018 (clnicaltrials.gov/NCT03598114).

A conceptual model for building program sustainability in public health settings: Learning from the implementation of the program sustainability action planning model and training curricula.

Background: The emergence of implementation science has driven an increase in research examining the implementation of evidence-based programs and policies. However, there has been less attention through program sustainability. To achieve the full benefit of investment in program development and implementation, there must be an understanding of the factors that relate to sustainability; additionally, there is a need for a robust set of tools and trainings to support strategic long-term program sustainability. This paper presents results of our sustainability training intervention and a new conceptual model of sustainability. The proposed conceptual model builds upon the intervention design, further specifying the implementation strategy, strategy-mechanism linkages, and effect modifiers. Methods: This research is part of the larger randomized control trial evaluating the effectiveness of the Program Sustainability Action Planning Model and Training Curricula. Specifically, this multimethod study establishes a conceptual model for program sustainability and related capacity-building interventions. The training intervention was delivered through workshops and technical assistance to 11 state tobacco control programs, principally entailing the development and implementation of a sustainability action plan. We utilize descriptive statistics and participant perspectives to evaluate the training intervention and propose an empirically-grounded conceptual model for sustainability capacity-building interventions in public health settings. Results: Participants found intervention components (workshop, workbook, instructor and resources) to be effective. Overall, participants found the intervention improved their ability to develop sustainability action plans and assess their program and partners. Throughout the study, program managers emphasized the importance of the workshop in providing direction for their sustainability work and the value of robust, ongoing technical assistance. Program managers identified several factors that interfered with intervention reception including staff turnover, competing priorities, partnership challenges, and the COVID-19 pandemic. Conclusion: The present study documents the development and implementation of a novel Program Sustainability Action Planning Model and Training Curricula, one of the first interventions designed to improve program sustainability. In addition, we present an empirically-grounded conceptual model for program sustainability. Considering the paucity of research in this understudied and undefined topic area, this is an important contribution that can serve as a framework for similar intervention designs and implementation efforts. Clinical Trail Registration: ClinicalTrails.gov identification number is NCT03598114.

Implementation of Flexibilities to the National School Lunch and Breakfast Programs and Their Impact on Schools in Missouri.

BACKGROUND: In 2018, the United States Department of Agriculture (USDA) issued flexibilities to the National School Lunch and Breakfast Programs, relaxing the nutrition standards for milk, whole grains, and sodium. This study examines the implementation decision-making among Missouri school food services and the impact of implementing these flexibilities on the meals served. METHODS: We developed a survey using the Consolidated Framework of Implementation to determine schools' implementation of the flexibilities and factors related to implementation. To determine how the implementation of flexibilities affected participation, we merged the survey results with school-level meal county data from the Missouri Department of Elementary and Secondary Education. We used ordinary least squares regression to examine how flexibility adoption related to the number of meals served. RESULTS: Most schools implemented the wheat, milk, and sodium flexibilities. Common reasons for implementation were increasing participation, meeting students' preferences, expanding menu variety, and saving money. The implementation of flexibilities was associated with more lunches and breakfasts being served per month, particularly among free and reduced-price meals. CONCLUSIONS: Continued research is needed to determine how the increased uptake of school meals that do not fully meet dietary guidelines by low-income students results in inequities in health outcomes. The findings can inform the design and implementation of future policies, especially as new rules related to flexibility design are determined.

Understanding Misimplementation in U.S. State Health Departments: An Agent-Based Model.

INTRODUCTION: The research goal of this study is to explore why misimplementation occurs in public health agencies and how it can be reduced. Misimplementation is ending effective activities prematurely or continuing ineffective ones, which contributes to wasted resources and suboptimal health outcomes. METHODS: The study team created an agent-based model that represents how information flow, filtered through organizational structure, capacity, culture, and leadership priorities, shapes continuation decisions. This agent-based model used survey data and interviews with state health department personnel across the U.S. between 2014 and 2020; model design and analyses were conducted with substantial input from stakeholders between 2019 and 2021. The model was used experimentally to identify potential approaches for reducing misimplementation. RESULTS: Simulations showed that increasing either organizational evidence-based decision-making capacity or information sharing could reduce misimplementation. Shifting leadership priorities to emphasize effectiveness resulted in the largest reduction, whereas organizational restructuring did not reduce misimplementation. CONCLUSIONS: The model identifies for the first time a specific set of factors and dynamic pathways most likely driving misimplementation and suggests a number of actionable strategies for reducing it. Priorities for training the public health workforce include evidence-based decision making and effective communication. Organizations will also benefit from an intentional shift in leadership decision-making processes. On the basis of this initial, successful application of agent-based model to misimplementation, this work provides a framework for further analyses.

Program adaptation by health departments.

Introduction: The dissemination of evidence-based interventions (i.e., programs, practices, and policies) is a core function of US state health departments (SHDs). However, interventions are originally designed and tested with a specific population and context. Hence, adapting the intervention to meet the real-world circumstances and population's needs can increase the likelihood of achieving the expected health outcomes for the target population from the implemented intervention. This study identified how SHD employees decide to adapt public health programs and what influences decisions on how to adapt them. Materials and methods: SHD employees (n = 45) were interviewed using a qualitative semi-structured interview guide. Telephone interviews were audio-recorded and transcribed verbatim. The transcripts were consensus-coded and themes were identified using thematic analysis. Several themes aligned with the Model for Adaptation Design and Impact. Results: Data, outcomes, and health department evaluations influenced decisions to adapt a program (pre-adaptation), and reasons to adapt a program included organizational and sociopolitical contextual factors. SHD middle-level managers, program managers and staff, and local agencies were involved in the decisions to adapt the programs. Finally, the goals for adapting a program included enhancing effectiveness/outcomes, reach and satisfaction with the program; funding; and partner engagement. After SHD employees decided to adapt a program, data and evidence guided the changes. Program staff and evaluators were engaged in the adaptation process. Program managers consulted partners to gather ideas on how best to adapt a program based on partners' experiences implementing the program and obtaining community input. Lastly, program managers also received input on adapting content and context from coalition meetings and periodic technical assistance calls. Discussion: The findings related to decisions to adapt public health programs provide practitioners with considerations for adapting them. Findings reaffirm the importance of promoting public health competencies in program evaluation and adaptation, as well as systematically documenting and evaluating the adaptation processes. In addition, the themes could be studied in future research as mechanisms, mediators, and moderators to implementation outcomes.

Leading the way: competencies of leadership to prevent mis-implementation of public health programs.

Public health agencies are increasingly concerned with ensuring that they are maximizing limited resources by delivering effective programs to enhance population-level health outcomes. Preventing mis-implementation (ending effective activities prematurely or continuing ineffective ones) is necessary to sustain public health efforts and resources needed to improve health and well-being. The purpose of this paper is to identify the important qualities of leadership in preventing mis-implementation of public health programs. In 2019, 45 state health department chronic disease employees were interviewed via phone and audio-recorded, and the conversations were transcribed verbatim. Thematic analysis focused on items related to mis-implementation and the manners in which leadership were involved in continuing ineffective programs. Final themes were based on a Public Health Leadership Competency Framework. The following themes emerged from their interviews regarding the important leadership competencies to prevent mis-implementation: '(1) leadership and communication; (2) collaborative leadership (3) leadership to adapt programs; (4) leadership and organizational learning and development; and (5) political leadership'. This first of its kind study showed the close interrelationship between mis-implementation and leadership. Increased attention to public health leader competencies might help to reduce mis-implementation in public health practice and lead to more effective and efficient use of limited resources.

At Home and on the Brink: U.S. Parents' Mental Health during COVID-19.

Though the COVID-19 pandemic required significant changes and adaptations for most Americans, parents faced acute challenges as they had to navigate rapidly changing schooling and child care policies requiring their children to spend more time at home. This study examines the effects of COVID-19 school and workplace policies as well as environmental and economic characteristics on parental mental health, worry, hopelessness, and anxiety. Using data from four waves of the Socio-Economic Impacts of COVID-19 Survey and regression analysis, we explore associations between parents' mental health, worry, hopelessness, and anxiety and school learning environment, child grade and learning disability, employment characteristics, and sociodemographic factors. We find that having a child attend a private school or school with above average instructional quality was associated with better mental health of parents. Hybrid schooling options offering both in-person and online learning was associated with poor parental mental health, as was working from home. Being female or experiencing job or income loss were associated with worse mental health while having older children, a bachelor's degree, or high income were associated with better mental health. Results can help inform school and workplace family supports as well as opportunities to reduce mental health strains at home from various policy options.

How Did School Meal Access Change during the COVID-19 Pandemic? A Two-Step Floating Catchment Area Analysis of a Large Metropolitan Area.

SARS-CoV-2 (COVID-19) resulted in school closures and contingencies across the U.S. that limited access to school meals for students. While some schools attempted to provide alternative meal access points where students or parents could pick up meals, many students-especially those in low-income households-lacked adequate transportation to these access points. Thus, physical proximity to meal access points was particularly important during the pandemic. In this study, we explore how school meal access changed during the COVID-19 pandemic, especially as it relates to race/ethnicity and socio-economic status. Taking into account both the "supply" (meal access points) and the "demand" (low-income students) for free meals, we employed a two-step floating catchment area analysis to compare meal accessibility in St. Louis, Missouri before and during the pandemic in the spring and summer of 2019 and 2020. Overall, while school meal access decreased during the spring of 2020 during the early months of the pandemic, it increased during the summer of 2020. Moreover, increased access was greatest in low-income areas and areas with a higher proportion of Black residents. Thus, continuing new policies that expanded access to school meals-especially for summer meal programs-could lead to positive long-term impacts on children's health and well-being.

Approaches for Ending Ineffective Programs: Strategies From State Public Health Practitioners.

Background: Public health agencies are increasingly concerned with ensuring they are maximizing limited resources by delivering evidence-based programs to enhance population-level chronic disease outcomes. Yet, there is little guidance on how to end ineffective programs that continue in communities. The purpose of this analysis is to identify what strategies public health practitioners perceive to be effective in de-implementing, or reducing the use of, ineffective programs. Methods: From March to July 2019, eight states were selected to participate in qualitative interviews from our previous national survey of US state health department (SHD) chronic disease practitioners on program decision making. This analysis examined responses to a question about "…advice for others who want to end an ineffective program." Forty-five SHD employees were interviewed via phone. Interviews were audio-recorded, and the conversations were transcribed verbatim. All transcripts were consensus coded, and themes were identified and summarized. Results: Participants were program managers or section directors who had on average worked 11 years at their agency and 15 years in public health. SHD employees provided several strategies they perceived as effective for de-implementation. The major themes were: (1) collect and rely on evaluation data; (2) consider if any of the programs can be saved; (3) transparently communicate and discuss program adjustments; (4) be tactful and respectful of partner relationships; (5) communicate in a way that is meaningful to your audience. Conclusions: This analysis provides insight into how experienced SHD practitioners recommend ending ineffective programs which may be useful for others working at public health agencies. As de-implementation research is limited in public health settings, this work provides a guiding point for future researchers to systematically assess these strategies and their effects on public health programming.

Actual Causes of Death in Relation to Media, Policy, and Funding Attention: Examining Public Health Priorities.

Despite numerous public health advancements over the last century, we continue to under-invest in prevention and public health efforts. As a result, one of the most challenging aspects of public health is prioritizing the use of limited resources. Building on the foundation of previous researchers, the goal of this exploratory study was to provide current estimates for the actual causes of death, media attention, policy focus, and research funding in the United States. In addition, we sought to calculate and compare media attention, policy attention, and research funding trends to better assess the nation's prioritization of health issues. Using a systematic approach, we searched available databases, including Media Cloud, Nexis Uni, Congress.gov, and the Department of Health and Human Services Tracking Accountability in Government Grants System from January 1, 2010-December 31, 2019 and compared how the actual causes of death in the United States align with health-related media attention, policy attention, and federal spending. Overall, our findings suggest that our priorities are not well-aligned with the actual causes of death. Certain actual causes appear to be consistently misaligned across media, legislative, and financial sectors (e.g., tobacco). This work highlights the importance of multiple strategies-media coverage, national legislation, and government spending-as indicators of public health attention and priorities. These results may inform discussions about how to best allocate U.S. public health resources to better align with the actual causes of death.

Network influences on the development and implementation of active transportation policies in six U.S. cities.

Many communities have prioritized policy and built environment changes to promote active transportation (AT). However, limited information exists on the partnerships and processes necessary to develop and implement such policy and environmental changes, particularly among organizations in non-health sectors. Within the transportation sector, metropolitan planning organizations (MPOs) are increasingly recognized as organizations that can support AT policies. This study examined inter-organizational relationships among MPOs and their partners working to advance AT policies in six U.S. cities. In fall 2015, an average of 22 organizations in each city participated in an online survey about partnerships with MPOs and other organizations developing and implementing AT policies. Measures included organizational characteristics and relational attributes including: level of AT policy collaboration, information transmission, resource sharing, and perceived decisional power. Descriptive network analysis and exponential random graph modeling were used to examine organizational attributes and relational predictors associated with inter-organizational collaboration in each network. MPOs served as collaborative intermediaries, connecting other organizations around AT policies, in half of the cities examined. Organizations in each city were more likely to collaborate around AT policies when partners communicated at least quarterly. In half of the cities, the probability of AT policy collaboration was higher when two agencies exchanged resources and when organizations had perceived decisional authority. Network analysis helped identify factors likely to improve partnerships around AT policies. Results may contribute to best practices for collaboration among researchers, practitioners, policymakers, and advocates across diverse sectors seeking to promote population-level physical activity.

State-Level Point-of-Sale Tobacco News Coverage and Policy Progression Over a 2-Year Period.

BACKGROUND: Mass media content may play an important role in policy change. However, the empirical relationship between media advocacy efforts and tobacco control policy success has rarely been studied. We examined the extent to which newspaper content characteristics (volume, slant, frame, source, use of evidence, and degree of localization) that have been identified as important in past descriptive studies were associated with policy progression over a 2-year period in the context of point-of-sale (POS) tobacco control. METHOD: We used regression analyses to test the relationships between newspaper content and policy progression from 2012 to 2014. The dependent variable was the level of implementation of state-level POS tobacco control policies at Time 2. Independent variables were newspaper article characteristics (volume, slant, frame, source, use of evidence, and degree of localization) and were collected via content analysis of the articles. State-level policy environment contextual variables were examined as confounders. RESULTS: Positive, significant bivariate relationships exist between characteristics of news content (e.g., high overall volume, public health source present, local quote and local angle present, and pro-tobacco control slant present) and Time 2 POS score. However, in a multivariate model controlling for other factors, significant relationships did not hold. DISCUSSION: Newspaper coverage can be a marker of POS policy progression. Whether media can influence policy implementation remains an important question. Future work should continue to tease out and confirm the unique characteristics of media content that are most associated with subsequent policy progression, in order to inform media advocacy efforts.

Evaluating centralized technical assistance as an implementation strategy to improve cancer prevention and control.

PURPOSE: In 2015-2016, the Comprehensive Cancer Control National Partnership provided technical assistance workshops to support 22 cancer coalitions in increasing human papillomavirus (HPV) vaccination uptake and increasing colorectal cancer (CRC) screening in their local communities. As national efforts continue to invest in providing technical assistance, there is a current gap in understanding its use as a strategy to accelerate implementation of evidence-based interventions (EBIs) for cancer prevention. The objective of this study was to evaluate the impact of technical assistance on the participants' knowledge, attitudes, and skills for implementing EBIs in their local context and enhancing state team collaboration. METHODS: Data were collected August-November 2017 using web-based questionnaires from 44 HPV workshop participants and 66 CRC workshop participants. RESULTS: Both HPV vaccination and CRC screening workshop participants reported changes in knowledge, attitudes, and skills related to implementing EBIs in their local state context. Several participants reported increased abilities in communicating and coordinating with partners in their states and utilizing additional implementation strategies to increase HPV vaccination uptake and CRC screening rates. CONCLUSIONS: Findings from this study suggest that providing technical assistance to members of comprehensive cancer control coalitions is useful in promoting collaborations and building capacity for implementing EBIs for cancer prevention and control.

Developing an evidence-based program sustainability training curriculum: a group randomized, multi-phase approach.

BACKGROUND: The emergence of dissemination and implementation (D&I) science has driven a rapid increase in studies of how new scientific discoveries are translated and developed into evidence-based programs and policies. However, D&I science has paid much less attention to what happens to programs once they have been implemented. Public health programs can only deliver benefits if they reach maturity and sustain activities over time. In order to achieve the full benefits of significant investment in public health research and program development, there must be an understanding of the factors that relate to sustainability to inform development of tools and trainings to support strategic long-term program sustainability. Tobacco control programs, specifically, vary in their abilities to support and sustain themselves over time. As of 2018, most states still do not meet the CDC-recommended level for funding their TC program, allowing tobacco use to remain the leading cause of preventable disease and death in the USA. The purpose of this study is to empirically develop, test, and disseminate training programs to improve the sustainability of evidence-based state tobacco control programs and thus, tobacco-related health outcomes. METHODS: This paper describes the methods of a group randomized, multi-phase study that evaluates the empirically developed "Program Sustainability Action Planning Training" and technical assistance in US state-level tobacco control programs. Phase 1 includes developing the sustainability action planning training curriculum and technical assistance protocol and developing measures to assess long-term program sustainability. Phase 2 includes a group randomized trial to test the effectiveness of the training and technical assistance in improving sustainability outcomes in 24 state tobacco control programs (12 intervention, 12 comparison). Phase 3 includes the active dissemination of final training curricula materials to a broader public health audience. DISCUSSION: Empirical evidence has established that program sustainability can improve through training and technical assistance; however, to our knowledge, no evidence-based sustainability training curriculum program exists. Therefore, systematic methods are needed to develop, test, and disseminate a training that improves the sustainability of evidence-based programs. TRIAL REGISTRATION: NCT03598114 . Registered 25 July 2018-retrospectively registered.

Toward optimal implementation of cancer prevention and control programs in public health: a study protocol on mis-implementation.

BACKGROUND: Much of the cancer burden in the USA is preventable, through application of existing knowledge. State-level funders and public health practitioners are in ideal positions to affect programs and policies related to cancer control. Mis-implementation refers to ending effective programs and policies prematurely or continuing ineffective ones. Greater attention to mis-implementation should lead to use of effective interventions and more efficient expenditure of resources, which in the long term, will lead to more positive cancer outcomes. METHODS: This is a three-phase study that takes a comprehensive approach, leading to the elucidation of tactics for addressing mis-implementation. Phase 1: We assess the extent to which mis-implementation is occurring among state cancer control programs in public health. This initial phase will involve a survey of 800 practitioners representing all states. The programs represented will span the full continuum of cancer control, from primary prevention to survivorship. Phase 2: Using data from phase 1 to identify organizations in which mis-implementation is particularly high or low, the team will conduct eight comparative case studies to get a richer understanding of mis-implementation and to understand contextual differences. These case studies will highlight lessons learned about mis-implementation and identify hypothesized drivers. Phase 3: Agent-based modeling will be used to identify dynamic interactions between individual capacity, organizational capacity, use of evidence, funding, and external factors driving mis-implementation. The team will then translate and disseminate findings from phases 1 to 3 to practitioners and practice-related stakeholders to support the reduction of mis-implementation. DISCUSSION: This study is innovative and significant because it will (1) be the first to refine and further develop reliable and valid measures of mis-implementation of public health programs; (2) bring together a strong, transdisciplinary team with significant expertise in practice-based research; (3) use agent-based modeling to address cancer control implementation; and (4) use a participatory, evidence-based, stakeholder-driven approach that will identify key leverage points for addressing mis-implementation among state public health programs. This research is expected to provide replicable computational simulation models that can identify leverage points and public health system dynamics to reduce mis-implementation in cancer control and may be of interest to other health areas.

Assessment of the Sustainability Capacity of a Coordinated Approach to Chronic Disease Prevention.

OBJECTIVE: This article outlines some factors that influenced the sustainability capacity of a coordinated approach to chronic disease prevention in state and territory health departments. DESIGN: This study involved a cross-sectional design and mixed-methods approach. Quantitative data were collected using the Program Sustainability Assessment Tool (PSAT), a 40-item multiple-choice instrument that assesses 8 domains of sustainability capacity (environmental support, funding stability, partnerships, organizational capacity, program evaluation, program adaptation, communications, and strategic planning). Qualitative data were collected via phone interviews. PARTICIPANTS: The PSAT was administered to staff and stakeholders from public health departments in 50 US states, District of Columbia, and Puerto Rico, who were involved in the implementation of coordinated chronic disease programs. Phone interviews were conducted with program coordinators in each state. MAIN OUTCOME MEASURE(S): Sustainability score patterns and state-level categorical results, as well as strengths and opportunities for improvement across the 8 program sustainability domains, were explored. RESULTS: On average, programs reported the strongest sustainability capacity in the domains of program adaptation, environmental support, and organizational capacity, while funding stability, strategic planning, and communications yielded lowest scores, indicating weakest capacity. Scores varied the most by state in environmental support and strategic planning. CONCLUSION: The PSAT results highlight the process through which states approached the sustainability of coordinated chronic disease initiatives. This process included an initial focus on program evaluation and partnerships with transfer of priority to long-term strategic planning, communications, and funding stability to further establish coordinated chronic disease efforts. Qualitative interviews provided further context to PSAT results, indicating that leadership, communications, partnerships, funding stability, and policy change were perceived as keys to success of the transition. Integrating these findings into future efforts may help those in transition establish greater sustainability capacity. The PSAT results and interviews provide insight into the capacity for sustainability for programs transitioning from traditional siloed programs to coordinated chronic disease programs.

Setting the agenda for a healthy retail environment: content analysis of US newspaper coverage of tobacco control policies affecting the point of sale, 2007-2014.

BACKGROUND: Tobacco control policies affecting the point of sale (POS) are an emerging intervention, yet POS-related news media content has not been studied. PURPOSE: We describe news coverage of POS tobacco control efforts and assess relationships between article characteristics, including policy domains, frames, sources, localisation and evidence present, and slant towards tobacco control efforts. METHODS: High circulation state (n=268) and national (n=5) newspapers comprised the sampling frame. We retrieved 917 relevant POS-focused articles in newspapers from 1 January 2007 to 31 December 2014. 5 raters screened and coded articles, 10% of articles were double coded, and mean inter-rater reliability (IRR) was 0.74. RESULTS: POS coverage emphasised tobacco retailer licensing (49.1% of articles) and the most common frame present was regulation (71.3%). Government officials (52.3%), followed by tobacco retailers (39.6%), were the most frequent sources. Half of articles (51.3%) had a mixed, neutral or antitobacco control slant. Articles presenting a health frame, a greater number of protobacco control sources, and statistical evidence were significantly more likely to also have a protobacco control slant. Articles presenting a political/rights or regulation frame, a greater number of antitobacco control sources, or government, tobacco industry, tobacco retailers, or tobacco users as sources were significantly less likely to also have a protobacco control slant. CONCLUSIONS: Stories that feature procontrol sources, research evidence and a health frame also tend to support tobacco control objectives. Future research should investigate how to use data, stories and localisation to encourage a protobacco control slant, and should test relationships between content characteristics and policy progression.