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Chapter 2: Describe the Program
Another early step in evaluation is to develop a clear and
succinct description of your program that will clarify the program's
purpose, activities, and capacity to decrease tobacco use and improve
health. This description is necessary for two reasons:
- To ensure that the stakeholders share the same level of understanding
about the program's components, implementation, and intended effects.
- To foster strategic thinking about the program.
In many cases, the process of negotiating with stakeholders to formulate
a concise program description will produce benefits long before data are
available to measure program effectiveness.18
Once you have appropriate stakeholders at the table, you need to make
sure that they all have the same knowledge and information about the program
and that they view the program from a shared frame of reference. To do so,
you will need to describe the program's components and its possible effects
clearly. This program description should include the need for the program,
its expected effects, the proposed activities of the program, the resources
available to conduct the program, the program's stage of development, the
social and political context in which the program will be implemented, and a
working logic model. `
To create change effectively, you need to have clearly linked goals,
objectives, and strategies. By looking at your program in this manner you
can determine whether an action or event has the potential to cause the
desired effect. Doing so may also enable you to identify gaps or missing
links between your program's actions and its desired effects.
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The description of the need for your program should explain the health
problem addressed by the program. In it, you should answer the following
questions:
- What is the health problem and its consequences for the state or
community?
- What is the size of the problem overall and in various segments of the
population?
- What are the determinants of the health problem?
- Who are the target groups?
- What changes or trends are occurring?
The description of the need for your program should include an analysis
of the magnitude of tobacco use and related morbidity and mortality in
various segments of the population in your state. Do not overlook the
economic burden of tobacco use in your state. Analyses of the estimated
costs associated with tobacco-related morbidity and mortality will further
clarify the need for your program. Smoking Attributable Morbidity,
Mortality, & Economic Costs (SAMMEC) software version 3.0 can be used to
calculate deaths, years of potential life lost, direct health care costs,
indirect mortality costs, and disability costs associated with cigarette
smoking. SAMMEC is designed to calculate the health and economic burden of
disease from tobacco use at the national and state levels for adults 35
years or older. (Additional information on SAMMEC is in Appendix A.)
Ideally, you should use state or regional data in combination with
national data to justify the need for a comprehensive tobacco-use prevention
and control program. It is important to identify tobacco-related health
disparities among specific population segments or communities when
discussing the need for your program. This is a first step in reaching
populations disproportionately impacted by tobacco-related morbidity and
mortality.
In accordance with Healthy People 2010,4 disparities
include but are not limited to differences that occur by gender, race or
ethnicity, education or income, sexual orientation, geography, or disability
status. Identifying and eliminating the disparities related to tobacco use
and its effects among different population groups is the fourth goal of the
CDC's National Tobacco Control Program (NTCP). This goal is unique in that
it is both an independent objective and an overarching priority within the
other three NTCP goals. For example, a key goal of a state program may be to
decrease exposure to ETS. Upon closer examination, the state may find that a
particular subgroup or community has a significantly higher prevalence of
ETS exposure than the general population. Once this has been established,
the state could address the tobacco-related health disparities of this
particular subgroup by ensuring the development and implementation of
targeted interventions.
To assist you in identifying disparate populations in your state, CDC is
in the process of compiling supporting information for the fourth goal.
These materials include a logic model, sample objectives, indicators, and
potential data sources. The section to follow provides a starting point for
the identification of disparate populations in your state. Additional
materials will be disseminated by CDC, as available.
Identifying high-risk and historically underserved populations will help
program managers, staff, and stakeholders in focusing interventions when
state data specific to the health status of diverse communities are not
complete. This process requires a working knowledge of the make-up of your
state population.
The State Data Center (SDC) Program is one of the Census Bureau's longest
and most successful partnerships. It is a cooperative program between the
states and the Census Bureau that was created in 1978 to make data available
locally to the public through a network of state agencies, universities,
libraries, and regional and local governments. The program's mission is to
provide easy and efficient access to U.S. Census Bureau data and information
through a wide network of lead, coordinating, and affiliate agencies in each
state, the District of Columbia, and the outlying areas of American Samoa,
Guam, Northern Mariana Islands, Puerto Rico, and the Virgin Islands.
The SDCs are official sources of demographic, economic, and social
statistics produced by the Census Bureau. The SDCs make these data
accessible to state, regional, local, and tribal governments and to
nongovernmental data users at no charge or on a cost-recovery or
reimbursable basis, as appropriate. The SDCs also provide training and
technical assistance in accessing and using Census Bureau data for research,
administration, planning, and decision making by local governments, the
business community, and other interested data users. Additional information,
including contact information for your state, is available at
www.census.gov/sdc/www.
Program managers, staff, and stakeholders are also encouraged to consider
available national and state data addressing the health status of specific
groups. For example, indicators of tobacco-related disparities include, but
are not limited to, prevalence, access to effective and appropriate
cessation programs, issues of addiction and relapse, morbidity, mortality,
current policies (e.g., policies related to exposure to ETS, youth access,
health insurance), and tobacco industry marketing (e.g., targeted
advertising and promotions). Other indicators are capacity and
infrastructure (e.g., availability of researchers or research data; the
availability of appropriate and effective programs, community leadership,
organizations, and networks). Sources of data for these indicators include,
but are not limited to, national and state surveys, regional or community
surveys, case studies, expert panels, and stakeholder panels. The
identification of disparate populations is a collaborative process and
should involve a diverse group of stakeholders.
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You should also describe the goals and objectives of your program. To be
considered successful, what does your program need to accomplish? The answer
to this question depends on what is realistic and achievable given your
resources and the maturity and comprehensiveness of the program. Clearly
defined objectives are critical to program evaluation because they identify
the targets by which you will measure your program's progress.
A goal expresses the overall mission or purpose of a program. The
goals of a program will guide its development. In tobacco prevention and
control, the overarching purpose is to reduce tobacco-related morbidity and
mortality. As previously noted, comprehensive tobacco control programs seek
to reduce disease, disability, and death related to tobacco use by
fulfilling the four CDC program goals:
- Preventing the initiation of tobacco use among young people.
- Promoting quitting among young people and adults.
- Eliminating nonsmokers' exposure to environmental tobacco smoke (ETS).
- Identifying and eliminating the disparities related to tobacco use and
its effects among different population groups.
Objectives are statements describing the results to be achieved
and the manner in which these results will be achieved. In tobacco control,
program objectives should be conceptually linked at the national, state, and
local levels. In other words, objectives at the local level should not be
selected in isolation, but should be logical extensions of national and
state objectives.
The specific objectives outlined in Healthy People 20104
are a starting point for tobacco control efforts. CDC encourages NTCP
partners to use the objectives outlined in Healthy People 2010 as an
initial guide for focusing state activities. The complete list and a
discussion of Healthy People 2010 tobacco objectives are available
online at
www.health.gov/healthypeople.
Good objectives are specific and measurable. Well-written and clearly
defined objectives are important because they—
- Set program priorities.
- Aid in monitoring progress toward achieving goals.
- Set targets for accountability.
A well-written and clearly defined objective is SMART: Specific,
Measurable, Achievable and Ambitious, Relevant,
and Time bound.
| Specific:
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It identifies a specific event or action that will take place. |
| Measurable:
|
It quantifies the amount of change to be achieved. |
Achievable
and Ambitious: |
It is realistic given available resources and plans for
implementation, yet challenging enough to accelerate program efforts. |
| Relevant:
|
It is logical and relates to the program's goals. |
| Time-bound:
|
It specifies a time by which the objective will be achieved. |
Here is an example of a SMART objective:
In state X, increase the percentage of adult nonsmokers who report they
have not been exposed to cigarette smoke in the prior 7 days from 40% in
2001 to 50% in 2010.
- The objective is specific because it identifies a defined
event: adult nonsmokers will not be exposed to cigarette smoke.
- The objective is measurable because it specifies a baseline
value and the quantity of change the intervention is designed to achieve:
from 40% to 50%. It would be worthwhile to note whether there is already a
data source for the objective.
- The objective is achievable because it is realistic given the
10-year time frame and ambitious because achieving the goal would
be a significant accomplishment.
- The objective is relevant because it relates to the elimination
of exposure to ETS.
- The objective is time-bound because it provides a specified
time by which the objective will be achieved (from 2001 to 2010).
There are two general types of objectives: process and outcome.
Process objectives describe program activities. They specify actions to
be taken and are useful in measuring program implementation. Outcome
objectives are the intended results of program activities. They quantify
anticipated program effects by specifying "the amount of change expected for
a given health problem/condition for a specified population within a given
time frame."23 Outcome objectives are often divided into
short-term, intermediate, and long-term objectives. They generally state
"who will achieve how much of which outcome by when." "Who" is typically
stated as a population; "how much" as a percentage or target amount; and "by
when" as a month, or year(s), or period after the program begins.24,25,26
Objectives must logically link to each other. For one long-term outcome
objective, there may be several intermediate outcome objectives. Similarly,
there may be a number of process objectives for each short-term outcome
objective. Below are examples of outcome and process objectives specific to
the goal of eliminating exposure to ETS. These examples assume that baseline
data collected to identify tobacco-related disparities among population
groups indicated that African American adults and children were
disproportionately burdened by tobacco-related morbidity and mortality.
Complete sets of example objectives for two goal areas—preventing the
initiation of tobacco use among young people and promoting smoking cessation
among young people and adults—can be found in Appendices B and C.
Program goal
Eliminate exposure to environmental tobacco smoke in state A.
Sample long-term objectives for eliminating exposure to ETS
- Decrease the percentage of adult nonsmoking African Americans exposed
to ETS at work from X% in 2002 to Y% in 2007.
- Increase the percentage of African Americans younger than age 18 who,
during the previous 7 days, have not been in the same room with someone
who was smoking from X% in 2002 to Y% in 2007.
Sample intermediate objectives
- Increase the percentage of African American adults who are employed at
work sites with a formal policy that prohibits smoking at the workplace
from X% in 2002 to Y% in 2005.
- Increase the percentage of African American homes that have household
smoking bans from X% in 2002 to Y% in 2005.
- Increase the percentage of African American adults who report asking
someone not to smoke around them in order to avoid exposure to their
tobacco smoke from X% in 2002 to Y% in 2005.
Sample short-term objectives
- Increase the percentage of adults who believe that breathing
secondhand smoke is harmful to them from X% in 2002 to Y% in 2003.
- Increase the percentage of adults who believe smoking should not be
allowed in workplaces from X% in 2002 to Y% in 2003.
- Increase the percentage of adults who believe that breathing
secondhand smoke is harmful to children from X% in 2002 to Y% in 2003.
Sample process objectives
- By March 2002, design a media campaign about the health effects of ETS
and the importance of smoke-free homes and automobiles, with tailored
messages for African American families.
- By April 2002, negotiate placement of at least two billboards on the
harmful effects of ETS in each of the eight major African American
communities in the state.
- By August 2002, publish at least three antitobacco newspaper articles
on ETS in at least two community newspapers in the state.
- By May 2002, develop model voluntary smoke-free policies tailored to
work sites with African American employees.
- By July 2002, distribute sample voluntary smoke-free policies to at
least 50 % of work sites in communities with African American populations
of more than 5,000.
SMART objectives should be rooted in well-planned program activities.
Like program objectives, program activities should be linked at the local,
state, and national levels to maximize their effect.
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Program activities describe what the program is actually doing to affect
the health problem. For example, possible tobacco control activities to
reduce youth smoking rates might include counter-marketing, retailer
enforcement, and school-based prevention programs. It is important to
describe the different activities, determine how they relate to each other
and to the program's goals, and identify the different steps or actions
expected to occur. Program activities are often specified in a series of
process objectives.
States often describe their tobacco control efforts using a program
framework. A program framework such as the National Tobacco Control Program
(NTCP) Matrix (Figure 2) clearly outlines program components and links them
to evidence-based strategies and goals. The NTCP Matrix can apply to
planning and implementing state and local activities. Regardless of which
goal you are focusing on, surveillance and evaluation is a necessary
component.
States may choose to organize their programs according to funding
categories for budget-planning purposes. CDC's Best Practices for
Comprehensive Tobacco Control Programs describes nine components of
comprehensive tobacco control programs.2 You may want to consider
these when describing your program:
- Community programs to reduce tobacco use.
- Chronic disease programs to reduce the burden of tobacco-related
diseases.
- School programs to prevent or delay the onset of smoking during the
school year.
- Enforcement of tobacco control policies to enhance their efficacy.
- Statewide programs to increase the capacity of local programs and
expand their reach.
- Counter-marketing efforts to counter pro-tobacco influences and
increase pro-health messages and influences.
- Cessation programs to assist youth and adult smokers to quit.
- Surveillance and evaluation activities to monitor and document
implementation and achievement for stakeholders.
- Administration and management to facilitate collaboration and
coordination among public health program managers, policymakers, and other
state agencies.
In many instances, program components highlighted in the NTCP Matrix and
Best Practices overlap. It is worthwhile to consider both approaches
prior to describing program activities.
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Resources necessary to conduct a tobacco control program include money,
staff, time, materials, and equipment. Program evaluation activities often
include accountability for resources to funding agencies and stakeholders.
Therefore, you should clearly identify the resources you need to administer
the program.
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