Tri-County Health Department
Implementing a noncompetitive funding process to engage school district partners in tobacco prevention
Tri-County Health Department (TCHD) is the largest local health department in Colorado, serving more than 1.4 million residents of Adams, Arapahoe, and Douglas Counties. TCHD serves a large and diverse region, including 15 school districts serving 271,520 students, approximately one-third of whom are eligible for free or reduced-price lunch. While great strides have been made in lowering smoking prevalence and reducing exposure to secondhand smoke, reducing and eliminating youth initiation remains a priority.
The overarching goal of the TCHD Tobacco Prevention Program is to decrease youth tobacco use and initiation by 50%, with a particular emphasis on populations experiencing a high burden of tobacco use and with low socio-economic status. The practice objective was to engage a minimum of 12 school districts to strengthen, communicate, and enforce tobacco-free schools policies while reducing youth access and exposure. Goals and objectives are in line with the Colorado State Tobacco Education and Prevention Partnership funding program, which funds TCHD's tobacco prevention efforts.
TCHD structured a noncompetitive subcontracting model for school districts in Adams, Arapahoe, and Douglas counties to strengthen and implement comprehensive tobacco-free schools policies with an evaluation component consistent with Colorado's Tobacco-Free Schools Law, and Teen Tobacco Use Prevention Act utilizing the RMC Health 5 Essential Components of Effective Tobacco Prevention for Schools (http://rmc.org/wp-content/uploads/2015/08/FINAL-Essential-Components-of-Effective-Tobacco-Prevention-for-Schools-5_1.pdf) .
The subgrant practice requires partnering school districts to designate one staff member to serve as the grant coordinator and primary point of contact between TCHD and the school district on all tobacco-grant related matters. Grant dollars can be used to support this position in a salaried or contract capacity. The subgrant process requires response to a non-competitive RFA, which supports an opt-inâ€ approach that indicates a level of readiness. An annual work plan is developed and agreed upon by both parties. Approved work plans are included in each subgrant contract and are built into quarterly reports. Payment is based on reimbursement of incurred costs, following a review to ensure alignment with state-level grant requirements. Most expenses fall under the approved categories of staff time and benefits, mileage reimbursement, office supplies, educational materials, printing/copying, refreshments for meetings, youth incentives, and tobacco-free signage.
TCHD provided technical assistance, including regular site visits and phone calls with staff in all participating districts. Quarterly capacity-building trainings were held every quarter throughout the funding period. These trainings provided networking and educational opportunities through guest speakers, resource demonstrations, and peer sharing.
The initial funding cycle was 2012-2015. Twelve school districts received awards to assess and strengthen their Tobacco-Free Schools Policies using the Tobacco-Free Schools Policy Checklist Toolkit, a collaborative project of RMC Health, the Colorado Department of Public Health & Environment's State Tobacco Education & Prevention Partnership and local health agencies throughout Colorado. TCHD completed objective assessments for all school districts, and districts used their assessment results to guide their tobacco prevention plans. TCHD then completed the same objective assessment process for all districts to measure changes in policy provisions. At the end of the first three-year funding cycle, 10 school districts strengthened district-level tobacco-free schools policies (including approval and adoption by District Boards of Education), resulting in more consistent implementation and enforcement, including alternatives to suspension and support for cessation. Two districts were successful in policy change at the school level; one strengthened language in the high school code of conduct manual, and the second added non-punitive options for consequences of tobacco use to their discipline matrix. Healthy Kids Colorado Survey (Colorado's version of the Youth Risk Behavior Survey) data in 2015 showed reduced youth tobacco use compared to 2013 in two of TCHD's three counties for which data are available.
Implementing a process to formalize the practice of sub-granting significant funds ($25,000-$40,000) to school district partners to promote collaborative achievement of program objectives was key to influencing sustainable change. By design, the process allows a funded school district to conduct policy and implementation work according to its own practices, builds on shared goals of supporting healthy students, establishes and invests in organizational relationships designed to build capacity and minimize power dynamics, and maximizes efficiency of allocated funds. The willingness of TCHD to include organizational learning as a goal and expectation was also key to our success.
Many local organizations play important roles in improving student health. Collaborating with diverse school districts ensures a variety of perspectives are considered when implementing evidence-based strategies. TCHD believes focusing efforts toward policy change will have the most systematic and long-term effect on reducing prevalence of tobacco use among young people.
TCHD's website is www.tchd.org.
The noncompetitive subgrant model is both responsive and innovative, building on a pilot of this strategy initiated by TCHD with a Communities Putting Prevention to Work grant from 2010-2012. TCHD recognizes that school districts are in a strategic position to influence a student's ability to make healthy choices. According to the 2013 Healthy Kids Colorado Survey, 10.7% of Colorado high school students reported smoking cigarettes on one or more of the past 30 days. Nearly 22% of high school students reported they had ever smoked a whole cigarette. When broken down by age, youth reporting having ever smoked a whole cigarette more than doubles from age 15 and under (16.2%) to age 18 and older (34.4%). One-third (34.6%) of students attending an alternative school reported smoking cigarettes on one or more of the past 30 days, thus early intervention in middle school is important to prevent and reduce high school tobacco use. This process was begun in 2013 to influence student health through school policy and environment changes around tobacco.
According to the Colorado Department of Education (CDE), the total number of pre-school through grade 12 students enrolled in the TCHD jurisdiction in 2013 was 269,524. The 12 districts who participated in the first funding cycle represented nearly 62% of these students. In the current funding cycle, CDE lists the 2015 student total at 271,520. Currently, TCHD is funding 13 school districts, increasing the student population being served by this grant to 76.6%. One half of public school students in the three counties (49.5%) are non-White racial/ethnic minorities, and more than one third (37.0%) are eligible for free and reduced-price lunch. Participating school district size ranges from 176 students to more than 66,000.
The Colorado Department of Public Health and Environment administers local grants funded through Colorado state tax revenue on cigarettes and other tobacco products. TCHD began receiving these funds upon the program inception in 2005. Previously, TCHD did not work with school districts on tobacco-free schools policies; most tobacco control work was focused on promoting cessation. No funds were subgranted, and TCHD led all community-based tobacco control work. When a new funding cycle began in 2012, TCHD reached out to school districts to collaborate on youth prevention work through tobacco-free schools policies, and a subgrant model was proposed to promote efficiency, build capacity, and allow policy change to be made from within the organization.
The non-competitive subgrant strategy serves to enhance and prioritize the capacity of local school districts to strengthen, communicate, and enforce tobacco-free schools policies. The funding and resulting outcomes were issue-focused, but the process of creating a noncompetitive funding option allowed for a reciprocal relationship between the two organizations. By focusing on district capacity, TCHD minimizes dependence on the local health department for communication and enforcement of Tobacco-Free Schools laws. This is a better practice because it is a collaborative, capacity-building approach to reduce the burden of preventable disease. We are aware of no other health department in Colorado using a similar practice of sharing financial resources with external partners in the absence of a mandate. The process of bringing together multiple school districts to jointly impact tobacco prevention in a way that invites collaboration and joint learning has generated new enthusiasm for addressing this public health burden.
While school-based policies by themselves have not been shown to be effective, comprehensive policies that include tobacco as a subcomponent within broader school and community wellness policies have been proven as an effective tobacco control strategy to prevent youth tobacco use initiation. A tobacco-free schools policy supports safe schools, promotes clean indoor air, and creates an environment where students are encouraged to make healthy choices.
The primary goal of this ongoing strategy is to reduce youth initiation of tobacco. Recognizing that responsibility for health should not be limited to health-related entities, TCHD set an objective to engage no fewer than 12 school districts in the development and consistent implementation of Tobacco-Free Schools Policies. The organization interacts with school districts through many of its programs, and has a history of working collaboratively on health-related issues. Through previous programs, TCHD's Strategic Partnerships Manager had built a strong relationship with many superintendents. We first reached out to these superintendents about the public health impact of tobacco, youth usage of tobacco, and TCHD's goals around tobacco-free schools and preventing youth initiation. The program was proposed to all districts, and all were given the opportunity to request the noncompetitive funding.
The subgrant process was determined the most appropriate tactic to enhance existing partnerships by creating a source of funds to support scientifically-sound, well-designed strategies that have a high potential for replication in school-based settings. All public school districts in Adams, Arapahoe, and Douglas counties were eligible to apply for funds. If a school district prefers another organization to apply for funds on its behalf, this is allowable. Such organizations must have the signature of the district superintendent illustrating district support and willingness to participate. For example, one district preferred the school-based healthcare provider be the grant recipient on the district's behalf.
The timeframe for the practice has run on concurrent 3-year cycles. The first cycle was 2012-2015, and we are midway through the second cycle that runs 2016-2018. These are consistent with the three-year funding cycles of TCHD's grant from the Colorado Department of Public Health and Environment. Funds are guaranteed only one year at a time, and are dependent upon receipt of funds by TCHD from the Colorado Department of Public Health and Environment.
The relationships established and trust built with school district partners as a result of this process has added depth to our work. Process feedback from partners has resulted in improved reporting forms, and user driven content for technical assistance and professional development at quarterly meetings.
This practice is primarily a collaboration between the local health department and the school districts. Additional stakeholders include the Colorado Department of Public Health and Environment, TCHD's funder; RMC Health, a national technical assistance provider headquartered in metro Denver who provides assistance and training on tobacco-free schools best practices; nonprofit and community-based organizations in each school district, including school-based healthcare providers, PTOs, and district foundations. The American Lung Association has been a lead partner with TCHD and all school districts in support of cessation opportunities for students and staff.
Start-up costs associated with this practice are primarily in salary for staff time. TCHD staff dedicated time to write the noncompetitive RFA, review applications and work plans, and work collaboratively with districts to finalize work plans. Refreshments were provided at the initial superintendent meeting and continue to be provided at quarterly training meetings. Grant funds total approximately $350,000 for the first 12 districts participating.
The objective was to engage no fewer than 12 school districts in the development and consistent implementation of Tobacco-Free Schools Policies utilizing a noncompetitive subgrant model to achieve the larger goal of preventing youth initiation of tobacco. Evaluation of the subgrant process effectiveness comes from the following sources: 1) qualitative progress reports submitted by funded partners, 2) an objective policy analysis tool, 3) structured dialogue at quarterly meetings, and 4) Healthy Kids Colorado Survey data (Colorado's version of the school-based Youth Risk Behavior Survey).
1) Quarterly and annual reports submitted by funded partners provide documentation of accomplishments, challenges, and strategies to address challenges. Accomplishment examples include documentation of strengthened policies, integration of tobacco-free messages into existing activities, dedicated tobacco-free page on district website, cessation programs offered for students, professional development for school staff, installation of new or upgraded signs, tobacco-free messages placed on district school buses, and engaging students in prevention activities such as Kick Butts Day. Ongoing challenges include competing health priorities (mental health, asthma, marijuana use), competing education priorities (focus on testing, days are already full), and staff turnover. Strategies to address these challenges include integrating strategies into existing health promotion efforts such as classroom instruction, professional development for school staff and parents on emerging trends affecting youth, and expectations for enforcement. These reports also provide evidence that the subgrants were implemented as proposed, and document justification for proposed modifications.
2) Pre and post policy analysis during the first 3 year funding cycle documented successful district-level policy change in 10 of the 12 participating districts. The remaining districts were successful in policy change at the school level. Policy changes fell under categories of tobacco-free environment, policy organization, enforcement, and prevention/treatment. Examples included expanding the definition of tobacco products to include electronic devices used to deliver nicotine; a policy that is in effect 24 hours a day, 365 days a year; dress code language that prohibits wearing of tobacco related or promoting items for students, staff, and visitors; explicit consequences for violations, and tobacco education training for teachers and staff.
3) Structured dialogue at quarterly meetings ensures we are collecting data for learning, not just reporting. All funded school districts participate in quarterly meetings. Focused conversations and group process activities solicit sharing of successes and hardships, and help maintain enthusiasm for the work.
4) Healthy Kids Colorado Survey data, available statewide and by county beginning in 2013, provide prevalence of youth tobacco use as well as other risk and protective factors such as ease of access (risk factor) and school involvement (protective factor). Data from 2013 are available for all three of TCHD's counties, however 2015 data are only available for two of three counties as one county did not participate. Two survey points for Adams and Arapahoe counties indicate a decrease in tobacco use among high school students that is promising. We are eager to see a third data point following the 2017 survey to determine whether this will prove to be a significant trend.
In 2013, 21.8% of Colorado high school students reported having ever smoked a cigarette, and this decreased to 20% in 2015. In Arapahoe and Adams Counties, the prevalence was 19.8% and 24.5% respectively in 2013, which had decreased to 14.6% and 17.7%, respectively, in 2015. This decrease in youth initiation is promising, and we are pleased that our counties have shown reductions greater than the State as a whole.
In 2013, the percentage of Colorado high school students who reported smoking on one or more of the past 30 days (current smoker) was 10.7%, reducing to 8.6% in 2015. In Arapahoe and Adams Counties, the prevalence of current smoking was 8.5% and 11.1%, respectively, in 2013, and 6% and 7.2%, respectively in 2015.
In 2013, the percentage of Colorado high school students who reported using chew, snuff, or dip on one or more of the past 30 days was 6.4%, reducing to 4.9% in 2015. In Arapahoe and Adams Counties, the prevalence of smokeless tobacco use was 4.3% and 6.2%, respectively, in 2013, and 3.5% and 5.9%, respectively, in 2015.
We find these initial results very promising given the strategic investment of noncompetitive grant funds to address tobacco prevention in school districts serving these counties. We have seen a reduction in student use as well as initiation of tobacco.
Qualitative data are also utilized for process improvement, and several process adjustments have been made as a result of partner progress reports. The most valuable has been restructuring the reporting template. Modifications included fewer open ended questions, incorporating the work plan with space to describe progress under each activity, and the addition of new questions to capture achievements beyond the agreed-upon work plan. Informal feedback indicated that these change were helpful in ensuring focus on the objectives of the grant, delineating accountability for different tasks, and creating a clear historical timeline for the purposes of record keeping and orienting new staff to the process.
While stronger policies are the goal, we recognize that it is equally important to build a constituency that will promote policy change and monitor its effective implementation. The subgrant approach aims to engage and prepare school districts to strengthen their existing tobacco-related policies, and to develop and implement plans for implementation and enforcement of those policies. This model has resulted in strengthened district-level policies, increased health education, and greater capacity within district staff to influence change. Tobacco prevention is just one component of comprehensive school wellness. A school district team that demonstrates success in tobacco prevention, both environmentally and educationally, is well equipped to apply the process to other components of school health.
Through this process, TCHD has learned many lessons. School districts often have many layers in the process of adopting new policies, and this can be a challenge to moving forward with changes at the district level. However this is one of the leading reasons to utilize a subgrant process; policy change coming from within the district can be more successful because it is an internal process led by staff who understand district practices. We have also learned the importance of listening to partners and engaging them in the development of programs targeted to their communities. We engaged our school district partners in the development of work plans and in the structure of the funding. This fosters partner buy-in.
We have also learned lessons in relation to partner collaboration, specifically with school districts. It is essential to engage and support districts on multiple levels, from parent organizations and wellness staff, to superintendents and district boards. School district staff know what strategies will work best in their own district. They have many competing priorities and limited resources to dedicate to new initiatives. Additionally, ongoing communication and structured networking opportunities during trainings, quarterly meetings, and site visits structured for joint learning are worthwhile to support increased capacity and collaboration.
This subgrant model is designed to build sustainable capacity within school districts and sustainable policy change to support healthy students, thus reducing dependence on inconsistent grant funding sources. School districts are committed to the health of their students, and have shown a commitment to sustaining the outcomes through implementation and enforcement of tobacco-free schools policies adopted through this process.