As public health funding is increasingly threatened, a better understanding is needed about how periods of funding uncertainty impact program staff, activities, and outcomes. In North Carolina, 2 years of uncertainty and threats of funding cuts for a statewide youth tobacco prevention initiative contributed to reduced grantee morale and confidence about achieving program goals, displaced focus from core program activities, and caused premature loss of personnel, resulting in substantially reduced program activities and outcomes. The range of negative impacts of funding uncertainty and threats highlights the need for programs to create an infrastructure to support ongoing sustainability planning and activities

Goldstein, A.O.

McCullough, A.

Ranney, L.M.

Simons, D.J.

Carolina Digital Repository

‘‘The Job Has Become Advocating for theJob’’: Threats to Funding DramaticallyInfluence Program OutcomesAnna McCullough, MSW, MSPH1, Leah M. Ranney, PhD1,Daniel J. Simons, MA1, and Adam O. Goldstein, MD, MPH1AbstractAs public health funding is increasingly threatened, a better understanding is needed about how periods of funding uncertaintyimpact program staff, activities, and outcomes. In North Carolina, 2 years of uncertainty and threats of funding cuts for a statewideyouth tobacco prevention initiative contributed to reduced grantee morale and confidence about achieving program goals, dis-placed focus from core program activities, and caused premature loss of personnel, resulting in substantially reduced programactivities and outcomes. The range of negative impacts of funding uncertainty and threats highlights the need for programs tocreate an infrastructure to support ongoing sustainability planning and activities.Keywordsprogram sustainability, program funding, advocacy, tobacco controlIntroductionIn 2001, North Carolina established the Health and WellnessTrust Fund (HWTF), with 25% of North Carolina’s MasterSettlement funding, to reduce and prevent youth and youngadult tobacco use.1 In 2003, HWTF launched a statewide TeenTobacco Use Prevention and Cessation Initiative (Teen Initia-tive) that engaged youth in community and school-based pro-grams focused on education, prevention, and policy andenvironmental change. Coupled with a statewide media cam-paign, the Teen Initiative contributed to dramatic declines andhistorically low youth smoking rates.2 Despite documentedsuccess, in May 2011, the North Carolina General Assemblyabolished the HWTF, effective June 30, 2011; 1 year of non-recurring funds for youth tobacco prevention shifted to theNorth Carolina Department of Health and Human Services(DHHS) as part of the 2011 to 2013 biannual state budget act.Approximately 3 months passed between the initial threat offunding cuts in 2011 and the decision to abolish the HWTF,creating a period of sustained uncertainty for HWTF programgrantees. The 2-year state budget adopted in 2011 shifted fundsto DHHS for only fiscal year (FY) 2012 (July 1, 2011, to June30, 2012), sustaining youth tobacco prevention grantee effortsfor that year with the possibility that an additional year’s fund-ing would be provided in the annual budget adjustment processconducted in 2012. This possibility created an atmosphere ofcontinued uncertainty for program staff and grantees throughmost of FY 2012. Ultimately, the FY 2013 state budget allo-cated drastically reduced tobacco cessation and preventionfunding, essentially dismantling the statewide youth preventioninfrastructure built by HWTF and sustained by DHHS throughFY 2012.Eliminating state tobacco control programs is associatedwith reductions in key program outcomes, including reducedawareness of countermarketing campaigns and increased ado-lescent susceptibility and use.3-5 However, little is known abouthow threats of funding cuts and periods of uncertainty about thefuture of an established program, such as those experienced inNorth Carolina, may impact public health programs’ abilities toimplement core activities and achieve program goals. As stateand federal funding for public health programs is increasinglyuncertain, improved understanding of how such periods ofuncertainty may impact programs can inform improved pro-gram sustainability planning. We present findings from a pro-cess and outcome evaluation of the North Carolina youthtobacco prevention programs over a 3-year period in whichprogram funding was secure, threatened, transferred to anotherentity, and ultimately drastically reduced.1 Department of Family Medicine, School of Medicine, University of NorthCarolina at Chapel Hill, Chapel Hill, NC, USACorresponding Author:Anna McCullough, Department of Family Medicine, School of Medicine,University of North Carolina at Chapel Hill, 590 Manning Drive, CB #7595,Chapel Hill, NC 27599, USA.Email: annamc@unc.eduMethodsIndependent evaluation data for FY 2010 to 2012 are presented.Evaluation data collected from program grantees via a web-based reporting tool and surveys included quantitative processand outcome measures related to programmatic foci (eg, youthempowerment, youth access, and smoke-free policy adoption)and qualitative data (eg, descriptions of youth empowermentactivities). In April 2012, 2 focus groups were conducted with atotal of 15 grantees to explore experiences related to commu-nicating with policy makers about the program. Focus groupswere audio-recorded and transcribed; transcripts were loadedinto MAXQDA 10 (VERBI Software, Marburg, Germany) andanalyzed using a deductive coding approach.ResultsOverall programmatic activity declined 15% in the last quarterof FY 2011 compared to the last quarter of FY 2010, withsubstantial decreases in key program areas including youthempowerment and point-of-sale efforts as HWTF funding wasunder threat. Youth engagement (a primary program focus)declined 13% between January 2011 and January 2012 amidcontinued uncertainty about program funding. Granteesreported decreased confidence in achieving programmaticgoals in the second half of both FY 2011 and FY 2012, asfunding cuts were threatened or impending. Several granteesleft their positions in FY 2012, resulting in a premature end toprogram activities and incomplete final evaluation reporting bymore than 25% of grantees.Focus group results illustrated funding threats’ negativeimpact on grantees’ morale and perceived ability to effectivelyimplement programs. As funding cuts were threatened, manygrantees reported a perceived need to shift their time and energyto educating policy makers in an effort to sustain program fundingto the detriment of core program activities and youth engagement.This past year . . . my action plan hasn’t even been looked atbecause everything that we had intended to do was put on holdbecause of reaching out to elected officials and trying to get themto save the program.I really feel like my job has shifted from being working with youtheducating other youth about tobacco prevention to really fightingfor our job.Grantees reported significant frustration with this shift infocus and with perceived barriers to effectively communicatingwith policy makers. Many grantees described a significant bar-rier related to state policies prohibiting the use of stateresources for lobbying activities, describing feeling stymiedby the ‘‘fine line’’ between educating and lobbying.It’s hard as a county employee to do some of the outreach . . . Youhave to be very careful what you do on work time, what you sendout, how you send it out, to not cross that line between advocacyand lobbying.Many grantees described frustration that their efforts toreach policy makers often went unanswered, saying that thelack of response made them question their communicationefforts and made it difficult to keep youth engaged in effortsto communicate with policy makers.We send stuff out, but we don’t get feedback back. So, we don’tknow what’s working and what’s not. I mean, I send e-mail, I sendletters, I send them copies of press releases, but I’m not hearingback from them . . .Some grantees highlighted a lack of guidance at the programlevel as a barrier to effective communication with policymakers; grantees who had been with the program for severalyears focused on inconsistent emphasis on policy maker edu-cation over the years, whereas newer grantees described relyingon guidance from external advocacy groups in the absence ofprogram-level guidance.Until funding was in jeopardy, I never . . . ever considered my jobgetting in touch with legislators . . . my job was working with youthand teen tobacco prevention. But, I feel like the job has becomeadvocating for the job.I think that Health and Wellness could have done more [to] encour-age us to do the things within our parameters to contact our legis-lators or . . . We probably should have been doing that the wholetime so that they always knew how important this program is.DiscussionOur findings demonstrate that even the threat of fundingloss, well in advance of cuts being implemented, canadversely impact public health programs. In North Carolina,2 years of uncertainty about future funding for the statewideyouth tobacco prevention program reduced grantee moraleand confidence about achieving programmatic goals, dis-placed focus from programmatic activities to communicat-ing with policy makers about the need for continued funding,and caused premature loss of personnel. Taken together,these factors contributed to substantially reduced programactivities and outcomes in the statewide program’s final2 years.Further, grantees encountered a number of barriers to effec-tive communication with policy makers at a time when pro-gram funding was being targeted. Uncertainty about theeffectiveness of communication strategies and frustration overlack of responses from policy makers were identified as a sig-nificant barrier by many grantees. Focus group findings alsohighlighted important structural barriers, including barriersrelated to restrictions on using paid work time to engage inadvocacy and a perceived lack of consistent proactive guidancefrom program leaders about sustainability-related educationand advocacy efforts with legislators.Grantees expressed difficulty with balancing program sus-tainability efforts and perceived ‘‘core’’ program activities dur-ing times of funding uncertainty. Ensuring that efforts relatedto sustainability, including communication with policy makers,are consistently emphasized throughout a program’s lifecyclemay support program staff in viewing sustainability work as anintegral part of achieving overall program goals. When proac-tively communicating with policy makers, emerging evidencesuggests that engaging constituents in direct communicationwith legislators, framing the benefits of public health programsin ways that align with policy makers’ expressed values, andemphasizing the economic value of programs may be valuablecommunication strategies.6Since program funding was ultimately drastically reduced,resulting in elimination of the statewide youth prevention infra-structure, it seems unlikely that grantee advocacy efforts mea-surably impacted the final legislative decision. There is someevidence that appropriate relationship development betweenprogram staff or partners (eg, evaluators) and policy makers,along with proactive, consistent communication regarding pro-gram outcomes, may help increase policy maker support for pro-grams.7,8 However, it is important to note that threats to NorthCarolina’s youth tobacco prevention program coincided with asignificant political shift in the North Carolina General Assembly,as both the house and senate became Republican majority for thefirst time in more than 100 years. Given the well-documentedhistory of tobacco industry influence in North Carolina poli-tics,9,10 it seems likely that industry lobbying mitigated tobaccocontrol advocacy efforts as the new legislative leadership becameincreasingly hostile toward tobacco control efforts.Taken together, the negative impacts of funding threats onprogram outcomes, multilevel barriers to communicating withpolicy makers, and a perceived disconnect between sustainabil-ity efforts and core program goals experienced by youth tobaccoprevention programs in North Carolina highlight a need for pub-lic health programs to create an infrastructure that supportseffective, consistent efforts to ensure ongoing program fundingand impact. Such efforts may be supported by implementing asustainability framework designed to help programs conceptua-lize their capacity for sustainability and identify areas whichthey can incorporate sustainability efforts in their day-to-daywork,11 taking into account relevant political climates and com-peting lobbying interests. As public health funding at the federaland state levels is continually under threat, deliberate and stra-tegic sustainability planning is increasingly critical.Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect tothe research, authorship, and/or publication of this article.FundingThe author(s) received no financial support for the research, author-ship, and/or publication of this article.References1. Davis JW. The Health and Wellness Trust Fund Commission. N CMed J. 2002;63(3):165-166.2. North Carolina Department of Health and Human Services. Teensmoking rates drop to historic low. 2012. NC Department ofHealth and Human Services Web site. http://www2.ncdhhs.gov/pressrel/2012/2012-05-17_teen_smoking_drops.htm. AccessedMay 18, 2016. Updated 2012.3. Davis KC, Crankshaw E, Farrelly MC, Niederdeppe J, Watson K.The impact of state tobacco control program funding cuts onteens’ exposure to tobacco control interventions: evidence fromFlorida. Am J Health Promot. 2011;25(3):176-185.4. Pizacani BA, Dent CW, Maher JE, et al. Smoking patterns in Oregonyouth: effects of funding and defunding of a comprehensive statetobacco control program. J Adolesc Health. 2009;44(3):229-236.5. Sly DF, Arheart K, Dietz N, et al. The outcome consequences ofdefunding the Minnesota youth tobacco-use prevention program.Prev Med. 2005;41(2):503-510.6. Schmidt AM, Ranney LM, Goldstein AO. Communicating pro-gram outcomes to encourage policymaker support for evidence-based state tobacco control. Int J Environ Res Public Health.2014;11(12):12562-12574.7. Dodson EA, Stamatakis KA, Chalifour S, Haire-Joshu D,McBride T, Brownson RC. State legislators’ work on publicSO WHAT?What is already known on this topic?Despite documented successes in outcomes, publichealth funding for tobacco control programs is increas-ingly threatened across the country. In 2011, the NorthCarolina General Assembly abolished the Health andWellness Trust Fund funded by the Master SettlementAgreement, despite documented historic reductions ofyouth tobacco use in the state as a result of the TrustFund’s tobacco programs.What does this article add?The study findings show that even threats of funding lossthat occurred long before the program ended, adverselyimpacted public health programs. Uncertainty aboutfuture funding impacted morale, reduced confidence inachieving program goals, displaced focus from programactivities to program sustainability, and caused prema-ture loss of personnel; process changes that led todecreased program outcomes.What are the implications for health promotion practice orresearch?Threats to program funding, even in the absence of fund-ing cuts, may adversely impact program outcomes. Thereis a need for public health programs to create an infra-structure that supports effective, consistent efforts toensure not only program evaluation but also programsustainability once positive outcomes are achieved.Building sustainability efforts into the framework of pub-lic health programs provides freedom from unforeseenfunding threats that may eliminate otherwise successfulprograms.health-related issues: what influences priorities? J Public HealthManag Pract. 2013;19(1):25-29.8. Nelson DE, Reynolds JH, Luke DA, et al. Successfully maintain-ing program funding during trying times: lessons from tobaccocontrol programs in five states. J Public Health Manag Pract.2007;13(6):612-620.9. Goldstein AO, Bearman NS. State tobacco lobbyists and organi-zations in the united states: crossed lines. Am J Public Health.1996;86(8):1137-1142.10. Washington M, Barnes RL, Glantz S. Chipping away attobacco traditions in tobacco country: tobacco industry poli-tical influence and tobacco policy making in North Carolina1969-2011. Center for Tobacco Control Research and Edu-cation. 2011. Web site. http://escholarship.org/uc/item/7kc398r4.11. Schell SF, Luke DA, Schooley MW, et al. Public health programcapacity for sustainability: a new framework. Implement Sci.2013;8(1):15.

“The Job Has Become Advocating for the Job”: Threats to Funding Dramatically Influence Program Outcomes

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“The Job Has Become Advocating for the Job”: Threats to Funding Dramatically Influence Program Outcomes

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