AMCHP 2006 ANNUAL CONFERENCE
EARLY CHILDHOOD: BUILDING THE FOUNDATION FOR LIFELONG HEALTH
March 4-8, 2006
VIVIAN GABOR: I apologize for being a couple of minutes late. I wasn’t registered and then I came from teaching a class in my daughter’s religious school this morning. I live here locally. And we were talking, I was there volunteering to talk about community service, and tried, they’re six and seven year olds. And to talk about what, how, what they think about people in their community who help others, how they can help others. And at the end we came up with the idea of doing a food drive at our temple from now on, once a month, which is really kind of think it would be a lot of fun. And the kids, of course, their faces are wonderful. Their interest was great. Their focus was incredible for six and seven year olds, I thought. But I though it was kind of apropos because you’re probably the grown ups of those six and seven year olds who have committed your life to service in your states. And I want to say that I think your--the advocacy and the work although I’m sure at sometimes it doesn’t seem like your, maybe some days or some weeks or some months it doesn’t seem like you’re making a difference working at the state level trying to setup systems of care, trying to document, to evaluate, provide funding so that kids with special needs can get direct services. You’re saving lives and you’re trying as hard as you can and I appreciate, I sort of like the transition for my daughter’s past years. So I wanted to make that personal comment.
I work for Health Systems Research. You may know some of you may have come across our company. We’re a public policy consulting firm based in Washington D.C. We’ve been around for 25 years. I would say, anybody raise their hand whose heard of Health Systems Research? Okay. Straw poll, it’s 50 or 60 percent of you. We’ve done, we do a lot of work with the states directly in providing technical assistance. We have folks who have come from the state agency level, our local Health Department. I’ve worked at a local Health Department. We have PhDs in evaluation. We have health policy experts, people who have worked in policy in federal government and/or Capitol Hill. We try to bring together in our research some of that cycle that you were talking about Dr. Acuna. What is the data, not only what do the data show, but what do the data mean and what are the implications and how can we get the information out? You may have also heard about us through some of our conferences and Web casts because we really do believe that the information that we put together needs to be practical and shared and used and not set on a shelf somewhere.
So we hope to the best of our ability that when we write reports that they are practical and usable and they’re something you can take. And we always appreciate when people call us that they actually, that they’re using what we do. And I hope, the intent of this evaluation, I think the driving force, Jack mentioned, is a push at the federal level to find out what programs are working and what we can--any quantitative evaluation of human service, Health and Human Service program has its caveats in terms of your ability to draw quantitative analysis. But we think we’re going to be, we’re actually looking at preliminary results and I think there’ll be some nice things that you’ll see.
I’m going to, I was going to tell you a lot more about HSR but with all those hands, I’m not going to tell you about HSR. We do have an exhibit booth I think on Monday and Tuesday if you want to pick up some of our publications, meet some of our staff, we’ll be here. The project generally that’s the title, "Assessment of Title V Block Grant Programs MCH Infrastructure Building of Investments." We’re going to, in this report we’re going to describe what you’ve been doing since the 2000 needs assessment in terms of the nature and extent of infrastructure building activities that are going on and how that’s grown despite not significant increases in funding. We’re going to describe any available evidence that we can find from performance measures, the national and the state level outcome measures and health systems capacity indicators about the relationship between investments and all of these, I would say, broadly defined outcomes or effects. And we’re also going to talk to a select number of states to focus groups and interviews to find out what else we can talk about, more descriptively in terms of what is happening in infrastructure building and how you’re really looking at the effects.
I have to say before I go into our study, I assume that after the investment of these five to ten more EPI folks that there in fact will be more infrastructure building going on in the states than we found, of course, in 2004, 2005. And that’s really exciting, the potential that’s out there. I want to tell you today about the study purposes. I hope you can go home knowing what we’re doing, why we’re doing it, how we’re doing it, and some preliminary findings. Some that will be on the slides and some that are not official yet, so I will just tell you them from my notes. And Jack, you may hear them for the first time as well, but--
JACK TENENBAUM: I’m looking forward to it.
VIVIAN GABOR: I think they are small but good news that we--we got this contract in October. We’ve been working full steam ahead because we only have a year to work on it. And we spent the first few months putting together background, looking at your applications, your annual reports, and the TBIS data, find out what’s there, what’s not there, putting it into our own data systems for analysis. And we have, we did write a literature review that is currently under review and clearance in MCHB that we think will be helpful to you. I’ll talk a little bit about it. And we’ll be, we’re in the midst of data analysis now, I would say neck or nose deep in data analysis, and we’ll be doing, some of you have heard about our focus groups that we’re having at the sessions at AMCHP. This week we’ll be trying to get input from you there about your experiences and what you’re doing. And we’ll be doing some interviews over the phone with probably eight to 10--12 states to try and collect some more standardized information than we’re getting from the focus groups. And we hope to have a report by the fall.
MCHB needs it for January of next, beginning of next year so we are moving on a fast track on this. And I also want to thank besides thanking Jack, I want to thank Cassie and all her staff who have helped us find people to talk to in the focus groups, who’ve made sure--we want to make sure this is a study that you have input on and for their review of our literature view, every product that we do through the division. Pam Mason is not here but she’s our key contact and she has, besides being a very wonderful, nice person, she’s also provided some good feedback throughout the process and we look forward to working with the division. Okay.
The purpose of this is to provide both a quantitative and qualitative evaluation about describing, as I said, what infrastructure building activities are going on in the states and territories and what evidence there is or associations there are with effects. And effects, that means effects on systems not just on infant mortality or low birth weight, but effects in terms of system capacity. How many more data systems are being implemented? How many more services are accessed? How many more systems are being built? How many more, if there are changes in health status or risk and health outcomes. I think we’re looking at sort of that health circle of applied science that Dr. Acuna talked about in terms of habits. What does this data mean?
We’ll be looking at some additional focus using state data that will ask if you have additional documents that are not, or additional information through evaluations that are not available through the TBIS. Perhaps you’ve been doing your own tracking or own advocacy in your states to try and get support for infrastructure building activities and we want to know how you’re documenting effects in other ways if we can, that are not through the traditional performance measures and capacity indicators. We’ll be trying to get, we’ll be getting our portraits through our focus groups and interviews of promising practices in infrastructure building and evaluation of those. And we hope to come out at the end with methods for ways that you can improve MCH perhaps, MCHB can improve the assistance they are giving you to build these infrastructure capacity and document their effects. And I should say MCHB and CDC, the combination of the MCH EPI program probably has a big role in this as well because a lot of the, much of the infrastructure not proportionally but important infrastructure is that EPI capacity.
The reason we were asked to focus on an infrastructure building, in terms of our evaluation perspective, is it is a common thread of services that runs through all Title V programs. As you know you vary in extent in terms of how much direct service you’re currently involved in and how much enabling services and population based, but we know that infrastructure building is not, runs through all the programs and it is, of course, at the base of the pyramid. So it’s a direction that you all are building the foundation of your systems upon. It is also, of course, infrastructure building is key to core public health functions of assessment, assurance, and policy making. And the infrastructure building services are really what the 10 essential MCH services are all about that were defined in the 1990’s.
I told you we did a literature review. It’s currently under review. We think it’ll be, you’ll be interested in the findings. We looked at--we tried to document why public health is, and Maternal Child Health is moving towards infrastructure building at this time in history, what research is available to identify unmet needs in infrastructure building. There’s some studies on EPI--evaluating the EPI capacity of states that were done. There’s not been much other research done on the extent of infrastructure building capacity in states in unmet needs. We do try to pull out what’s there from the other public health literature and other aspects of Public Health Preventive Services chronic needs et cetera so that we can look at other models of research, look at the turning points evaluations that looked at infrastructure and its impact on communities and on systems. So we tried to find out what other research is there out there that’s looking, describing an unmet need and looking at the impacts or infrastructure if it’s not maternal child, help then if there was anything in Maternal Child Health. The bottom line is there is actually not a lot of research in this area but there are some good research frameworks for going from infrastructure building investment to outcomes and how we need to ask those questions. And our final report, as I said, we hope to have for you based on the research that we’re doing in fall 2006 and present at least the preliminary findings at the partnership conference in October.
What we--literature view findings, I just want to briefly mention that while there’s limited research documenting impact effects of infrastructure building, there is strong consensus that the ability of health departments, public health system in the nation to build effective infrastructure will determine our nation’s capacity to respond to health care needs in our communities and our states. Of course, increasing attention was brought to infrastructure with 9/11 and with Katrina, but it’s something that’s been, it’s an issue all along in terms of long-term health care needs. Would you say Dr. Acuna that a lot of the investment in EPI was sort of driven by those sort of emergency events of public health in the state infrastructure?
JUAN ACUNA: It changed it. It changed it. It diverted focused.
VIVIAN GABOR: Diverted focus. So it’s coming back?
JUAN ACUNA: I wish.
VIVIAN GABOR: So I said there are no systematic studies of Maternal Child Health infrastructure building in states looking at how much is going on compared to the need, except there was one study assessing Public Health EPI at the capacity in various aspects of public health including Maternal Child Health. And it did document some increase in MCH EPI capacity of those small compared to those other areas of public health, bioterrorism, disaster relief, et cetera.
We found what there is out there, is it shows varied state capacity and overall public health capacity. A lot of the studies that came out after 9/ll and after Katrina showed that states have big gaps in their capacity and their infrastructure and they certainly vary from state to state. And the greatest focus of expanding public health infrastructure building investments so far has been for emerging public health issues and threats. I want to say, if you have not seen an article that I reference there, it’s a very good article by Arden Handler, Bernard Turnock, and I’m forgetting Issel’s first name that was published in the American Journal of Public Health in 2001, talking about how to do research and how to think about research for a public health system that really looks at inputs, macro environmental effects and outcomes. And how we need to be really thinking at system level evaluation. So we use something similar to their model in the way we’re thinking about our evaluation. We’re going to be looking at infrastructure building investments and we’re looking at dollars spent, proportion of money spent, number of activities, diversity of activities that you all have invested in and we’re going to be looking at measures of system capacity, which would probably be impacted by those investments one hopes and assumes and, of course, program performance. And then the ideal impact that we, that we’re all doing this work for is MCH outcomes.
And I can’t, you can’t talk about any evaluation or any study because if human services or health services without recognizing that the macro environmental factors including disasters, budget cuts, change in governor, Avian flu, things that have come up in the environmental factor are going to impact how much you’re able to invest, what you do invest in can effect your system capacity separately, your program performance and your MCH outcomes. So as I said, the real, live dimension of this kind of research recognizes these macro environmental factors. And we will be discussing those in our report. And we want to hear more about what those are when we talk to you in our interviews in our focus groups. What is preventing you from implementing infrastructure building the way you’d like to? What is helping you do it that might help other states implement it? And what are some other impacts on your system building capacity. Now, I handed out a sheet of categories on how we’re looking at infrastructure building activities. I have a copy here but it’s a one pager, if folks have it. I have four or five slides that sort of list them but I thought you really ought to have them on one piece of paper in front of you. Do you know how we’re dividing up our infrastructure building or categorizing them?
UNKNOWN SPEAKER: Can I ask you (inaudible) a fine question.
VIVIAN GABOR: Yeah.
UNKNOWN SPEAKER: I’m to be a, being relatively new--
VIVIAN GABOR: Oh no, no, no, no.
UNKNOWN SPEAKER: I’m trying to grip my arms around conceptually the various categories of infrastructure building services that would count.
VIVIAN GABOR: Right.
UNKNOWN SPEAKER: So, for instance, just focus in on the first two state level (inaudible) without the public and private agencies, community developments, development efforts to identify and solve MCH local problems. So let’s assume that I, infrastructure building effort is focused on enhancing public participation, say in a city. And we are capable of inspiring residents of poor neighborhoods to say encourage women to get into the first trimester of pregnancy at their natal care bases. And somehow that works, but it’s not our doing necessarily and it doesn’t directly reflect on our program activities, narrowly construed. So how do you measure the impact that that public participation enhancing activity had when it doesn’t ultimately show up necessarily in your more narrowly defined program at the end? But it did have an impact and it, but you may not count it. So if it has any--
VIVIAN GABOR: No, no. Yes, yes.
UNKNOWN SPEAKER: -- affect, complexities, mythological that you can have a measuring what you do and how it ends up effecting your own out comes.
VIVIAN GABOR: I mean, I think, we talked about all those macro environmental factors affecting every stage of it. We can, what we will be doing to, just one thing, there’s one thing that we want in terms of defining infrastructure building activities. I think I should just step back for a second. In that folks who are the Title V folks know that they are, we sort of talk about services that you fund and you support and you try to get other people to bring to the table as direct services, enabling services should outreach, improving directly, trying to improve access in education. And population-based services like media campaigns or outreach campaigns or social marketing campaign or immunizations, population-based led screening. And then there’s infrastructure building, which are, we tried, there was no, there actually is no definition of infrastructure building activities that we were able to find. Clearly in the literature what we found the closest connections were to the essential public health services. So I’ve tried, we’re categorizing them and I’m trying to tell you how we have defined them because we may be the first that categorized, the first to have categorized it in some way. But we looked at all your activities and in some ways, that were infrastructure, reported as infrastructure building activities. And I would say some of them are actually not infrastructure building activities. They are enabling or population-based services. So when we know that they’re clearly infrastructure, but we actually looked at those, we looked at the literature in terms of essential Public Health Services. And we came up with these 12 categories to categorize, describe what people are doing.
But when we calculate effects, we’re not--we don’t know how much, we’re going to take what you said you spent on infrastructure building. What, however you defined it and that will be the input or the investment. But when we describe by detail the kind of programs that you’ve implemented and investments, we’re divided up the discussion by categories so people can think about the type, you can think about the types of things people are doing, how that’s changed over time, whether it’s changed over time. And whether it’s changed in number, in terms of the number of activities in these areas.
So, but the answer to your underlying question, I didn’t, is not, you know, easily answered which is why this, we’ll have certain, I think we’ll find some associations in evaluation even if we found associations with improved outcomes in that community and it was an infrastructure building activity, it might not be caused by the, the activity that the Title V agency created. But you can only do the best you can, in terms of looking at correlations and associations. And we actually, you know, we do a very stiff job in terms of our quantitative analysis and we’ll be adding some qualitative descriptive work as well.
So the first category on your list is State Collaboratives. I wanted to give you some examples from the Title V applications of what we’re talking about here. The state led and supported a genetic screening, an advisory committee to examine issues of access to genetic services, especially genetic counseling would be an example of a state led partnership or promotion of a collaboration. In one other state, the state Title V agency participates as a lead agency in the Governor’s Cabinet for Children’s Cabinet, which is a variety of inner agency work promoting children’s well being. And they’re on a particular youth development advisory committee that was highlighted in this group for it. The community development work is something where Title V agency stagings are promoting supporting, providing TA to help community development efforts, to help community-based planning, needs assessment and coalition building. So there we’re, some of the projects that we saw--some of the investments that we’ve seen are this Title V agency encouraging and funding local level suicide prevention for coalitions. Title V agency developing and supporting community development models for assessing needs, planning services and advocacy for systems of care with kids with special needs. I’m not going to mention specific states because, just if, and you may know who you are if you’re doing this, but some of these projects or activities ran across states. And this is no way comprehensive. I’m just trying to help define my categories.
Again I, establishing or enhancing coordinated care systems and linkages between services or systems, besides being a mouthful to say, here we were talking about investments made in systems, in coordinated care systems. And developing the medical home model at the state level, the community level. In setting up better referral and linkage systems between early intervention systems and special ed and newborn screening from the beginning. And let’s see if I can, one state developed, talked about developing protocols and working in many other ways to improve the quality and follow up of children identified at birth with either birth defects or special conditions including low birth weight to make sure the get in. Those linkages are made with early intervention. But at that point we were not talking about the data systems. So we have a separate code. The states have done better system of tracking those kids that’s different than actually, the people and the services that have been put together.
The fourth category is infrastructure building activities that you’ve developed to improve access or quality of services. And there we don’t mean direct one-on-one outreach, but the programs or systems that you’ve built that actually do the outreach, that actually improve the access. And that are designed to improve quality. So for example, one state talked about working on system changes, this is a very narrow one but it shows you what we put under here. System changes to improve audiologist's participation in the early intervention program and IEPs for school age children. So you’re actually doing something to improve the quality of care in a system level way. Now if there was training for those audiologists that was categorized in a different way. It was a separate activity.
Number five is the provision of TA and consultation on systems building. I think you probably know what that means. We, if you called the TA and we understood it as a TA, we reported it as a TA activity. You’re not generally, a Title V is not in the business except in some cases of direct division, direct services, but you are providing TA to direct providers and as well, not only to health providers but let’s say help Head Start providers, childcare providers, others.
The next category was improvements to like information technology and surveillance capacity including the development of data bases, data linkages, and also as an example, the hiring of an epidemiologist who is certainly increasing your data capacity if you, if that was reported as an infrastructure building activity. We included it under this number six category. Investments you’re making to improve your data collection and analysis capacity.
The seventh category was actually the data collection efforts. Those are infrastructure-building things. What did you do? What kind of surveys? Did you do some--did you implement or enhance your mortality reviews? Did you implement or enhance PRAMS? Did you conduct and design and tract data on children’s health? There’s special state health surveys or children with special health care needs surveys, a variety of stuff that folks are doing in that area, of course.
And then the eighth category is any training, anything you’ve done to improve the competency and quality of the work force that is serving children, women and families in your state and that might be training school nurses, training health professionals, dental professionals and others.
And nine is legislative, sorry. Nine is anything you’re doing to develop, implement or promote new legal requirements. And there we included activities that you called infrastructure that were involved in internal advocacy in the state as well as implementation of new laws and helping to write regulations.
Our 10th category is research and there we included evaluations as well as policy-based research. Specific program evaluations and the policy-based research that you were talking about in terms of your second category Dr. Acuna, of research, what insurance status has to do with access for people on Medicaid, et cetera. Our description of what you did is from your applications. And we define what you did and how much you did. We read your applications and quantified it that way just so you know.
Our 11th category, actually these are other, things that did not fit in the other ten categories and that were sort of, they really weren’t easily grouped and that also weren’t as many of which were not, would not be defined objectively that public health as infrastructure per se. It would also be enabling a population-based service. More like, if you have to pick a category that would, where it would fall.
So that’s the other category, there’s 11 and 12 is needs assessment. And this was not the toot that we, states did not, you guys did not in 2000 report that you were doing needs assessment because everybody did it, the five year needs assessment. So we, but we found that states were reporting that they did needs assessment in the in between years when you’re doing small needs assessment on specific populations or specific targeted services or training needs. Whatever kind of needs assessments you did that really looked at either capacity resource or health needs. That was a category. And we didn’t find many, when you see, we looked, we compared 1999 to 2003 and the only reason we don’t have any 1999 to compare with is because people didn’t consider it something worth documenting because you all were doing a major, major effort that year. So those are our categories.
That’s what we--that’s what I mean when I use the word infrastructure-building investments, all those kind of activities and we hope, we’re going to ask you in your focus groups how you define infrastructure-building activities. We’ll be, but I think through the literature and these all match up with 10 essential public health services.
So what’s the question that we’re going to ask? The primary quantitative big question, were there any questions, I should say? Was there a national, or even perhaps at the regional level, trend in the types or the nature and the number of activities or investments that were made after the 2000 needs assessment? So our base year is 1999 and as reported in the 2001 application in our sort of end-point year will be the 2005 application, which is the 2003 annual, as you know, 2003 annual report. Is that right? Have I got those numbers right? 2004 Annual report. Sorry about that. So, I may have my numbers confused. You just submitted your 2006 application?
UNKNOWN SPEAKER: Yes.
VIVIAN GABOR: Is that right?
JUAN ACUNA: They’ll be submitting their ’07 applications.
VIVIAN GABOR: That’s right. You just missed it right. So we didn’t look at this year’s application. We started with the 2005 application. We compared the 2000 to the 2005 application, in terms of looking at your activities. And we want to look at--we looked at not only these, the text that you provided about the activities that you served, but also the budget expenditure data. And we’re looking at how many dollars you spent in ’99 and also we’re looking at what percent of the total budget is spent on infrastructure, on average between 1999 and 2003. The reason I mention 2003, that’s right, because the last budget data is only available for 2003. Is that correct? The final budget numbers.
UNKNOWN SPEAKER: In those three submitting year, ’05 report should show.
UNKNOWN SPEAKER: Why haven’t, you have looked at much further than 1999 as a baseline here?
VIVIAN GABOR: We were--it was some--how should I say it? I think when we read what folks were interested in at MCHB, it was really what happened, what may have happened since that time period, and since the needs assessment, based on priority needs and new state performance measures that states put in place, how did the world, how did things change? Because that’s when you first did those major, set those 10, I think seven to 10 priority needs and performance measures. And how is that, they’re tying in sort of, as you looked at your infrastructure building and needs, how is that, how did that change?
UNKNOWN SPEAKER: We don’t need it, don't you have the TBIS or whatever they call (inaudible) before that that they were also talking about infrastructure building. I just sort of--
VIVIAN GABOR: Yeah. No we used as a base point because, mostly I think, I don’t know because I haven’t looked behind further our, you know, our structure of the analysis was to look at what happened based on needs and performance measures that people identified in 2000, sort of what, what do you see as a change?
UNKNOWN SPEAKER: Okay.
VIVAN GABOR: And that the investments probably reflected some sort of strategic planning that happened around the 2000 period, 1999-2000 period.
So, here’s some preliminary findings about the type of activities that folks are doing. And this, and we looked at, we have in terms of your reports of implemented--these are both implemented and planned activities. So though it says 1999 and 2003, if you said it was planned in that 2001 application, it may have happened, it may have been actually implemented in 2001. And if you said in the 2005 application that you did some activities, we know that some of those were planned and some of those were actually implemented, but states varied in whether they used the tense--the future, the past or the present tense. And we couldn’t interpret whether you had actually implemented or just planned to implement the activity, proposed to implement it. But we, we took your word. That if you said this was an activity that you were reporting, that you were actually going to be, either had implemented or just about to implement it.
So, as you see, most of the activities that were reported are in the state collaboratives, they fall under the category of state collaboratives or forced investments to improve access, improve quality of services. And I’m going to say I combined six and seven. I wanted to combine six and seven because they were groups that were very closely tied, people investing in both your infrastructure, your data capacity and actually carrying out the surveillance systems of the surveys. So if you take all the IT and all the sort of the EPI work together in the data analysis work, that’s category six and seven and that was the third largest category. And then the fourth largest category was actually training, which happened in a lot of, and when we say largest, we don’t know how many dollars, you may have spent more dollars on this activity although it’s small. We just, we don’t--you don’t report how many dollars you’re spending on each activity. We just know how many activities you reported and we have to count them each, give them each equal weight when we looked at how much you, how much you’re doing.
And again in terms of investments or dollars, we do have, everything is equal. Dollars are equal Louisiana and Missouri, et cetera. So we did compare dollars-to-dollars. But in terms of the extent of activities, here’s what we saw. And if you’ll see that we, this is sort of the distribution between one and 10. We took out needs assessment because it wasn’t reported very much in 2000 and the 2001 application and we took out other because it’s other, because it’s not comproable. And we see that the distribution of the type of activities, the number of the type of activities and its proportion did not change between 1999 and 2000. You have this, and these are just percentages here but if you look, the next slide there are many more activities reported in 2005 application than in 2001 infrastructure. So there’s a big increase in the amount of activities. But the kinds of activities and the range and where you weighted them in terms of importance was the same both years.
The only, as you see, it’s usually doubling or tripling except for a few categories in terms of the number of activities you reported in 2000 and, now I want to say just between these four wheels, we don’t know if you actually did more activities in 2005 application when you reported than you did in the 2000 one, we just know how many you reported that you did. So we hope, we know that it may be some reporting bias if you wanted to report more, if you were--the structure was changed in the application in 2005 as well, as you know, with those tables of reporting activities by pyramid level for each performance measure. But we do think that they’re showing--there is, during this same time period, there was a very small increase in dollar investments that you reported in infrastructure-building activities. So that many of these increased activities must have leveraged other resources. Obviously, you didn’t have more dollars to report and it was a very, also a very small increase in the proportion of your spending on infrastructure-building activities compared to direct services, enabling and population based services. I don’t have that slide because it’s preliminary at this point.
So we’re going to be trying to look, as we, we talked about this is the descriptive information, those bar graphs that I gave you. But we want to look at is the relationship between changes in your investment and there we’ll probably be looking at the size of your investment in 1999, not just the changes, but the size of the investment in the state and the average proportion of dollars that are spent on infrastructure building activities. I have to say since we looked at the data again this week, that first question, the way I would word it would probably be different than I prepared the slides. So we really want to look at how much you’re investing and whether there is an association with outcomes. And interestingly there, for some performance measures we did find some significant correlations between a few of the performance measures that we’ve looked at so far and the size of the investment that the state makes in infrastructure building activities and the proportion combined with, factored with the proportion of your spending on infrastructure building activities.
We’re going to try to talk about how strong these relationships are, of course. And we’re also going to be looking at the state performance measures and what type of these state specific measures provide--impact of information on impact. And the other finding is that you folks have, in state performance measures, there are 600 of them, I believe, that you have put together, 507 and they have, about half of them have improved, the indicators have improved from the first year, from 2000 to 2004, or the first and last year you’ve provided data for. The ones that have the biggest improvement were those measures that are really specifically looking at infrastructure building capacity. It’s only 20 percent of all your measures but they did have, as a group, the largest improvement. I’m told I better hurry up.
Where we’re getting all this information is, your applications, the TBIS data and your expenditure reports that you provided to MCHB as well as some state specific documents that we’ll be getting from a sample of states. We’ll be talking to you through focus group discussions. We’re meeting with about 22 state officials on Tuesday and Wednesday in three focus groups. And we’ll be having telephone discussions with about eight to 12 of you. And we look forward to hearing from you at the study. We know we want the results. We want this--we want it to help the program improve. We want people to know that infrastructure and Title V investments over all, if they are, how they are making a difference and we want to be able to document it to the extent we can with measures and in other qualitative ways to help the program move forward.