Public Health: What It Is and How It Works, 2^nd Edition

PUBLIC HEALTH PRACTICE EXERCISE 1

• Objectives

• Scenario

• Directions

• Guide for Establishing Public Health Priorities

Objectives

With the completion of this part of the exercise, learners will be able to:

identify geographical, topographical, political and demographic factors that are important for planning public health interventions and the reasons for their importance

evaluate diverse data and incorporate the data into the priority setting process

identify the factors to consider in the priority setting process, and

apply the Basic Priority Rating System to these factors as one method of quantifying priorities

Scenario

You recently joined the Chicago Health Improvement Planning Committee, formed by the Chicago Board of Health, to develop a community health improvement plan for the City of Chicago based on an assessment of needs and resources consistent with the statewide IPLAN initiative.

The first order of business is to determine what information is needed to initiate this process and how the process should proceed. Your initial task is to identify and gather background information about health status and health resources that are needed in the planning process. Various forms and formats for this information should be considered, including both hard copy and electronic sources. (Some examples are identified in Chapter 6 of the text in addition to the data and information sources on the Internet’s World Wide Web accessed in previous exercises associated with this course.) Considerable data and information is provided by the Illinois Department of Public Health in the IPLAN data set, and the task before the committee is to consider this and other information in determining Chicago's most important health problems. There are several other "health data and information sites" listed on the "Additional Resources" page that may be useful for this exercise.

The committee now represents a planning coalition that brings together many organizations, institutions and interests in the city concerned with the health status of city residents. Your task is to come up with a short list of the three most important problems to be addressed and specifically with a number one priority. In the course of the coalition’s deliberations, a number of issues and questions (such as those listed below) will likely be discussed. It is not your task to fully answer or solve these questions, although some thought and discussion may be helpful in establishing the priorities for your community health improvement process.

Review the materials assembled by your committee and consider the following questions:

• What information did your planning committee determine to be necessary to carry out its carry out its charge? What sources were used?

• What is the socio-demographic distribution of the population of Chicago? What are the potential effects of these demographics on program planning?

• Describe the physical geography of the city. What are the potential effects of geography on public health programming?

• Public health interventions require a variety of resources both for program management and provision of services. What resources and resource limitations exist?

• How might the resource limitations influence priorities? How might they influence the planning process or program implementation?

• Mortality rates and numbers of deaths are important indicators of the impact of various diseases and conditions in a community. Based on mortality data, both numbers and rates over time, what is the relative impact of the various diseases and conditions? How do numbers of deaths and rates differ for various racial and ethnic groups?

• Local incidence data are not always available in the IPLAN data set for many important diseases and conditions. How applicable might state or national data be to assist in the priority setting process?

• Mortality is changing over time at different rates. To what extent should rate of change moderate response to either high or low mortality rates in the priority setting process?

• Should interventions be targeted to populations whose rates are high independent of the potential number of persons who could be affected by those programs?

• What risk factor data are available for the local population? How do those data, when combined with mortality information, influence planning decisions? (Use a broad definition of risk factor!)

• Since risk factors for a number of diseases and conditions are the same, is it possible and/or appropriate to adequately prioritize actions based only on conditions? What other factors might be considered? For which are any data available?

• What is known of the potential for preventing or controlling these diseases and conditions? What is the estimated number of persons for whom mortality from a particular disease or condition can theoretically be prevented?

Directions

First, review the information your planning coalition has assembled for this exercise as well as any other materials you deem relevant. Meet together as a group to prioritize among possible health problems and to plan your coalition’s summary report. Each member of your group should participate, playing the role of an important community partner (for example: health officer, hospital administrator, practicing physician, labor leader, school principal, community organization president, United Way coordinator, etc.) They should participate in this planning exercise with the perspective of that community partner in mind. The discussion questions listed above may be useful in stimulating discussion, but please note that answering these questions is not the task here! The critical task is to apply the process described in "A Guide to Establishing Public Health Priorities" (see below) to health problems in Chicago and to develop a consensus list of priorities. You may wish to examine some of the tools presented in the Community Tool Box, especially the sections on Skill Building Tools for additional insights. Various sections of the Healthy People 2010 Toolkit may also be useful in this exercise.

The final product of your deliberations will take the form of an Executive Summary of your committee's report to the Chicago Board of Health.  Basically, this Executive Summary will present your three highest priority health problems and the rationale for their selection by your planning group.  Your coalition is free to use whatever additional information, documentation, or evidence you believe will bolster the credibility of your findings and recommendations.  However your Executive Summary is limited to no more than 1000 words. You should include at least 3 references/citations for data and information provided in your Executive Summary.  It will be judged based on how clearly and effectively the evidence and arguments for your priorities are communicated.

A GUIDE FOR ESTABLISHING PUBLIC HEALTH PRIORITIES

(Modified from CDC Case Study: Translating Science into Practice)

Establishing priorities from the multitude of public health problems facing communities today is a necessary and increasingly difficult task. Public health administrators and managers often faced with an increasing range of pressing problems in light of decreasing resources. A method to establish priorities that is fair, reasonable, and easy to calculate is a necessary management tool.

The method described here provides means to compare different health problems in a relative, not absolute, framework, as equally as possible, and in a somewhat objective manner.

This method, called both the Hanlon Method and the Basic Priority Rating System (BPRS), is described in Public Health: Administration and Practice (Hanlon and Pickett, Times Mirror/Mosby College Publishing) and Basic Health Planning (Spiegel and Hyman, Aspen Publishers).

 The method has three major objectives:

Basic Priority Rating Formula

Based on review of repeated trials conducted in identifying health problems, a consistent pattern of criteria became apparent. This pattern is reflected in the components of this system.

These components translate into two formulas that provide a numerical score, giving highest priority to those diseases/conditions with the highest scores.

The difference in the two formulas becomes apparent as Component D (PEARL) is described.

It is important to recognize and accept that, as with many such processes, a large amount of subjectivity is present. The choice, definition, and relative weights assigned to the components are a group decision and flexible. Further, the ratings are the judgments of the individual raters. However, some scientific control can be achieved by using precise definitions of terms, and using appropriate and accurate statistical data.

Components

Component A – Size of the Problem

This component is one in which the factors are few in number. Choices usually are limited to a percentage of population directly affected by the problem, i.e. incidence, prevalence, or mortality rates and numbers.

Size can also be considered in more than one way. Both the entire population and potential target populations can be considered. Also, diseases with common risk factors that are amenable to a common solution might be considered together. For example, if tobacco-related cancers were considered, lung, esophagus, and oral cancers might be considered as one. If more diseases were also being considered, cardiovascular diseases might also be considered. The maximum value of this component is 10. The decision of how to define size is usually a group consensus.

Component B – Seriousness

The group should consider possible factors that define the seriousness of the problem; however, the number of factors should be kept reasonable. The group should be careful not to bring the issues of size or preventability into the discussion, as they fit elsewhere into the equation.

The maximum score in this component is 20. The factors must be weighted and carefully defined. By using this number (20), Seriousness is considered to be twice as important as Size.

Factors that could be used are:

• Urgency: emergent nature of the problem; trends in incidence, mortality, or risk factors; importance relative to the public; current access to needed service.

• Severity: survival rates, average age at death, disability, relative premature mortality.

• Economic loss: to the community (city/county/State), to the individual.

Each of the factors must be weighted. As an example using four factors, the weights could be 0-5 or any combination that would equal a maximum of 20. It is usually helpful to establish what would be considered minimum and maximum in each factor. This will help to establish boundaries to keep some perspective in establishing a numerical rating. A way to consider this is to use as scale such as:

For example, if premature mortality is being used to define severity, then infant mortality would probably be a 5 and gonorrhea would be a 0.

Component C – Effectiveness of Intervention

This component should be considered as "How well this problem can be solved, if at all." The factor is scored from 0 – 10. This may be the most subjective component of the formula. There is a large amount of data available from studies that document the success of interventions.

The effectiveness rating, based on known success rates from the literature, is multiplied by the percent of the target population expected to be reached.

Example: Smoking cessation

An advantage in considering the target population and the number expected to be reached is getting a realistic feel for resources needed and expected ability to meet set objectives.

Component D – PEARL

The PEARL is a group of factors that, although not directly related to the health problem, have a high degree of influence in determining whether a particular problem can be addressed.

P – Propriety: Is the problem one that falls within the agencies’ overall missions?

E – Economic Feasibility: Does it make economic sense to address the problem? Are there economic consequences if the problem is not addressed?

A – Acceptability: Will the community and/or target population accept the problem being addressed?

R – Resources: Are resources available to address the problem?

L – Legality: Do current laws allow the problem to be addressed?

Each of these qualifying factors is considered, and the scoring for each factor of the PEARL is 1 if the answer is "yes" and 0 if the answer is "no." When scoring is complete, all of the numbers are multiplied to obtain a final answer. Since together these factors represent a product and not a sum, if any of the five factors is "no’, then D will equal 0. Because D is the final multiplier in the formula, if D=0, then the health problem will not be addressed in the OPR regardless of how high the problem ranks in BPR. However, part of the total planning effort might include addressing the intermediate steps needed to address the PEARL positively in the future. For example, if the intervention is just not acceptable to the population, steps might be taken gradually to educate the population as to the potential benefits of the intervention so that it can be considered in the future.