1. COMMUNITY ASSESSMENT 2:
PROBLEM PRIORITIZATION
AND ANALYSIS
Family Health Outcomes Project Staff
Geraldine Oliva, MD, MPH
Director
Judith A. Hager Belfiori, MA, MPH
Director of Planning and Evaluation
Brianna Gass, MPH
MCH Project Coordinator
Nadia Thind, MPH
Research Associate
Jennifer Gee
Training Coordinator
Mary Tran
Administrative Assistant
2. TABLE OF CONTENTS
Agenda 1
Session One. Presenting Data
Participants Guide 2
“Presenting Data on Problem Areas” PART 1
Brianna Gass, MPH 3
“Presenting Data on Problem Areas” PART 2
Brianna Gass, MPH 9
Session Two. Problem Prioritization
Participants Guide 14
“Community Health Assessment: Setting Priorities Among Identified Problems ”
Judith Hager Belfiori, MA, MPH 17
Session Three. Problem Analysis
Participants Guide 28
“Conducting a Formal Problem Analysis”
Geraldine Oliva, MD, MPH _____________ ________________ 31
Definition of Terms 50
Generic Framework for Health Problem Analysis 52
Blank Problem Analysis Diagram 53
3. TODAY’S AGENDA
By the end of the training, participants should be able to prioritize problems and understand
the basic components and concepts of a problem analysis. At the conclusion of this course, the
participant will be able to:
• Set priorities among identified problems
• Conduct a problem analysis
• Interpret and effectively present data
8:30 am Coffee and Registration
9:00 am Welcome and Introductions
Geraldine Oliva, MD, MPH
9:30 am Session 1. Presenting Data on Problem Areas (Part 1)
Brianna Gass, MPH
10:00 am Break
10:15 am Session 2. Setting Priorities Among Identified Problems
Judith Hager Belfiori, MA, MPH
11:00 am Exercise: Prioritizing Criteria using an FHOP Tool to Identify Problems
12:15 pm Lunch
1:15 pm Session 3. Conducting a Formal Problem Analysis
Geraldine Oliva, MD, MPH
2:00 pm Exercise: Brainstorm Precursors for a Problem and Identify Points in the
Causal Pathway for Intervention Development
3:15 pm Break
3:30 pm Exercise: Presentations
3:45 pm Session 4. Presenting Data on Problem Areas (Part 2)
Brianna Gass, MPH
4:15 pm Wrap-Up and Conclusions
FHOP Community Assessment 2 Training February 2004 1
4. COMMUNITY ASSESSMENT 2:
PROBLEM PRIORITIZATION
AND ANALYSIS
Session One
Data Presentation
Presented by:
Brianna Gass, MPH
MCH Project Coordinator
Family Health Outcomes Project
FHOP Community Assessment 2 Training February 2004 2
5. PARTICIPANTS GUIDE
Session One
Presenting Data on Problem Areas
LEARNING OBJECTIVES
By the end of the presentation and session, participants will be able to:
1. Effectively interpret and present data
2. Determine the best way to present data on an indicator
3. Understand the purpose of presenting data to a planning group and in the needs
assessment report
REFERENCES FOR THIS SESSION
Developing an Effective MCH Planning Process: A Guide to Local MCH Programs,
Chapter 2 “Community Health Assessment: Identifying Maternal, Child Health Needs and
Setting Priorities” and Appendix II-H.
FHOP Community Assessment 2 Training February 2004 3
6. 1
Presenting Data on
Presenting Data on
Problem Areas
Problem Areas
(Part 1)
(Part 1)
Brianna Gass, MPH
Family Health Outcomes Project (FHOP)
Community Needs Assessment II Training
February 11 and 18, 2004
Title V Needs Assessment
Title V Needs Assessment
z Identify problems faced in your
community
z Present these problems to planning
group
z Prioritize among identified problems
z Discuss these priority issues in your
report
Session Objectives
Session Objectives
z Understand what can be inferred from
initial assessment of indicators
z Summarize indicator assessment for
planning group
z Identify ways to follow up selected
indicators with additional information
z Display this information to planning group
7. 2
What Does Your
What Does Your
Data Tell You?
Data Tell You?
z Data templates compare:
County to state
County to Healthy People Objective
z Data can demonstrate differences among
race/ethnic or age groups
z Is your county getting better or worse
over time?
What Does your Data
What Does your Data
NOT Tell You?
NOT Tell You?
z Indicator data points to a problem but details
(who is affected, where, why) are still unclear
z Some indicator data doesn’t include age or
ethnic groups
z Geographic variation within your county
z Demographic details (e.g. income, education,
employment)
z Other factors (e.g. insurance status,
awareness of community resources, etc.)
Presenting summary indicator
Presenting summary indicator
data to your planning group
data to your planning group
Indica tor
Hea lthy People 2010
Objective
Most
Current
Yea r of
Da ta
Ca lifornia
Ra te
County
Ra te
County
Trend
County
Sta tus1
Births
Births to Teens Age 15-17
43 births or less/1,000 females
aged 15-17
2001 26.6 35.3 O !
Low Birth Weight 5.0% or less of live births 2001 6.3% 4.7% z
Very Low Birth Weight 0.9% or less of live births 2001 1.2% 1.1% z
Preterm Births (37 w ks gest) NA
2
2002 9.8% 9.5% z
Births w ithin 24 mths 6% or less of live births 2000 2.2% 1.7% O z
Births to Teens Alrea dy Mothers NA 2002 DP
3
16.8% ?
1z = County rate in right direction and/or meets HP2010 objective,
! = County rate in wrong direction and/or does not meet HP2010 objective
2NA=not available
3DP=data pending
8. 3
When presenting data to
When presenting data to
your planning group:
your planning group:
z Convey who is affected and how
z Try to highlight comparative information
z Include background information about
county or problem that might be
relevant
Example: Teen Births
Example: Teen Births
Births Per 1,000 Girls Ages 15-17
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
CountyUpper 95% C.I. County Point Estimate CountyLower 95% C.I. State Point Estimate
Teen births by race/ethnicity
Teen births by race/ethnicity
Births Per 1,000 Women Ages 18-19
0
20
40
60
80
100
120
140
1990-1992 1993-1995 1996-1997 1999-2001
County Upper 95% C.L. County Point Estimate
County Lower 95% C.L. State Point Estimate
Whites Blacks
Hispanics Asians
9. 4
Example: Teen Births
Example: Teen Births
Non-Hispanic Teens Hispanic Teens
Births Per 1,000 Girls Ages 15-17
0.00
5.00
10.00
15.00
20.00
25.00
30.00
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
County
Upper 95%
C.L.
County
Point
Estimate
County
Lower 95%
C.L.
State Point
Estimate
Births Per 1,000 Hispanic Girls Ages 15-17 for
Monterey County vs. California, 1994-2001
0.0
20.0
40.0
60.0
80.0
100.0
120.0
1994 1995 1996 1997 1998 1999 2000 2001
County
Upper 95%
C.L.
County
Point
Estimate
County
Lower 95%
C.L.
State Point
Estimate
Example: Unintentional Injury
Example: Unintentional Injury
Top 5 Causes of Injury
Top 5 Causes of Injury
z Motor vehicle
occupant
z Unintentional- Fall
z Suicide/self-inflicted
z Unintentional- other
z Homicide/assault
z Homicide/Assault
z Motor vehicle occupant
z Suicide/self inflicted
z Unintentional- Fall
z Unintentional- Struck
by object
COUNTY* STATE
*Order of causes varies by year in county
*Number of instances in each category for county is less than 20
10. 5
Example: Overweight children
Example: Overweight children
z In 1999-2000, 15.4% of children in US
were overweight
z 25% of Hispanic children were
overweight
z County population aged 5-19 years is
49% Hispanic
Source: FHOP population datasheets
CDC Health, United States, 2002 Chartbook, Table 71
Example: overweight children
Example: overweight children
County vs. California, 2002:
% in 85-95th
Percentile
% in 95th
Percentile or
higher
California 18.1 20.8
County 21.1 21.1
The same source informs us that the
prevalence of overweight children in CA
is higher than the prevalence nationally (15%).
Example: Children in poverty
Example: Children in poverty
Percent of Children living in Poverty______
0%
5%
10%
15%
20%
25%
30%
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
County Upper 95% CL County Point Estimate County Lower 95% CL
State Point Estimate Healthy2010 Objectives
11. 6
Example: Children in poverty
Example: Children in poverty
Example: Children in poverty
Example: Children in poverty
# % # % # % # %
Carmel-by-the-Sea 120 2.9% 3,783 92.7% 178 4.4% 4,081 1.0%
Del Rey Oaks 109 6.6% 1,367 82.8% 174 10.6% 1,650 0.4%
Gonzales 6,474 86.0% 782 10.4% 269 3.6% 7,525 1.9%
Greenfield 11,055 87.9% 1,188 9.4% 340 2.7% 12,583 3.1%
King City 8,922 80.4% 1,892 17.1% 280 2.5% 11,094 2.8%
Marina 5,822 23.2% 9,500 37.8% 9,779 3.9% 25,101 6.2%
Monterey 3,222 10.9% 22,246 75.0% 4,206 14.1% 29,674 7.4%
Pacific Grove 1,108 7.1% 12,957 83.5% 1,457 9.4% 15,522 3.9%
Salinas 96,880 64.1% 36,535 24.2% 17,645 11.7% 151,060 37.6%
Sand City 72 27.6% 160 61.3% 29 11.1% 261 0.1%
Seas ide 10,929 34.5% 11,526 26.4% 9,421 29.0% 31,696 7.9%
Soledad 9,779 86.8% 1,032 9.2% 548 4.0% 11,263 2.8%
Unincorporated Area 33,477 33.5% 59,077 59.1% 7,422 7.4% 99,976 24.9%
Total
1
187,969 46.8% 162,045 40.3% 51,748 12.9% 401,762 100.0%
1Percent for each column's total is the percent for all reported cases
Table. County Population by Community and Race/Ethnicity, 2000.
Source: 2000 Federal Census
Other
White
His panic
Total for
Community
Community
Summary
Summary
z Indicator data alone not always enough
for prioritization process
z Provide additional information to say
more about a particular problem when
possible
z Goal for planning group should be to
make informed decisions about county
priorities
12. 1
Presenting Data on
Presenting Data on
Problem Areas
Problem Areas
(Part 2)
(Part 2)
Brianna Gass, MPH
Family Health Outcomes Project (FHOP)
Community Needs Assessment II Training
February 11 and 18, 2004
Session Objectives
Session Objectives
z Identify ways to convey how problems
were prioritized in your county
z Understand how to effectively display
more detailed information about
problems
By now you have:
By now you have:
z Collected data for all indicators
z Presented indicator data to the planning
group and prioritized among identified
problems
z Begun compiling more detailed
information regarding priority problems
z Conducted a formal problem analysis
for at least one priority issue
13. 2
Priority: Teen births
Priority: Teen births
z County overall rate is higher than CA,
and higher than HP 2010 objective
z County problem is worst within Hispanic
community
z Hispanic population is concentrated in
specific geographic locations throughout
county
Teen Births
Teen Births
Non-Hispanic Teens Hispanic Teens
Births Per 1,000 Girls Ages 15-17
0.00
5.00
10.00
15.00
20.00
25.00
30.00
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
County
Upper 95%
C.L.
County
Point
Estimate
County
Lower 95%
C.L.
State Point
Estimate
Births Per 1,000 Hispanic Girls Ages 15-17 for
Monterey County vs. California, 1994-2001
0.0
20.0
40.0
60.0
80.0
100.0
120.0
1994 1995 1996 1997 1998 1999 2000 2001
County
Upper 95%
C.L.
County
Point
Estimate
County
Lower 95%
C.L.
State Point
Estimate
Possible Causal Pathway
Possible Causal Pathway
PovertyÆ
Inadequate educationÆ
lack of knowledge about birth control and
lack of life options (real and perceived)
for young womenÆ
don’t use contraceptionÆ
pregnancy
14. 3
Risk factors: Poverty
Risk factors: Poverty
Geographic distribution of poverty- concentrated in particular areas
Risk Factors: Education
Risk Factors: Education
0%
5%
10%
15%
20%
25%
30%
35%
40%
Pe
rc
e
nt
o
f
To
tal
Liv
e
Births
His pa nic White Othe r
His panic 34.6% 28.6% 22.4% 10.5% 3.8%
White 0.4% 5.9% 28.9% 27.8% 37.1%
Othe r 2.2% 8.9% 34.1% 30.4% 24.4%
Le s s than 9
Ye ars
9 to 11 Ye ars 12 Ye ars 13 to 15 Ye ars 16 to 17 Ye ars
Percent of births by ethnicity and years of education
Priority: Overweight children
Priority: Overweight children
z California has higher rate of overweight
children than US
z County levels are at or higher than CA
z Rates of obesity are higher among
Hispanic populations
z County population is 49% Hispanic
15. 4
Risk Factors:
Risk Factors:
Overweight children
Overweight children
z Lack of knowledge about proper
nutrition
z Lack of physical activity
z Lack of access to healthy food
z Poverty- can’t afford healthy foods
and/or lack of access in community
Summary
Summary
z Demonstrate why indicators selected
are considered priorities
z Use information gained from problem
analysis
z Present detail on associated risk factors
z Explain next steps for investigating
problem areas and developing
interventions
16. COMMUNITY ASSESSMENT 2:
PROBLEM PRIORITIZATION
AND ANALYSIS
Session Two
Problem Prioritization
Presented by:
Judith Hager Belfiori, MA, MPH
Director of Planning and Evaluation
Family Health Outcomes Project
FHOP Community Assessment 2 Training February 2004 15
17. PARTICIPANTS GUIDE
Session Two
Setting Priorities Among Identified Problems
LEARNING OBJECTIVES
By the end of the presentation and session, participants will be able to:
1. Articulate the benefits of using an objective, facilitated problem priority setting
process
2. Describe the FHOP group process for setting priorities among identified MCAH
problems, using weighted criteria to score problems
3. Identify the challenges of successfully managing the priority setting process
4. Gain hands-on experience by participating in an MCAH problem prioritization
exercise
REFERENCES FOR THIS SESSION
Developing an Effective Planning Process: A Guide to Local MCH Programs,
Chapter 2 “Community Health Assessment: Identifying Maternal, Child Health Needs and
Setting Priorities” and Appendices II--I
SESSION
This session consists of a lecture/slide show presentation titled “Setting Priorities among
Identified Problems.” Following the slide show, the workshop participants will break into
groups and participate in a problem prioritization exercise.
FHOP Community Assessment 2 Training February 2004 16
18. EXERCISE
You will use the following scenario for Activity 1.
Scenario: The group convening today is the Maternal, Child and Adolescent Health Coalition
of OUR County. The group has previously developed its vision and goal statements as follows.
Vision Statement: OUR County will be recognized as a premier county in
California where all pregnant women, mothers, infants, children, adolescents and
families live in safe and nurturing environments that optimize physical and
emotional health and empower them to achieve their full human potential
Goal 1: All infants born to mothers living in our county will be healthy
Goal 2: All children and adolescents in our county will live in a safe, nurturing
environment, which promotes optimal health, growth and development
Goal 3: To prevent duplication of services and maximize resources, agencies serving
children and families, including County MCAH staff, will engage in collaborative
and countywide planning and coordination to ensure assessment of county health
needs and status and the provision of a comprehensive community-based health
care system for this population
MCAH staff collected and analyzed data for the required State indicators, as well as
additional indicators chosen by this group at a previous meeting, to identify MCAH
problems. A community survey was also conducted to determine problems of highest
concern among residents. The meeting objective is to use the data and a formal group
process to assist in determining which problems will be identified as priorities in the
MCAH plan. These will be the priority problems that MCAH will direct interventions
and resources to over the next five years.
Activity 1: The group, guided by a facilitator, will develop prioritization criteria, review data
and prioritize the problems using 1) a point allocation method and 2) the complete facilitated
FHOP prioritization process.
You will be receiving a data sheet and an indicator assessment sheet and will make decisions
based on this information. In your actual local process, the planning group would be receiving
a presentation on the data and participate in a full discussion of the data findings. Members of
the group may ask for additional information.
The facilitator of your group will lead it through the FHOP recommended process for setting
priorities among identified problems. This process is described in Chapter II and a Facilitator’s
Guide to Problem Prioritization is included as Appendix II-I of “Developing an Effective MCH
Planning Process: A Guide for Local MCH Programs.” The guide can be accessed on the FHOP
website http://www.ucsf.edu/fhop/
FHOP Community Assessment 2 Training February 2004 17
19. Your group will complete the following steps of the FHOP recommended process. It will:
1. Review the overall objectives and process of prioritization
2. Select prioritization criteria for the ranking of problems
3. Develop criteria rating scales
4. Weight the prioritization criteria
5. Review / discuss indicator data
6. Agree on the problem list
7. Use weighted criteria to score problems
8. Sum participant’s scores / rank problems
9. Discuss and confirm results/ reach agreement about the final list of priorities
Activity 2. The group will critique its group process and priority setting outcome. Did the
process work well? What worked? What was problematic? Could these problems be avoided?
Were there benefits in using the formal priority setting method? What were they?
FHOP Community Assessment 2 Training February 2004 18
20. C O M M U N I T Y H E A L T H A S S E S S M E N T I I :
S E T T I N G P R I O R I T I E S A M O N G
I D E N T I F I E D P R O B L E M S
Judith Hager Belfiori, MA, MPH
Family Health Outcomes Project (FHOP)
Community Needs Assessment II Training
February 11 and 18, 2004
Objectives for Session
1. Articulate the b e n e f i t s of using a formal
priority setting process
2. Describe the FHOP group p r o c e s s for
setting priorities among problems
3. Identify the challenges of m a n a g i n g the
process
4. Gain e x p e r i e n c e by participating in a
prioritization exercise
Program Planning Cycle
C o n v e n e
Community
Coalition
Assess Community Health
Needs and Resources
Set Priorities among
Identified Needs
Analyze Problems and
Select Interventions
Develop Objectives and
Performance Measures
Program and Evaluation
Planning and Implementation
Evaluation
FHOP Community Assessment 2 Training February 2004 19
21. MCAH Health Assessment
• C o n v e n e a p l a n n i n g g r o u p
• Develop mission goals
• D e v e l o p a n d a s s e s s c o m m u n i t y
health and resource profiles
• A s s e s s M C H i n d i c a t o r d a t a
• Identify health problems
• Prioritize health problems
T o a s s i s t w h e n t h e r e a r e
m a n y p r o b l e m s t o
a d d r e s s a n d d i v e r s e
p a r t i c i p a n t s i n t h e p r i o r i t y
s e t t i n g p r o c e s s
• Direct resources to have the greatest impact
on health status
• Direct resources to areas that matter most to
community partners
• Focus efforts to a manageable number of
p r o b l e m s
• Assure a fair and inclusive process
• Document a systematic, rational decision-
making process
Purposes of Formal
Prioritization Process
FHOP Community Assessment 2 Training February 2004 20
22. Agree on Method of Setting
Priorities
• A s s e s s / b u i l d t h e g r o u p
• A s s e s s l i k e l i h o o d o f m a j o r i s s u e s
• A g r e e o n m e t h o d ( l e s s o r m o r e
formal)
Basic Group Process
A d o p t R e v i e w S e t
C r i t e r i a D a t a P r i o r i t i e s
Approaches to
Problem Prioritization
S i m p l e C o m p l e x
• D e v e l o p c o n s e n s u s
• Rank using votes (e.g., allocate “points”)
• Adopt criteria then rank using votes
FHOP Community Assessment 2 Training February 2004 21
23. A Group Process Recommended
by FHOP includes these steps:
1. select criteria for setting priorities
2. develop criterion scoring scales
3. weight criteria
4. learn about each problem
5. individuals rate problems
6. scores are summed to produce a
group ranking
This process can be used
whenever a group wishes
to make difficult decisions
using a fair and rational
process
• I n d i c a t o r s
• P r o b l e m s
• I n t e r v e n t i o n s
Step 1. Select Criteria for
Setting Priorities
• Stakeholders participate in process
• Select and define criteria
• Assure thorough discussion of criteria
• Select a manageable number
• Participants “buy into” the process as
group selects criteria
FHOP Community Assessment 2 Training February 2004 22
24. Example Criteria for Setting
Priorities among Problems
• Problem is increasing
(trend)
• High incidence/ prevalence
(problem affects a large # of people)
• Community perception of importance of
the problem
• Feasibility of pooling resources across
a g e n c i e s
Step 2. Develop Criterion
Scoring Scales
A numerical scale is developed for each criterion with an
explicit definition for each value. Example:
Criterion: severity of problem consequences:
1 = Not life threatening or disabling to individuals or society
2 = Rarely life threatening, but could be disabling
3 = Moderately life threatening or moderate likelihood of
disability
4 = Moderately life threatening and/ or there is a
strong likelihood of disability
5 = High likelihood of death or disability
Step 3. Weight the Criteria
• How important are the criteria relative to each
other? Are some criteria more important than
others?
• Each criterion is given a weight,
for example:
1 = important
2 = more important
O R
3 = very important
FHOP Community Assessment 2 Training February 2004 23
25. Step 4. Learn About Problems
• D a t a p r e s e n t e d t o t h e g r o u p
– Identify problems
Ø What, who, where
Ø Other information (e.g. survey results)
Ø Target to the audience
– Methods for comparing problems
• G r o u p d i s c u s s e s t h e d a t a
• Q u e s t i o n s a d d r e s s e d
Step 5. Individuals Rate Problems
They apply the criteria using the agreed upon scoring
and weighting values.
Apply the criteria to the problem by:
• Determining the numeric “ score” (1 to 5) for the
criterion
• Multiplying the numeric score by the “ weight ” for that
criterion, that is:
1 = Important
2 = Very important
3 = Most important
Example:
16
2 x 3 = 6
5 x 2 = 10
Disparities
in Infant
Mortality
20
4 x 3 = 12
4 x 2 = 8
Asthma
(children)
TOTAL
Problem is Increasing
(Trend)
(3)
Severity of
Consequences
(2)
PROBLEM
CRITERIA
( Weight )
FHOP Community Assessment 2 Training February 2004 24
26. Step 6. Scores are Summed to
Produce a Group Ranking
48
15
12
15
6
Asthma (Children)
P A R T I C I P A N T S
30
8
12
6
4
Homelessness
38
12
6
10
10
Smoking, Alcohol
and Drugs
36
6
9
12
9
Disparities in
Infant Mortality
T O T A L
4
3
2
1
P R O B L E M
P r o c e s s :
R a n k P r o b l e m s C o n f i r m A g r e e m e n t
H i g h e s t S c o r e = T o p R a n k e d P r o b l e m
From previous example:
A s t h m a 48
Smoking, alcohol, drugs 38
Disparities / infant death 36
H o m e l e s s n e s s 30
Challenges
We learned from:
C o n s u l t a t i o n s
E v a l u a t i o n s
E x p e r i e n c e s
FHOP Community Assessment 2 Training February 2004 25
27. The Major Pitfalls
Failure to build confidence
in the planning process
Lack a framework /
expertise in data selection,
analysis and presentation
Poor priority setting process
• Participants don’t understand the process
• They suspect a predetermined outcome
• Unorganized process
• Too many decisions made outside of
group
• Wrong or too limited a group ranking
Failure to Build Confidence
in the Planning Process
• F r a g m e n t e d a p p r o a c h
Participants ask “Why are we here now?”
• Inadequate communication
S u c c e s s
⇒ Involve stakeholders as early as possible
⇒ Clarify purpose and explain the process
⇒ Articulate / demonstrate commitment to
o u t c o m e
F a i l u r e t o B u i l d C o n f i d e n c e i n t h e P r o c e s s
FHOP Community Assessment 2 Training February 2004 26
28. • Staff are overwhelmed with work
• Participants don’t understand data
– Too much, too complex
– Left out data important to them. Why?
– Need comparative data
– Don’t understand analysis
– Why was data organized as it was?
– What does the data mean?
L a c k a F r a m e w o r k / E x p e r t i s e i n D a t a
S e l e c t i o n , A n a l y s i s a n d P r e s e n t a t i o n
Success
⇒ Must oversee the process to
assure quality and inclusiveness
⇒ Develop / invest in credible process
(time, facilitator, expertise)
⇒ Use a framework for data organization
(target population/service/goal)
⇒ Use different types of data
(qualitative, quantitative, assets, political context)
Success
(continued)
⇒ Adequate level and quality of
analysis (race/ethnicity, income)
⇒ Meaningful presentation
(tell a story)
⇒ Explanation of what has been left
out and why
FHOP Community Assessment 2 Training February 2004 27
29. Poor Priority Setting Process
• Unorganized
• Biased / Appears biased
• P o o r- t i m e m a n a g e m e n t
• Participants not engaged
• Lacks participant buy- in
Success
⇒ Good facilitator skills
⇒ Facilitator / content experts work in sync
⇒ Provide data in advance
⇒ Organized / efficient process
⇒ Adequate time for process, criteria selection,
questions, discussion
⇒ Document the process and results and
distribute to a large audience
I n S u m m a r y :
A v o i d a n d M a n a g e P i t f a l l s b y A s s u r i n g
• Leadership commitment to results of
a rationale, inclusive process with
involvement early in the process
• Best data and process within
r e s o u r c e s
• Well facilitated process
S u c c e s s
FHOP Community Assessment 2 Training February 2004 28
30. Y o u r T u r n
FHOP Community Assessment 2 Training February 2004 29
31. COMMUNITY ASSESSMENT 2:
PROBLEM PRIORITIZATION
AND ANALYSIS
Session Three
Problem Analysis
Presented by:
Geraldine Oliva, MD, MPH
Director
Family Health Outcomes Project
FHOP Community Assessment 2 Training February 2004 30
32. PARTICIPANTS GUIDE
Session Three
Conducting a Formal Problem Analysis
LEARNING OBJECTIVES
By the end of the presentation and session, participants will be able to:
1. Understand the value of doing a thorough problem analysis in selecting an
appropriate intervention for a problem identified in a community assessment
2. Define the terminology of problem analysis
3. Identify individual level/primary precursors, family/ institutional level/ secondary
precursors, and societal/ policy level/ tertiary precursors to an identified problem
4. Identify the most significant pathways and points at which to focus specific
interventions
5. Use basic epidemiologic data to identify groups or geographic areas at highest risk
and contributing the most to the number of cases
6. Describe the added value to a problem analysis of including relative risk and
attributable risk calculations
Following a slide show presentation on the steps and methods of conducting a problem
analysis, the workshop participants will be divided into small groups. You will use the
scenario below for your small group exercise.
REFERENCES FOR THIS SESSION
Developing an Effective MCH Planning Process: A Guide to Local MCH Programs,
Chapter 3 “Conducting a Formal Problem Analysis and Identifying Effective Interventions”
and Appendices III-A and III-B.
EXERCISE
Scenario: You are the MCAH Director/Coordinator in Wonderful County. You are
responsible for working with a planning group to develop the 5-year MCAH Plan to submit
to the state MCHB for Title V funding. The group has already defined its mission and goals
and identified asthma as a high priority problem to be addressed in the plan. It is meeting
to discuss possible interventions to prevent asthma. The meeting is being facilitated by a
planner on your staff. You have met with the planner previously. He/she will facilitate the
meeting and you will be participating as a member of the group.
FHOP Community Assessment 2 Training February 2004 31
33. The group will begin by reviewing the data on asthma that was collected during the
community assessment.
Community Assessment Data:
• The hospital-based utilization data revealed that asthma was the leading cause of
visits to the emergency room and hospitalizations in the pediatric/adolescent
age group 4-18 years of age. When compared to a community assessment,
completed 4 years prior, these same rates had increased 50%.
• The local school district had presented data that revealed that asthma was the
leading cause for school absenteeism for the past 2 years. This was particularly
true for African American and Hispanic children.
• A recent formal poll of PTA members revealed that asthma was the #1 leading
cause of missed work among parents of children with asthma.
• The community clinic representative to the committee reported on the high cost
to them of ER visits for asthma attacks among their population. This was
matched by information from the County that asthma was a high-cost, high-
prevalence condition.
You are now at the point where you need to develop a better understanding of some of the
possible causes for the high number of asthma attacks in preparation for selecting an
intervention or interventions. One approach to doing this is to construct a problem analysis
diagram.
Exercise: The planning group will be lead by the facilitator through the following
activities:
Activity 1: Review the Problem Analysis Framework
Facilitators will briefly review the material presented in the lecture on the definitions
of individual level/ primary precursors, family/ institutional level
factors/secondary precursors, and societal/ policy level/tertiary precursors
Activity 2: Brainstorm Potential Precursors and Review the Problem Analysis
Diagram
Review the scenario data and begin to brainstorm potential precursors for asthma in
Wonderful County. With the facilitator, place the precursors at the appropriate level
on the blank diagram on the wall. Review a model problem analysis diagram for
asthma attacks in children and youth, and discuss the diagram to make any
additions or deletions you think are needed.
Activity 3: Identify the Causal Pathways Suggested by the Data Available
Review additional data. Working from the problem analysis diagram, the group will
identify those causal pathways that are supported by the data.
Activity 4: Determine the Appropriate Points in the Causal Pathway for
Intervention Development
Discuss which pathways are the most important in leading to the poor outcome, and
why. In addition, discuss possible intervention points.
FHOP Community Assessment 2 Training February 2004 32
34. Activity 5: Develop Objectives and Activities for ONE of the Identified Causal
Pathways
Discuss issues that must be considered prior to writing an objective (if sufficient
time). Using one pathway, begin to develop objectives and activities.
Activity 6: Wrap-Up and Presentation
Brief discussion of whether participants feel that this approach will be useful and
how they might implement it. Select a presenter to explain the group’s findings to
the larger group.
FHOP Community Assessment 2 Training February 2004 33
35. Conducting a Formal
Problem Analysis
Geraldine Oliva M.D., MPH
Family Health Outcomes Project (FHOP)
Community Needs Assessment II Training
February 11 and 18, 2004
Program Planning Cycle
C o n v e n e
Public Health/ Community
Coalition
Assess Prioritize
Health Status/Problems
A s s e s s C o m m u n i t y
R e s o u r c e s S t r e n g t h s
Analyze Problem
Select Interventions
Evaluate/ Measure
Performance
Plan Implement
P r o g r a m s
Develop
Objectives
Session Agenda
- D e s c r i b e t h e r a t i o n a l e f o r a p r o b l e m
a n a l y s i s
- D e s c r i b e t h e s i x s t e p s o f a p r o b l e m
a n a l y s i s
- D e f i n e t e r m s u s e d i n a p r o b l e m a n a l y s i s
- I l l u s t r a t e t h e u s e o f a p r o b l e m a n a l y s i s
d i a g r a m
- P a r t i c i p a t e i n a p r o b l e m a n a l y s i s e x e r c i s e
FHOP Community Assessment 2 Training February 2004 34
36. Rationale for a Formal
Problem Analysis
I n o r d e r t o i d e n t i f y e f f e c t i v e
i n t e r v e n t i o n s t h a t w i l l s i g n i f i c a n t l y
i m p a c t a n e g a t i v e o u t c o m e i t i s
n e c e s s a r y t o t a r g e t t h e u n d e r l y i n g
p r o c e s s e s t h a t l e a d t o t h a t o u t c o m e
Why Do a Problem Analysis?
- T o a s s u r e r a t i o n a l a l l o c a t i o n o f
r e s o u r c e s
- T o a v o i d a l l o c a t i o n o f
r e s o u r c e s a l o n g
c a t e g o r i c a l l i n e s
Why do a Problem Analysis:
High Teen Birth Rate Example
T o i d e n t i f y p o s s i b l e c a u s e s o f t h e
p r o b l e m
– P o o r a c c e s s t o f a m i l y p l a n n i n g s e r v i c e s
– P o o r a c c e s s t o a b o r t i o n
– L a c k o f l i f e o p t i o n s f o r s u b g r o u p s o f w o m e n
– P o o r e d u c a t i o n a b o u t r e p r o d u c t i o n f o r g i r l s
a n d b o y s
– Financial barriers for teens
FHOP Community Assessment 2 Training February 2004 35
37. Prenatal Care??
Home Visiting???
So Now
What ??
Steps in a Formal
Problem Analysis
1. E x a m i n e t h e
epidemiological
data
2. Review the literature and
consult experts
3. Determine the extent to
which these factors are
active in the community
Steps in a Formal
Problem Analysis
4. Determine
contribution of each
identified factor
5. Identify
interrelationships
among factors
6. Determine
intervention points
FHOP Community Assessment 2 Training February 2004 36
38. 1. Review Epidemiology
of the Problem
l How does the rate compare to a standard?
(i.e. Healthy People 2010)
l Is the problem increasing or decreasing?
l Which populations are most at risk and which
contribute the greatest number of cases to the
overall problem ? And why?
l Which geographic areas contribute most to the
overall problem?
Issues to Address in
Reviewing Data
l W h e n d o e s t h e d i s e a s e / p r o b l e m
o c c u r ?
l W h a t c a u s e s t h e p r o b l e m ?
l W h i c h f a c t o r ( s ) c o n t r i b u t e s m o s t t o t h e
s i z e o f t h i s p r o b l e m ?
l C o u l d t h e o b s e r v e d d i f f e r e n c e s b e d u e
t o c h a n c e ?
Comparing Risks
• Most public health reports compare percents
or rates of occurrence of conditions, problems
or outcomes among a number of groups
• These differences are used to identify and
quantify disparities in health by age,
geography, race/ethnicity or social class
• In order to be meaningful, statistical tests
need to be applied to determine the likelihood
that observed differences are not due to
c h a n c e
FHOP Community Assessment 2 Training February 2004 37
39. Risk Difference (RD)
l Definition: t h e d i f f e r e n c e s i n r a t e s o f
o u t c o m e s f o r s u b g r o u p s o f t h e
p o p u l a t i o n (e.g. race or income groups)
l C a l c u l a t i o n : t h e r a t e i n o n e g r o u p
m i n u s t h e r a t e i n a c o m p a r i s o n g r o u p
Risk Difference Calculation
If the infant mortality rate is 14 per 1000 in
African- American infants and 7 per 1000 in
White infants the risk difference is:
14 per 1000 minus 7 per 1000 = 7 per thousand
This means that African American infants have
a 7 per thousand or twice the risk of dying than
white infants
Limitations in Use of Risk
Differences Alone
l Can be misleading if tests of statistical significance
are not included in report
l Using rates or percents doesn’t take into account
the number of cases for each group (e.g. a group
with a high rate may have very few cases and therefore not
warrant a major focus)
l Rate differences do not take into consideration the
factors that may contribute to the outcome in a
particular group (e.g. behavioral risk factors, SES)
FHOP Community Assessment 2 Training February 2004 38
40. R i s k D i f f e r e n c e s M u s t b e A c c o m p a n i e d
b y a C o n f i d e n c e I n t e r v a l
95% CI 95% CI
Using Confidence Intervals (CI)
l A confidence interval is the range of values
within which the “true” value is likely to fall
l 95% is the most commonly used CI
l A 95% CI indicates that there is a 95%
chance that the “true” value of the estimate
(rate) is included in the interval
l All risk calculations should be accompanied
by a CI
Effects of Sample Size on
the Confidence Interval
l T h e s m a l l e r t h e s a m p l e , t h e l a r g e r t h e
c o n f i d e n c e i n t e r v a l a n d t h e h a r d e r i t i s
t o d e t e r m i n e s t a t i s t i c a l s i g n i f i c a n c e
l T h e l a r g e r t h e s a m p l e , t h e s m a l l e r t h e
c o n f i d e n c e i n t e r v a l
FHOP Community Assessment 2 Training February 2004 39
41. 95% Confidence Interval
Confidence Interval Width
Number of Events
4.00%
5.00%
6.00%
7.00%
8.00%
6,000
LBW
a
n
d
100,000
Total
Births
600
LBW
and
10,000
Total
Births
60
LBW
and
1,000
Total
Births
Low
Birthweight
Percent
Upper 95% CI
LBW Percent
Lower 95% CI
Key Questions to Answer
When Comparing CIs
I n E n g l i s h
l C o u l d t h e o b s e r v e d d i f f e r e n c e s b e d u e
t o c h a n c e ?
l A r e t h e r e t r u e d i f f e r e n c e s a m o n g t h e
g r o u p s t h a t I a m c o m p a r i n g ?
I n S t a t i s t i c a l L i n g o
l D o t h e c o n f i d e n c e i n t e r v a l s o v e r l a p ?
2. Review Literature and
Consult Experts
P u r p o s e : T o a s s i s t i n t h e i d e n t i f i c a t i o n
o f c a u s a l o r r i s k f a c t o r s
A p p r o a c h e s :
- C o n d u c t a l i t e r a t u r e s e a r c h
- I n v i t e e x p e r t s t o p a r t i c i p a t e
FHOP Community Assessment 2 Training February 2004 40
42. Literature Review: How
Literature Is Structured
Journals,
Conference
Proceedings
Reviews, Indexes,
Abstracts, Monographs
Encyclopedias,
Handbooks, Textbooks, Web
P r i m a r y
L e v e l
S e c o n d a r y
L e v e l
T e r t i a r y
L e v e l
The Search Strategy
Tertiary Sources
S e c o n d a r y S o u r c e s
Primary
S o u r c e s
Searching Via Internet
Good places to Start:
• Search with G o o g l e
• Go to known sources of data such as CDC site
- Provides raw data
- Provides summaries of major health issues
- Provides information on evidence based
p r o g r a m s
• Go to http://locatorplus.gov/http://locatorplus.gov/
Provides links to:
- MedlinePlus
- Medline = P u b M e d
FHOP Community Assessment 2 Training February 2004 41
43. MedlinePlus
Health information site from the National
Library of Medicine
Drugs, dictionaries, medical encyclopedia
Links to quality full text information from the
government as well as other agencies
http://medlineplus.nlm.nih.gov/medlineplus/
3. Determine Whether Identified
Factors are Relevant
- C o n s u l t w i t h s t a t e o r l o c a l
e p i d e m i o l o g i s t s
- I d e n t i f y s t u d i e s o r r e s u l t s o f s u r v e y s
o f t h e t a r g e t c o m m u n i t y
- C o n s u l t o t h e r l o c a l a g e n c i e s o r
i n s t i t u t i o n s
4. Determine the Contribution of
Identified Factors
C a n u s e t h e s e m e t h o d s :
- Relative risk
- Attributable risk
- Multivariate analysis of factors
strongly associated with the
o u t c o m e
FHOP Community Assessment 2 Training February 2004 42
44. Relative Risk/ Risk Ratio (RR)
l D e f i n i t i o n : t h e r e l a t i v e r i s k i s t h e
c a l c u l a t e d r a t i o o f t h e i n c i d e n c e r a t e o f
a n o u t c o m e i n t w o g r o u p s o f p e o p l e , o n e
w i t h t h e r i s k f a c t o r o f i n t e r e s t a n d t h e
o t h e r w i t h o u t t h a t r i s k f a c t o r
Relative Risk Questions:
Example
l H o w d o t h e i n f a n t d e a t h r a t e s o f l o w
b i r t h w e i g h t b a b i e s c o m p a r e t o t h e
t h o s e w i t h o u t l o w b i r t h w e i g h t ?
O R
l H o w m u c h m o r e l i k e l y i s i t t h a t l o w b i r t h
w e i g h t b a b i e s w i l l d i e c o m p a r e d t o
b a b i e s w i t h o u t l o w b i r t h w e i g h t ?
Organizing Data for Risk
Analysis : The 2x2 Table
d
c
b
a
POOR OUTCOME
YES NO
Exposed
Not
Exposed
a+b
c+d
R R C a l c u l a t i o n : a / a + b d i v i d e d b y c / c + d
FHOP Community Assessment 2 Training February 2004 43
45. Risk Analysis – Infant
Mortality and LBW
I n f a n t D e a t h
Y e s No Births(n)
Y e s 240 (a) 19,760 (b) 20,000 (a+b)
No 160 (c) 19,840 (d) 20,000 (c+d)
Total 400 39,600 40,000
(a+c) (b+d)
L B W
Relative Risk (RR) for Infant
Death in LBW Infants
L B W R i s k R R
Y e s . 0 1 2 ( a / a + b )
= 1.5
N o . 0 0 8 ( c / c + d )
T h e r i s k o f i n f a n t d e a t h f o r L B W b a b i e s i s
1 . 5 t i m e s t h a t o f n o r m a l w e i g h t b a b i e s
What is Attributable Risk?
l Definition: T h e p o r t i o n o f t h e i n c i d e n c e
o f a n o u t c o m e a m o n g p e o p l e e x p o s e d t o
a r i s k f a c t o r t h a t c a n b e a t t r i b u t e d t o t h e
e x p o s u r e t o t h e r i s k f a c t o r
l C a l c u l a t i o n : T h e i n c i d e n c e r a t e a m o n g
e x p o s e d m i n u s ( - ) t h e i n c i d e n c e r a t e
a m o n g n o n - e x p o s e d
FHOP Community Assessment 2 Training February 2004 44
46. The Attributable Risk is a
Measure of Excess Risk
Population Attributable
Risk (PAR) and PAR%
In Public Health, attributable risk is usually
e x p r e s s e d i n r e l a t i o n s h i p t o t h e e n t i r e p o p u l a t i o n
Definition P A R : the proportion of the total
p o p u l a t i o n w i t h t h e o u t c o m e o f i n t e r e s t m i n u s
t h e p r o p o r t i o n o f t h o s e w i t h o u t e x p o s u r e w i t h
t h a t o u t c o m e
D e f i n i t i o n P A R p e r c e n t : % o f c a s e s w i t h a
n e g a t i v e o u t c o m e i n t h e t o t a l p o p u l a t i o n t h a t c a n
b e a t t r i b u t e d t o e x p o s u r e
Application of Risk Analysis
in Problem Analysis
K n o w i n g t h e R e l a t i v e R i s k a n d
P o p u l a t i o n A t t r i b u t a b l e R i s k % f o r
i d e n t i f i e d r i s k f a c t o r s o r p r e c u r s o r s c a n
a s s i s t i n i d e n t i f y i n g t h e i n t e r v e n t i o n f o c i
a n d p a t h w a y s t h a t w i l l r e s u l t i n t h e
g r e a t e s t i m p a c t o n t h e o u t c o m e o f
i n t e r e s t
FHOP Community Assessment 2 Training February 2004 45
47. 5. Identify the Problem Precursors
and Their Inter-relationships
- P r e c u r s o r s o f a h e a l t h o u t c o m e
- C o n s e q u e n c e s o f t h a t o u t c o m e
- L i n k a g e s b e t w e e n p r e c u r s o r s a n d
o u t c o m e s
- U n d e r l y i n g p r o c e s s e s o r c a u s a l
p a t h w a y s
Precursors
D e f i n i t i o n :
F a c t o r s t h a t h a v e b e e n p r o v e n t o b e
a s s o c i a t e d w i t h t h e p r o b l e m
- C a u s a l f a c t o r
- R i s k f a c t o r
- S y s t e m s b a r r i e r
- Protective factor
Individual Level/
Primary Precursors
D e f i n i t i o n :
F a c t o r s r e l a t e d t o t h e i n d i v i d u a l w i t h t h e
p r o b l e m , t h a t d i r e c t l y c a u s e t h e
o u t c o m e i n q u e s t i o n o r r i s k f a c t o r s
c l o s e l y l i n k e d t o t h o s e f a c t o r s -
cause/effect should be supported by peer reviewed
studies or evidence supporting risk factor
relationships are solid enough to act a proxies for
causal factors
FHOP Community Assessment 2 Training February 2004 46
48. Direct Precursors: Examples
for Low Immunization Rate
- Child allergic to vaccine
vehicle
- Frequent childhood illnesses
- Child has a disease that
compromises the immune
system
Family/Institutional Level
Factors/Secondary Precursors
D e f i n i t i o n :
F a c t o r s i n i n s t i t u t i o n s w i t h w h i c h t h e
i n d i v i d u a l d i r e c t l y i n t e r a c t s t h a t i n c r e a s e
a n i n d i v i d u a l ’ s r i s k o f d e v e l o p i n g a d i r e c t
p r e c u r s o r
May include family, school, workplace or
health provider characteristics that are often,
but not always, associated with the problem or
its determinants
Secondary Precursors:
E x a m p l e s f o r L o w I m m u n i z a t i o n R a t e
- M.D. has no tracking/ reminder
system
- Lack of available vaccine in this
community
- Parental refusal of vaccine due to
fear of side effects of vaccination
FHOP Community Assessment 2 Training February 2004 47
49. Societal/Policy
Level/Tertiary Precursors
Definition:
F a c t o r s t h a t a r e d e t e r m i n e d a t t h e s t a t e
o r n a t i o n a l l e v e l b y h e a l t h , s o c i a l o r
e c o n o m i c p o l i c i e s o r f a c t o r s r e l a t e d t o
b r o a d e c o n o m i c o r s o c i a l t r e n d s o r
a t t i t u d e s
Societal/ Policy Factor:
E x a m p l e s f o r L o w I m m u n i z a t i o n R a t e
- Poverty caused by economic downturn resulting in
lack of jobs
- Inadequate low income housing due to government
housing policies
- Lack of available health insurance for kids
- R a c i s m
Consequences
D e f i n i t i o n :
T h e e f f e c t s o f t h e p r o b l e m o n
i n d i v i d u a l s , f a m i l i e s a n d s o c i e t y
FHOP Community Assessment 2 Training February 2004 48
50. Consequences: Examples
for Low Immunization Rate
- P a r e n t m i s s e s w o r k
- L o s s o f h e r d i m m u n i t y l e a d i n g t o
f u r t h e r i n c r e a s e i n i n f e c t i o n s
- D e a t h o r d i s a b i l i t y f o r c h i l d r e n
i n f e c t e d
Generic Framework for Health Problem Analysis
Generic Framework for Health Problem Analysis
Societal/ Policy Level/ Tertiary Precursors Level
Lack of Affordable/Accessible Family Planning Clinics
Family/ Institutional Level/ Secondary Precursors
Individual Level/ Primary Precursors
SES
Factors
Education Policy Economic
factors
Environmental
Factors
Safety
Nuclear Family
Factors
Local School/
Workplace Factors
Quality issues
Identified Problem
Economic, Physical, etc
Genetic/Biological
Characteristics
Genetic/Biological Characteristics
Psychosychological
Factors
Cognitive Factors
Health
Behaviors
Specific Biological Risk
Factors
Immediate Causal
Factor(s)
Healthcare
Policies
Health Care Provider
Issues
Community
Networks
friends
Connection to religious or other
community groups
Consequences
Targeted Indicator
Causal Pathways
D e f i n i t i o n :
T h e a s s o c i a t i o n b e t w e e n
a p r o b l e m a n d i t s p r e c u r s o r s
- Review the literature
- C o n s u l t e x p e r t s
- A n a l y z e y o u r d a t a
FHOP Community Assessment 2 Training February 2004 49
51. P r o b l e m A n a l y s i s D i a g r a m w i t h C a u s a l P a t h w a y :
I n a d e q u a t e I m m u n i z a t i o n s
Societal/Policy Factors Precursors
Manufactures liability fears
Inadequatelowincomehousing
Nonationalfundingforvaccinesorproductliability
Family/Institutional
Factors
Familyhasnohealthinsurance
PoorM.D.adherencetonationalIZ
guidelines
Limited access to
quality medical care
o
Family has low education
Individual Level FactorsPrecursors
Allergictovaccinevehicle, air pollution,
Inadequate Immunization
Vaccine Ineffective
Family not given IZ education or regular
visit schedule
No schoolIZ policiesorprograms
Inadequate national health insurance
policies
High cost of vaccine/healthcare
Family has language/cultural
barriers
Parents refusal of
vaccine
Problem:
Consequences:
Preventable infection: Death, hospitalizations, ED visits, misse
d school/work
Manufacturer’s liability
fears
Family with transient housing
Immuno-compromising
condition
Lack of M.D. or DPH tracking and recall system
Protective Factors
D e f i n i t i o n :
A t t r i b u t e s o f f a m i l y , c u l t u r e , s o c i a l s y s t e m s
o r t h e e n v i r o n m e n t a s s o c i a t e d w i t h a
p o s i t i v e o u t c o m e
E x a m p l e s :
G o o d n u t r i t i o n , s a f e r e c r e a t i o n a l a r e a s ,
s t r o n g f a m i l y c o n n e c t e d n e s s (can be active at all
three level of problem diagram)
Systems Barriers
D e f i n i t i o n :
A t t r i b u t e s o f t h e h e a l t h , s o c i a l , e d u c a t i o n a l
a n d e c o n o m i c s y s t e m w h i c h a r e a s s o c i a t e d
w i t h t h e o b s e r v e d p o o r o u t c o m e
E x a m p l e s :
L a c k o f h e a l t h i n s u r a n c e , i n a d e q u a t e f o o d
s a f e t y n e t , a n d p o o r t r a n s p o r t a t i o n (can be
active at the second and third levels)
FHOP Community Assessment 2 Training February 2004 50
52. 6 . D e t e r m i n e I n t e r v e n t i o n P o i n t s
- D e t e r m i n e w h e r e y o u w o u l d g e t t h e
g r e a t e s t e f f e c t u s i n g r i s k a n a l y s i s d a t a
from Step 4
- D e t e r m i n e f r o m a l i t e r a t u r e r e v i e w
w h e t h e r t h e r e h a v e b e e n w e l l e v a l u a t e d
i n t e r v e n t i o n s
- A s s e s s t h e a v a i l a b l e r e s o u r c e s
Diagramming Critical Pathways to
Identify Effective Interventions
L o w p e r c e i v e d
threat of
c o m m u n i c a b l e
diseases
L o w
I m m u n i z a t i o n
R a t e
I n t e r v e n t i o n
Parental refusal
o f v a c c i n e
Points to Remember
B e f o r e s e l e c t i n g a n i n t e r v e n t i o n :
- Have adequate data relevant to your community
- Use data to identify precursors, protective factors,
system barriers and consequences
- Identify inter-relationships among these factors
(causal pathways)
AND
- Analyze the data to determine the relative
contributions of the precursors to the overall
problem
FHOP Community Assessment 2 Training February 2004 51
53. Perspective to Remember
Child
Family
Workplace
School
Daycare
Availability of
health services
County
State
National
Politics
Community
Housing
City
YOU
ARE
HERE
Healthcare
Provider
Jobs
Policies
Laws
Exercise
Activity 1: Review the Problem Analysis Framework
Activity 2: Brainstorm Potential Precursors and
Review the Problem Analysis Diagram
Activity 3: Identify the Causal Pathways
Activity 4: Determine Intervention Points
Activity 5: Develop Objectives and Activities
Activity 6: Wrap- Up and Presentation
FHOP Community Assessment 2 Training February 2004 52
54. DEFINITIONS OF TERMS
The following definitions will help to clarify terms used in the process of constructing a problem
analysis diagram:
Precursors — Aspects of personal behavior, life-style or genetic predisposition; family
influences; school, job or other institutional factors; and environmental conditions or other
community level characteristics that have been shown in the peer review literature to be
associated with a poor health outcome. Precursors can be categorized in a number of ways.
One useful approach is to define them as individual level/primary precursors, family/
institutional level/ secondary precursors and societal/ policy level/ tertiary precursors as
follows:
Individual level/ Primary Precursors – often called determinants, have a direct cause-and-
effect relationship to the health outcome. They include factors that are directly related to
the pathological processes that lead to the outcome. This direct cause and effect
relationship should be identified and supported by peer reviewed experimental studies.
For example, if the identified problem is low birth weight, individual level/ primary
precursors would include factors such as pre-term birth, maternal substance abuse,
poor maternal nutrition, or chronic maternal illness. Individual/ primary precursors
are, generally, those related to the characteristics or behavior of an individual
(biological, medical or behavioral).
Family/ Institutional Level/ Secondary Precursors – have a significant association with
the health outcome, but not a clear direct causal relationship. These usually include
characteristics of the family or characteristics of the institutions in which a person works,
studies or lives. They are often, although not always, related to direct factors.
For example, for childhood obesity, family/ institutional level/ secondary precursors
could include familial dietary patterns, families’ lack of knowledge of what constitutes
a healthy diet, or inadequate exercise.
Societal/ Policy Level/ Tertiary Precursors – often referred to as community or
environmental factors, are those global conditions or policies that impact health status.
They are often societal, political or environmental in nature and can include poverty,
racism, community violence, level of unemployment, inadequacy of health services, and
level of safe and affordable housing.
For example, for childhood obesity, they could include: advertising of fast foods to
young people, lack of availability of supermarkets selling healthy food, lack of safe
recreation areas providing opportunity for exercise, and lack of availability of
preventive health services.
FHOP Community Assessment 2 Training February 2004 53
55. DEFINITIONS OF TERMS
Consequences — the effects of the problem on individuals, families and society. Identifying
and quantifying consequences enables assessment of the significance of the problem.
For example, if assessing the consequences of frequent asthma attacks, assessment might
include the immediate costs in terms of medical care, the school absence leading to
poor school performance and possibly school dropout, as well as the physical
emotional and economic costs of the resulting death and/or disabilities. As can be
seen in this example, consequences of one step in the problem cycle can become
precursors to another problem. Consequences can also be categorized as individual
level/ primary, family/ institutional level/secondary or societal/ policy level/
tertiary.
Causal Pathways — the association between the problem and the various levels of precursors.
The concepts of relative risk and population attributable risk can be useful in identifying
causal pathways. Also, the literature research can inform how precursors are related. There
are well accepted theories of how various factors contribute to certain behaviors that in turn
contribute to poor health outcomes.
For example, cultural eating patterns that include foods high in fat are associated with
higher dietary fat intake in many of the individuals in that culture leading to high
serum cholesterol. This in turn is associated with increased formation of plaques on the
coronary arteries that result in higher rates of myocardial infarction.
Protective Factors – personal characteristics, attributes of the family or culture, or attributes of
the operating social systems, the environment or the community in which individuals live that
are associated with positive health status or outcomes.
For example, a high rate of literacy among adults, the presence of community agencies
that assist newcomers by providing translation services for health care visits, the
presence of safe after-school and evening recreational facilities for teens, the presence
of a neighborhood crime patrol.
Protective factors exist at all levels of the problem diagram. It is important to
determine not only whether there are community assets, but also whether the target
population is connected to the protective factors in the community or have other
protective factors characteristic of their distinct community.
Systems Barriers ⎯ Attributes of the health care delivery system, including financial,
geographical and cultural accessibility, which have been shown in the health and social
welfare literature to be associated with a poor outcome for a variety of health indicators.
System barriers can be family/ institutional level/secondary precursors societal/ policy level/
tertiary precursors.
For example, lack of health insurance, lack of culturally and linguistically appropriate
services, geographic inaccessibility or poor transportation. These fall into the category
of societal/ policy level/tertiary precursors.
FHOP Community Assessment 2 Training February 2004 54
