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Conducting a Formal Problem Analysis: the Foundation of an Effective Intervention Strategy

Conducting a Formal Problem Analysis: the Foundation of an Effective Intervention Strategy. Laurin Kasehagen, MA, PhD Senior MCH Epidemiologist / CDC Assignee to CityMatCH August 19, 2011. What is a Problem Analysis?. A way of identifying and articulating a specific problem,

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Conducting a Formal Problem Analysis: the Foundation of an Effective Intervention Strategy

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  1. Conducting a Formal Problem Analysis:the Foundation of anEffective Intervention Strategy Laurin Kasehagen, MA, PhD Senior MCH Epidemiologist / CDC Assignee to CityMatCH August 19, 2011

  2. What is a Problem Analysis? • A way of identifying and articulating • a specific problem, • the underlying factors that contribute to the problem, and • how the contributing factors relate to one another

  3. Convene Public Health / Community Coalition Evaluate / Measure Performance Plan & Implement Programs Assess Community Resources & Strengths Develop Objectives Program Planning Cycle Assess & Prioritize Health Status / Problems Select Interventions

  4. Convene Public Health / Community Coalition Evaluate / Measure Performance Plan & Implement Programs Assess Community Resources & Strengths Analyze Problem / Select Interventions Develop Objectives Program Planning Cycle Assess & Prioritize Health Status / Problems

  5. Roadmap for this Module • Articulate the rationale for a formal problem analysis • Describe the conceptual framework • Describe the 6 steps of a formal problem analysis • Define terms used • Practice conducting problem analyses in teams

  6. Rationale for a Problem Analysis? • In order to identify effective interventions or strategies, it is necessary to understand • the range of underlying factors that can impact a health outcome, and • how they relate to one another

  7. Parental refusal / waiver / exemption to vaccinate child Example for Rationale for a Problem Analysis - 1 Low perceived threat of communicable diseases Low Immunization Rate

  8. Parental refusal / waiver / exemption to vaccinate child Example for Rationale for a Problem Analysis - 2 Low perceived threat of communicable diseases INTERVENTION Low Immunization Rate

  9. Parental refusal / waiver / exemption to vaccinate child Example for Rationale for a Problem Analysis - 3 Low perceived threat of communicable diseases Perception that vaccines may cause learning disabilities, such as autism Perception that young children get too many vaccines in the first years of life Low Immunization Rate

  10. Parental refusal / waiver / exemption to vaccinate child Example for Rationale for a Problem Analysis - 4 Vaccine is expensive and no longer provided at a reduced cost Low perceived threat of communicable diseases Nearest clinic has a high client:provider ratio and wait time is very long Perception that vaccines may cause learning disabilities, such as autism Perception that young children get too many vaccines in the first years of life Vaccine was not produced in quantities needed Low Immunization Rate

  11. Why do a Problem Analysis? • To assure a rational allocation of resources • To assist in targeting limited resources to those factors that play the biggest role in causing the problem • To mitigate the risk of allocating resources based on political pressure

  12. Side Benefits of doing a Problem Analysis • Helpful in developing a problem statement to use when • developing a logic model, and • for designing and evaluating an intervention • Assists in identification of short, intermediate and longer term objectives

  13. Steps in a Problem Analysis - 1 1. Examine epidemiologic data 2. Examine literature and consult experts 3. Determine extent to which these factors are active in the community

  14. Steps in a Problem Analysis - 2 4. Determine relative contribution of each identified factor 5. Identify the interrelationships among factors – causal pathways 6. Determine the most effective points in the causal pathways for intervention

  15. 1. Examine epidemiologic data • How does the rate compare to a standard? (i.e., reference population) • Is the problem increasing or decreasing? • Is a particular group more affected than other groups and why? • When does the disease / problem occur? • What causes the problem?

  16. 2. Examine literature and consult experts to identify causal factors and risk / protective factors • Search the Web • Conduct a literature search • Locate a literature search conducted by a reliable source • Invite experts to participate

  17. 3. Determine extent to which these factors (the good and the bad!) are active in the community • Consult with state or local epidemiologists, anthropologists, public health professionals, etc. • Identify studies or results of surveys of the target community • Consult other local agencies or institutions

  18. 4. Determine the relative contribution of each identified factor Epidemiologists and data analysts use a variety of statistical models and tests to determine relationships between and among characteristics and risk / protective factors at individual, family, institutional, societal and policy levels

  19. Final Steps 5. Identify interrelationships among factors – causal pathways 6. Determine the most effective points in the causal pathways for intervention Determine how identified causal and risk and protective factors interact to either increase the chances of a negative outcome or to promote a positive outcome

  20. Definition: Precursor Factor that has been shown / proven to be associated with the problem

  21. Web of Causation of Diabetes in South Boston Definition: Individual Level - Primary Precursors Factors that operate on the level of the individual that directly cause the outcome in question (cause/effect should be supported by peer reviewed studies) Factors that increase the risk of an individual’s likelihood of having the outcome of concern (documented risk)

  22. Definition: Family, Community Level – Secondary Precursors Factors that operate at the level of the family or local community or institution(s) that increase an individual’s risk of developing a direct precursor May include local institutions such as health provider’s characteristics that are often, but not always, associated with the problem or its determinants

  23. Definition: Ecological Level – Tertiary Precursors Factors that are operational at the state or national level such as cultural, health, social, legal or economic policies

  24. Definition: Consequences The effects of the problem on individuals, families and society -- an include financial, physical and psychological effects

  25. Definition: Linkages The effects of the problem on individuals, families and society -- an include financial, physical and psychological effects

  26. Policy or laws limiting placement of affordable care clinics Lack of federal funding for vaccines Poverty TERTIARY Manufactures liability fears Limited availability of health insurance for the poor Racism / Discrimination SECONDARY Lack of tracking and reminder / recall systems Family lack of health Insurance or inadequate insurance coverage Mother’s Level of Education Newcomer status Transient housing High residential mobility Barriers to care: Language Cultural Transportation Financial Legal Families with many children Parent with alcohol or drug problem Domestic Violence Health Providers: Missed Opportunities Lack of availability of vaccines Inadequate record keeping Lack of a medical home Chronic Childhood Illness / immunocompromised PRIMARY Parental non-compliance Religious or philosophical objections Fear of vaccine side effects INADEQUATE IMMUNIZATIONS IN SCHOOL-AGE CHILDREN PROBLEM:

  27. Policy or laws limiting placement of affordable care clinics Lack of federal funding for vaccines Poverty TERTIARY Manufactures liability fears Limited availability of health insurance for the poor Racism / Discrimination SECONDARY Lack of tracking and reminder / recall systems Family lack of health Insurance or inadequate insurance coverage Mother’s Level of Education Newcomer status Transient housing High residential mobility Barriers to care: Language Cultural Transportation Financial Legal Families with many children Parent with alcohol or drug problem Domestic Violence Health Providers: Missed Opportunities Lack of availability of vaccines Inadequate record keeping Lack of a medical home Chronic Childhood Illness / immunocompromised PRIMARY Parental non-compliance Religious or philosophical objections Fear of vaccine side effects INADEQUATE IMMUNIZATIONS IN SCHOOL-AGE CHILDREN PROBLEM:

  28. Definition: System Barriers & Protective Factors Systems Barriers: Attributes of health and other related systems that are associated with a negative outcome (e.g., lack of health insurance and poor transportation) Protective Factors: Attributes of family, culture, social systems or the environments associated with a positive outcome (e.g., high rate of literacy and presence of community agencies)

  29. Benefits of Using a Problem Analysis • Clearly documents the decision-making process for the group and for others • Can use simplified problem analysis or causal pathway diagram to communicate rationale for intervention strategy to policymakers and the public

  30. Process for doing a problem analysis with a planning group - 1 • Do a brief presentation on the rationale for the process and what you hope to accomplish • Be clear about how group input will be used or not • Brainstorm precursors • Review definition of terms used in a problem analysis

  31. Process for doing a problem analysis with a planning group - 2 • Determine the level at which the precursors operate • Discuss possible linkages between and among precursors • Have quiet time for members to individually identify one causal pathway • Members share and discuss pathways

  32. Process for doing a problem analysis with a planning group - 3 • Identify any needs for more information, e.g., data, data analysis, public health literature, experts • Gather the information and send out • Meet again to revise diagram and make decisions on intervention strategies

  33. Points to Remember Before selecting an intervention: • Have adequate data relevant to your community; • Identify precursors, protective factors, system barriers and consequences; and • Identify inter-relationships among these factors (causal pathways)

  34. Acknowledgements The slides for this presentation were adapted from work prepared for the CityMatCHDaTA Institute by: Geraldine Oliva, MD, MPH Director Family Health Outcomes Project at the University of California at San Francisco http://familymedicine.medschool.ucsf.edu/fhop/index.htm

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