2. Risk Management and Strategy Prioritisation Intelligence Step 8 - Risk Management and Strategy Prioritisaiton Considering the risks associated with action (and/or inaction) to address public health nutrition issues are a professional and ethical responsibility Risk management involves identifying the risks of doing nothing and of implementing the proposed intervention, planning risk management strategies and weighing the intervention risks against the benefits. Appropriately selecting and prioritising intervention strategies involves analysing the risks or benefits associated with the determinants being addressed

3. Risk Management and Strategy Prioritisation

4. Assessing Risks and Benefits Risk refers to the probability a hazard will result in an adverse health event Benefit refers to the probability a protective/ promotive factor will result in a positive health event Assessing risks and benefits of determinants elicits information to help decide:  to take action on a determinant  to manage a determinant  how to prioritise between determinants

5. Risk Management and Strategy Prioritisation Assessing Risks and Benefits The following key questions are useful to consider when assessing risk and benefits:  What is the likelihood of a health risk or benefit  Which individuals/groups are most at risk/likely to benefit  How sever are the anticipated adverse effects/size of benefit  Is there potential to prevent the adverse effects  What is the nature and strength of evidence to support the conclusions regarding magnitude and nature of risk/benefit  What is the range of informed views and confidence about the evidence  What is the distribution of risk/benefit compared to other risks/benefits in the population?  What are the social/cultural consequences?

6. Risk Management and Strategy Prioritisation Assessing Risks and Benefits Stakeholders play and important role in providing information for use in risk assessment Most stakeholders will identify specific concerns of relevance to them  perceptions can vary substantially among stakeholders and assessment may be highly controversial The decision to take action, to manage risks and promote benefits should be based on scientific assessment. ‘Managing risks and benefits should reflect a preference for avoiding unnecessary health risks rather than unnecessary economic expenditures’

7. Risk Management and Strategy Prioritisation Types of Risks and Benefits There are three types of risks and benefits to health: 1.Expressed - a risk or benefit has a consistent link between the determinant and health issue, and can be measured 2.Potential - a risk or benefit that relates to a sporadic, unreported or non-existent health issue such that the prevalence of the determinant can only be estimated 3.Perceived - a risk or benefit that occurs when there is strong public perception that intervention is desirable despite the lack of scientific evidence to support action

8. Risk Management and Strategy Prioritisation In practice, people in a community that you engage with may not perceive the risk associated with poor nutrition. The community may instead identify immediate issues such as drug abuse, HIV or meningitis as the primary risk they are concerned about rather than expressed risk such as inadequate fruit and vegetable intake even though the expressed risk may have a bigger impact on health. Exploring differences between expressed, perceived and potential risks is important because it may influence the sort of strategies required to ensure ongoing community participation.

9. Strategy Prioritisation Strategy prioritisation is the decision making task of ordering identified strategies to assist with the development of a strategy portfolio Resources for PHN interventions are commonly limited so deciding which strategies to use and which to reject can be difficult Strategy prioritisation is a collaborative decision making process, where key stakeholders consider the  available intelligence on the health problem  known strategy options/ interventions to address the problem Risk Management and Strategy Prioritisation

10. Challenges in Strategy Prioritisation Risk Management and Strategy Prioritisation Agreeing on priorities and selecting strategies is a complex task that requires negotiation and collaboration skills There are some key challenges in strategy prioritisation and selection:  Vast range of strategy possibilities - prioritising strategies in a systematic, transparent manner can be challenging, particularly when several stakeholders are involved  Level of evidence available for prevention strategies – lack of high level evidence available for health promotion intervention strategies  Resources limitations – strategy selection and prioritisation needs to match limitations in funding, staff capacity, equipment etc

11. Risk Management and Strategy Prioritisation Challenges in Strategy Prioritisation Using criteria with specific definitions helps standardise strategy prioritisation and selection The choice and definition of each criteria component and relative weighting scheme should be based on group consensus Opening the criteria to critical analysis and scrutiny by the public and decision makers for transparency of the priority setting process Three useful tools to assist prioritising strategies include:  Assessment Protocol for Excellence in Public Health  Angelo Framework  ACE process

12. Risk Management and Strategy Prioritisation The Priority Rating Process The model incorporates factors of determinants including size, seriousness, effectiveness and contextual appropriateness to numerically prioritise health needs and interventions Using the gathered intelligence each component is scored and then applied to calculate the Basic Priority Rating (BPR) This process is very analytical and is not commonly used in practice BPR = [(A+B)xC/ 3] x D

13. Risk Management and Strategy Prioritisation The ANGELO Framework Linked to the socio-ecological approach and focused on creating supportive environments for making healthy choices → aided by health education, social marketing and skill development Systematically identifies and prioritises the following attributes of a health problem for intervention:  Potential behaviours  Knowledge/ skills/ attitudes  Environments Prioritisation involves the analysis team reviewing the changability and importance of each attribute

14. Risk Management and Strategy Prioritisation The ACE Process The ACE (assessing cost-effectiveness) process is a systematic method used to assess the cost-effectiveness of obesity interventions A numerical classification system assesses the strength of evidence of intervention strategy effectiveness A qualitative approach is used to assess the other judgement criteria by listing the contextual considerations and achieving a summary position A final overall assessment is determined for each intervention strategy to assist with prioritisation

15. Risk Management and Strategy Prioritisation CriteriaConsiderations Strength of evidenceThree levels: 1. Sufficient evidence of effectiveness (effect is unlikely to be due to chance or bias) 2. Limited evidence of effectiveness (effect is probably not owing to chance) 3. Inconclusive evidence of effectiveness (no position could be reached – only few and poor quality studies available) EquityIs the strategy selective, does it reach high priority groups? Is the impact evenly distributed, does it have high impact on a few people or a low impact on a lot of people? AcceptabilityIs the intervention strategy politically acceptable? Is the intervention strategy socially acceptable? Who supports/ is against the intervention? FeasibilityIs there adequate capacity to implement the strategy? Is the strategy feasible in the current context? Are there contextual factors that will interfere with strategy implementation? SustainabilityWhat is the sustainability of the action? Is on-going capacity and infrastructure required for the strategy to continue? Side-effectsWhat are the positive side-effects of the action? What are the negative side-effects of the action? How do these side-effects weight against each other? ACE Decision Making Criteria