1. Conducting a Formal Problem Analysis The Foundation of an Effective Intervention Strategy 1

2. Roadmap for this Module 2  Articulate the rationale for a formal problem analysis  Describe the conceptual framework  Describe the 6 steps of a formal problem analysis  Define terms used

3. 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 3

4. 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 4

5. Why do a Problem Analysis, continued  Necessary step in developing a problem statement to use when  developing a logic model, and  designing and evaluating an intervention  Assists in identification of short, intermediate and longer term objectives 5

6. Steps in a Problem Analysis 1. Examine epidemiologic data 2. Examine literature and consult experts 3. Determine extent to which these factors are active in the community 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 6

7. 1. Examining the 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? 7

8. 2. Examining the literature and consulting experts  To identify causal or risk factors:  Search the Web  Conduct a literature search  Locate a literature search conducted by a reliable source  Invite experts to participate 8

9. 3. Determining the extent to which the factors are active in the community  Consult with state or local epidemiologists  Identify studies or results of surveys of the target community  Consult other local agencies or institutions 9

10. 4. Determining the relative contribution of each identified factor  Epidemiologists and other data analysts use a variety of statistical tests to determine risks associated with particular individual level characteristics or risk factors  Statistical tests answer important questions such as  How much more likely to have a low birthweight infant is a woman who smokes compared to one who doesn’t smoke?  How many low birthweight births are the result of exposure to maternal smoking? 10

11. 5. Identifying the interrelationships among factors – causal pathways  Determine how identified causal and risk factors interact to either increase the chances of a negative outcome or to promote a positive outcome 11

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14. SECONDARY TERTIARY PRIMARY Mother’s Level of Education Newcomer status Transient housing Barriers to care: Language Cultural Transportation Financial Legal Families with many children Parent with alcohol or drug problem Domestic Violence Chronic Childhood Illness / immunocompromised Racism / Discrimination Poverty Limited availability of health insurance for the poor PROBLEM: INADEQUATE IMMUNIZATIONS Health Providers Missed Opportunities Lack of availability of vaccines Inadequate record keeping Lack of tracking & reminder / recall systems Parental non-compliance Religious or philosophical objections Fear of vaccine side effects Lack of federal funding for vaccines Manufactures liability fears Family lack of health Insurance 14

15. SECONDARY TERTIARY PRIMARY Mother’s Level of Education Newcomer status Transient housing Barriers to care: Language Cultural Transportation Financial Legal Families with many children Parent with alcohol or drug problem Domestic Violence Chronic Childhood Illness / immunocompromised Racism / Discrimination Poverty Limited availability of health insurance for the poor PROBLEM: INADEQUATE IMMUNIZATIONS Health Providers Missed Opportunities Lack of availability of vaccines Inadequate record keeping Lack of tracking & reminder / recall systems Parental non-compliance Religious or philosophical objections Fear of vaccine side effects Lack of federal funding for vaccines Manufactures liability fears Family lack of health Insurance 15

16. 6. Determining the most effective points in the causal pathways for intervention  Determine where you would get the greatest effect  Determine whether there have been well- evaluated interventions  Assess the available resources 16

17. Diagramming Critical Pathways to Identify Effective Interventions Low perceived threat of communicable diseases Low Immunization Rate INTERVENTION Parental refusal of vaccine 17

18. 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 18

19. 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) 19

20. Using a Problem Analysis in a Group Planning Process 20

21. Process for doing a problem analysis with a planning group  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 21

22. Planning Group Process, continued  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 22

23. Planning Group Process, continued  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 23

24. Definition of Terms & Examples 24

25. Definitions: Precursors  Factors that have been proven to be associated with the problem  Causal factor  Risk factor  Systems barriers  Protective factors 25

26. Individual Level - Primary Precursors  Definition :  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) OR  Factors that increase the risk of an individual’s likelihood of having the outcome of concern (documented risk) 26

27. Primary Precursors: Examples for Low Immunization Rate  Child who is immuno- compromised  Parental refusal of vaccine due to fear of side effects of vaccination 27

28. Family/Local Community/ Secondary Level Precursors  Definition :  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 28

29. Secondary Precursor / Risk Factor: Examples of Low Immunization Rate  Lack of provider tracking systems/ reminder calls  Transient housing  Missed opportunities where child has recurrent or chronic heath problems 29

30. Ecological - Tertiary Level Precursors  Definition :  Factors that are operational at the state or national level such as cultural, health, social, legal or economic policies 30

31. Ecological - Tertiary Level Precursor: Examples of Low Immunization Rate  Poverty  National vaccine shortage  Lack of available health insurance for kids 31

32. Consequences  Definition :  The effects of the problem on individuals, families and society  Can include financial, physical and psychological effects on the individual, the family or the community 32

33. Consequences: Examples of Low Immunization Rate  Parent misses work  Loss of herd immunity leading to costly increase in infections  Death or disability for children infected 33

34. Linkages  Definition :  The association between problem and precursors  Review the literature  Consult experts  Analyze your data 34

35. Systems Barriers and Protective Factors: Definitions  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) 35

36. Acknowledgements The slides for this presentation were adapted from work prepared for CityMatCH’s DaTA Institute by: Gerry Oliva, MD, MPH Director, Family Health Outcomes Project at the University of California at San Francisco http://familymedicine.medschool.ucsf.edu /fhop/index.htm 36