6. Prioritising Public Health Problems | CPP NCD Epidemiology



well hello and welcome to this lecture this is lecture number six in the certificate of professional practice in the epidemiology and control of non communicable diseases before we begin I just want to take a moment as always to thank those who made this lecture series possible including the Pacific Island Health Officers Association the University of Arizona Zuckerman College of Public Health the College of Micronesia public health training program and of course my home institution the Fiji National University School of Public Health and primary care and as always please keep in mind that without the backing of these institutions then these lectures could not be provided and of course as always I want to thank you the participant for your dedication and improving yourself no matter what your area practice is across the Pacific and beyond and of course I want to thank the United States Centers for Disease Control and Prevention from whom these lectures have been adapted and I do want to point out that the opinions I express here in are my own and do not necessarily represent those of the CDC pahoa Avenue or comm FSM okay so thus far in this lecture series we've talked about an introduction to what epidemiology is and its importance to non communicable diseases we've reviewed the burden of NCDs in the Pacific with an emphasis on related risk factors and the need for risk factor surveillance we covered the burden of disease including basic epidemiological measures such as incidence prevalence disability adjusted life years and so forth and we have talked about the different types of descriptive and analytical studies and most recently we discussed how to analyze and interpret surveillance data using primarily descriptive epidemiology so that brings us up to this lecture number six and in lecture number six entitled prioritizing public health problems we will discuss how to prioritize our public health problems by using criteria and research to reach a consensus with key stakeholders both within our organizations as well as within the communities we serve now this is an important lecture particularly for like health planners and program staff and anybody who works with communities as well as funding agencies now as you know public health does not exist in a bubble and it is critical that we work with our communities we cannot simply tell the community what they are going what they're doing wrong and how they should change and expect them to change this is if we come in with an approach like this it's going to cause resentment on the part of the community who are going to view us as interfering Outsiders rather we must work directly with the community to help them identify problems and appropriate solutions to these problems that will then be readily accepted and this is key to this the key to this working with stakeholders in the community such as communities and business and religious leaders is to engage them because when we engage them they feel involved in the process and hence the the communities that they represent are more willing to engage with us and to and we can secure buy-in from these communities now the same goes for the stakeholders within our own organizations including our own political and economic leaders who finance and support the programs that we design and implement now without their support then our programs cannot occur this is one reason to gather and use data to show our decision-makers that there are problems and that we as a public health or medical agency have the tools to address these problems if we're given the economic and political support that we need to do so so one of the key take-home messages from this lecture and by the way it's a rather short lecture should only take us about half an hour so that one of the key take-home messages is that you must prioritize the problems that you're facing is a public health or medical agency and in so doing you need to build consensus around these problems in both the community and within your own agency to address these prioritized issues so let's just go ahead and jump right in so at the conclusion of this lecture you the student should be able to do the following first identify the key stakeholders and partners within your community and organization with whom you wish to work on a public health issues issue then identify the criteria to be used in prioritizing the importance of different public health issues in your community so as to choose the most important and finally to develop a consensus among stakeholders and partners on which issues you wish to work so let's begin with the question of why do we prioritize public health problems the primary issue is that we do not have unlimited resources whereas in public health and medicine it seems that what we do have are limited problems which we are called upon to solve so it becomes critical that we prioritize the problems we are faced with to ensure that those we address are the most important ones facing our community based upon criteria that we will introduce later in this presentation so to start with let's discuss two concepts that we will use when prioritizing public health problems first participatory planning and second consensus building so let's start with participatory planning each of us comes from a different professional and cultural background and as such because of our different experiences and perspectives we will see the problems faced in our communities and the populations that we serve differently if our plans are to be effective decisions need to involve all of the concerns and affected parties this is called participatory participatory planning and it ensures that despite our different backgrounds and perspectives that our concerns will be addressed in the planning and program implementation phases now participatory planning involves two groups stakeholders and partners stakeholders who are persons or organizations that have an interest or investment in what we are doing as a public health or medical agency now examples of stakeholders includes such things as the Department of Health or it might be known as submit three of health's depending upon where you're listening to district and sub district medical officers community leaders and this can include things like religious leaders business leaders cultural and traditional leaders and so on and so forth as well as organizational leaders in the organization that we work for or the organizations which were with which we work and it also includes our target population as well now partners are defined as persons or organizations that are supportive of the work we do now partners can be the same as community stakeholders and this can include once again things like the Ministry of Health now the Ministry of Health might support our work that the MOH might not be directly involved in terms of finance personnel and so forth and so in that instance we would classify them as partners as opposed to stakeholders okay now I just want to mention the one critical definition of stakeholder that you need to always hold to is that it involves the members of the community in which you are working those individuals are always considered stakeholders so how would you involve stakeholders and partners in prioritizing diseases well examples of how to do that might include inviting them to a meeting in which you all discuss and prior to prioritize diseases and community problems together or it could involve sending a questionnaire to these stakeholders and asking them to prioritize problems on their own or it might be meeting with our stakeholders and our partners to explain the benefits of them working directly with us but regardless of how we do it the key is to get them involved and once again particularly to get the communities with which you work involved so that they feel valued and that their input is thought and that the issues that they bring up are heard in designing any interventions that we bring to their communities now when you involve the community there is much greater acceptance and buy-in to programs at the local level and hence there's greater impact of our programs now this process is known as consensus building and that's what we're going to talk about on the next slide now consensus building as you can see from the slide there is the process of collaborative decision making and it's collaborative decision-making that focuses on the development of strong working relationships between the stakeholders and these strong working relationships are evidenced by participative participation and leadership that ultimately builds an atmosphere of trust and flexibility between the key stakeholders and the agency that is developing the intervention now as I mentioned in the previous slide it is important that those with whom we work trust us and know that our efforts are directed in the best interest of the communities and organizations that they represent and the best way to develop this trust is through collaborative consensus building now consensus building allows us to ensure that everyone involved participates in making decisions that affect them that the process is objective and that everyone should agree with the process of deciding which problems on which to focus limited resources now notice what I said I said everyone should agree on the process I didn't necessarily say everyone was going to agree on the outcome because that can be a difficult goal to achieve so as I said they may not agree on the outcome that if they support the objective and the quantitative process by which we reach that objective in theory they're going to support the final evidence-based decision now I'm going to show you in a couple of slides how we undertake that evidence-based decision-making and how it's very quantitatively or numbers based now there are several key considerations in reaching a consensus first all stakeholders if possible should participate second no one is forced to agree to an idea or the final decision they must be allowed to dissent ultimately a decision opposite to theirs maybe made but if they have been allowed to voice their objection and understand the quantitative process by which the final decision is made then this can help alleviate any issues and third the final decision must be one that everyone can accept if there are different levels of support that's fine but everyone must be able to accept the final decision that is made by the group now reaching consensus can be very difficult but taking the time and effort to do so can help ensure success of the program in the long run so we will now talk about the criteria that can be used to prioritize health problems and thus help reach a consensus among stakeholders now this is an objective and quantitative process in other words it uses evidence in order to rank order problems in the community using various criteria and hence arrive at a numeric determination of which problems are most important and hence which problems should receive our limited resources and attention so to help reach a consensus you should establish criteria or standards now here are some examples of common criteria that can be used to prioritize problems in the community now while this list contains nine potential criteria from which to rank problems it is recommended that you choose no more than five when you do your own prioritization activities now I do want to mention briefly that equity which as you can see is the ninth common criteria their equity refers to the impact of a disease on a specific out risk population such as support so as you know the poor often times bear a disproportionate burden of disease in many of the jurisdictions that we serve across the Pacific and so it might be important to consider the equity of any solutions that we want to bring to the problems so we can start by discussing the size of the problem okay or rating the size of the problem now this simply refers to the or the percentages of people who are affected by a specific health problem in a specific area and you can see based on the criteria there we can rate the size of the problem using American numeric scale of one to five with one being the least number of people affected and five being the most number of individuals who are affected so here we see an example of rating the size of a problem for five common non communicable diseases that we would deal with on a routine basis in the Pacific now what I'm going to do is I'm going to go through and we'll give examples for size seriousness interventions impact and result and then wall well total enough to get a resulting rating now what I want to point out is that this is just an example okay these are essentially random numbers that have been put together to demonstrate the process and the ultimate resulting rating would be different depending upon the evidence in the data that you have for your particular jurisdiction so just see it for what it's worth it's an example of how the process works now as you can see the two highest rated ones are diabetes and alcohol while hypertension obesity and breast cancer still have high rankings the groups that put this together or put this prioritization list together felt that diabetes and alcohol affect larger numbers of the population than the other end CDs that we see on this list so like I said it's going to vary depending upon the data that you have for your particular jurisdiction so now that we've talked about ranking the size of the problem we can discuss ranking the seriousness of the problem now seriousness refers to the potential of a health problem to result in severe disability or death and it is data that is obtained from things like the Daly's that we've talked about before or cause specific mortality tables that should be available for your particular jurisdiction now once we've gathered this data then we can rank the seriousness of the problem using the scale that you see here once again it ranges from one to five with one representing not life-threatening or disabling to five representing a condition that has a high likelihood of death or disability in the population that you serve so here we see an example of ranking the seriousness of the problem so those who prioritize these problems ranked breast cancer is the most serious in terms of cause specific mortality or Daly's followed by diabetes and hypertension and then obesity with alcohol coming and last so what I'm hoping you're beginning to see is how this results in an evidence-based quantitative system to rank order problems according to their importance and hence where we should focus our prevention efforts and do keep in mind that remember we're trying to create consensus here and consensus is oftentimes easier to create if we have numeric data and so eventually what we're trying to result to develop is that resulting rating in the far right column where we can numerically see which of these is the greatest problem number one number two number three number four and number 5 and that will go a long ways to helping with those who dissent in terms of what we consider the most important problems for our jurisdictions people are inherently quantitative they want to see the numbers at the end of the day so next we have to consider the currently available interventions so here we must consider whether there are currently available evidence-based interventions that are considered to be widely available in our jurisdiction as well as being effective and whether or not these can be easily implemented all right so for example with breast cancer and interventions such as radiation therapy might be highly desirable but we simply don't have access to radiation therapy equipment equipment and radiation oncologists here in the Pacific and so that would not be practical for us to rank order so the information on currently available interventions that may take more time and energy to compile than some of the other criteria like size and seriousness and so you might want to assign this data gathering task to somebody with expertise in this particular area now sources for this data include things like peer-reviewed journal articles reports from w-h-o or local government focus groups community surveys and so forth now remember that epidemiology is a data-driven field so we need evidence to support any intervention that we might ultimately choose and as you can see we can then rank the available interventions one to five with five having the strongest evidence support its usage and one no evidence to support its usage so like in the example I gave if we were on the mainland with radiation therapy and breast cancer we would probably rank that a five because it's relatively easy to get access to a radiation therapy centers and radiation oncologist whereas out here in the Pacific conversely Luter rank that is what all right not because it's not because it's not effective but simply because it's simply not available out here in the Pacific so once again just illustrates how it's going to alter depending upon the jurisdiction in which you're gathering the data from and here we can see an example of how the available interventions were ranked according to their efficacy with the current interventions for obesity ranked highest followed by diabetes and breast cancer and finally with available interventions for alcohol use and hypertension being ranked Lois no once again this is a progressive process designed to produce a consensus based on numeric data and once again do keep in mind we're not saying that there aren't effective interventions for hypertension and alcohol use we're just saying that in the particular jurisdiction that did this rank order it might be that they don't have the personnel the equipment the human resources and so on and so forth to actually implement those solutions and that's why obesity and diabetes and breast cancer actually ranked higher so next we will consider economic and social impact of interventions so it is important that you consider the increased monetary and social costs of the health problems you're addressing what are the monetary costs associated with the health issue well these would include costs such as interact medical social services public services lost employment and productivity and so forth anything on which we can put a dollar sign conversely what are the social costs of a health problem well these would include the effects on the individual of the family if the person is unable to work cannot support their family cannot contribute to the community and so on and so forth so here we see the rating scale for economic and social impact once again you can see the range is from one to five with one being the least impact and five having the heaviest impact okay so this can be a difficult information to gather but potential sources include community leaders and stakeholders in terms of the social impact as well as surveys and studies in terms of the economic impact now if there are not economic impact studies for your area and there probably aren't depending upon where you're in you're out in the Pacific consider looking at studies for similar populations and one of my favorite cross cultural considerations that I always look at what I'm doing studies like this is I love to look at places like Sri Lanka that has a lot of data produced on it a lot of studies available in the literature as well as places like sub-saharan Africa and the Caribbean where I come from originally all right so go out and look at the literature that's come from those areas because there are a lot of times they'll be similar in terms of being island nations with limited resources and high burdens of n CDs and so once again this can take a lot of effort to go out and gather this data but it is worth it in the end and once again we see an example of the ranking of social and economic impact and here breast cancer has been ranked as having the highest economic and social impact followed by diabetes hypertension and alcohol with obesity having the lowest ranking so it's important to note that these are examples and once again like he keeps saying don't necessarily represent the actual rankings that you would do for your community based upon the best available research and resources that you have locally so now we can look at the final product of our prioritization here what has been done is not to add the rose but to multiply them so for example for diabetes we multiply five times four times four times four to give us a ranking of three or an impact of 320 now the reason for this is that multiplying rather than adding the numbers shows a greater difference and hence that makes it easier to rank the final list now as I mentioned before this is an example and your local results will vary so in review remember that the purpose of this exercise is to develop consensus okay but not just agreement but agreement that is based upon evidence that has been gathered from various data sources now the end result is a numeric comparison that shows a Quattro's quantitatively the seriousness of the problem to be considered and in this way everyone even if they don't agree with the final rank order can at least see how it was determined so congratulations you've made it through another one I do hope that you've learned something today this was a relatively quick presentation only about 15 minutes as always I want to thank our sponsors for supporting the lectures but most of all I want to thank you for your hard work and your dedication you're all busy people but you've chosen to take time away to improve yourself in regards to your knowledge of Epidemiology so well done I also want to ask that if you've been given time away from your job to complete these video lectures that you think your supervisor for their support as well now as always what you need to do is send me an email with your three learning points and then get ready for lecture number seven in CDs surveillance in public health and that will be released next month

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