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Conducting a Formal Problem AnalysisThe Foundation of an Effective Intervention Strategy

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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

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

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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

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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

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Steps in a Problem Analysis1. Examine epidemiologic data2. Examine literature and consult

experts3. Determine extent to which these

factors are active in the community4. Determine relative contribution of

each identified factor5. Identify the interrelationships among

factors – causal pathways6. Determine the most effective points

in the causal pathways for intervention

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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?

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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

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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

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?

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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

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SECONDARY

TERTIARY

PRIMARY

Mother’s Level of EducationNewcomer statusTransient housing

Barriers to care:LanguageCulturalTransportationFinancialLegal

Families with many childrenParent with alcohol or drug problemDomestic Violence

Chronic Childhood Illness / immunocompromised

Racism / Discrimination Poverty

Limited availability of health insurance for the poor

PROBLEM: INADEQUATE IMMUNIZATIONS

Health ProvidersMissed OpportunitiesLack of availability of vaccinesInadequate record keeping

Lack of tracking & reminder / recall systems

Parental non-complianceReligious or philosophical objectionsFear of vaccine side effects

Lack of federal funding for vaccinesManufactures liability fears

Family lack of health Insurance

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SECONDARY

TERTIARY

PRIMARY

Mother’s Level of EducationNewcomer statusTransient housing

Barriers to care:LanguageCulturalTransportationFinancialLegal

Families with many childrenParent with alcohol or drug problemDomestic Violence

Chronic Childhood Illness / immunocompromised

Racism / Discrimination Poverty

Limited availability of health insurance for the poor

PROBLEM: INADEQUATE IMMUNIZATIONS

Health ProvidersMissed OpportunitiesLack of availability of vaccinesInadequate record keeping

Lack of tracking & reminder / recall systems

Parental non-complianceReligious or philosophical objectionsFear of vaccine side effects

Lack of federal funding for vaccinesManufactures liability fears

Family lack of health Insurance

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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

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Diagramming Critical Pathways to Identify Effective Interventions

Low perceived threat of

communicable diseases

Low Immunizatio

n Rate

INTERVENTION

Parental refusalof vaccine

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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

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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)

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Using a Problem Analysis in a Group Planning Process

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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

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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

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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

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Definition of Terms & Examples

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Definitions: Precursors Factors that have been proven to be

associated with the problem Causal factor Risk factor Systems barriers Protective factors

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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)

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Primary Precursors:Examples for Low Immunization Rate

Child who is immuno-compromised

Parental refusal of vaccine due to fear of side effects of vaccination

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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

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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

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Ecological - Tertiary Level Precursors Definition: Factors that are operational at the state

or national level such as cultural, health, social, legal or economic policies

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

kids

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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

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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

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Linkages Definition: The association between problem and

precursors Review the literature Consult experts Analyze your data

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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)

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AcknowledgementsThe 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

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