Social Determinants of Health Program Planning in Public Health: What’s the Evidence?
Health Program Planning
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Transcript of Health Program Planning
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Health Program Planning
CHSC 433Module 1/Chapter 3
UIC School of Public HealthL. Michele Issel, PhD, RN
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Learning ObjectivesWhat you ought to be able to do by the end of this module:
1. List pros and cons of the types of planning identified by Beneviste.
2. Appreciate the challenges involved in being a health planner.
3. Understand where and how in the planning process involvement of stakeholders is appropriate.
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Notice:
Lack of planning
on your part does not
constitute an emergency
on my part.
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Planning is…
Effort to control social or collective uncertainty by taking action now to secure the future (Marris in Hoch, 94)
Good planning is the popular adoption of democratic reforms in the provision of public goods. (Hoch,1994)
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Purpose of Planning
To determine the program prioritization and gain support for the program
Part of Cycle (on next slide)
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Assessment of CommunityNeeds and Assets
Program Developmentand Evaluation Planning
Program Process TheoryImplementation
Participant-RecpientImpacts and Outcomes
Process EvaluationImplementation
Impact EvaluationImplementation
Trigger Event orOpportunity
Health ProgramPlanning
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Brief History of Public Health Planning
Environmental planning of water and sewer systems in antiquity
Population planning with the advent of immunizations
Blum advocated for rational approach for health planning
Advocacy planning of the 1960's was a break with the rational approach
Increasing attention on risks
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Risks and Protection
Risk as a perception about possibilities of adverse event
Active (requires behavior change) protection
Passive (change in the situation or environment, not the person) protection
Micro (individual) and macro (system) approaches to risk reduction
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Threats to effective risk reduction (Per Blum)
Conceptual anemia Wishful thinking Social irresponsibility Failure to analyze problems Failure to examine possible interventions Failure to be conversant with the
implementation pathways Blaming the victim
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Planning Perspectives
According to Beneviste
According to Forester
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Beneviste: Planning Perspectives
Comprehensive rational is systems approach Advocacy planning is client focused and citizen
participation focused Apolitical politics uses technical knowledge to
achieve compromises Critical planning is concerned with the
distribution of power and communication Strategic planning focuses on the organization Incrementalism takes small, discrete steps
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Examples in Public Health (can you think of other examples?)
Comprehensive rational ~ implementation of WIC program
Advocacy planning ~ CDPH’s anti-violence planning, advisory boards
Apolitical ~ Evidence based approaches to medicine and health care
Critical planning ~ HIV/AIDS groups Strategic planning ~ state health plan, local
health department annual plan Incrementalism ~ HP 2010
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Planning Perspectives: Reasons to Reject per Forrester
Rational approach assumes means and ends are known, can anticipate the future
Problem-solving technalizes social problems, assumes have solutions
Cybernetic (systems) perspective does not account for norms and values
Satisficing (meet minimum needs) perspective assumes a rational decision making
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Examples in Public Health (can you think of other examples?)
Rational approach~ State health plans
Problem-solving ~ Health educational programs
Cybernetic ~ State-wide immunization programs
Satisficing ~ ?
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Perspective Advocated by Forester
Communicative action perspective: Shapes attention of stakeholders Changes beliefs of stakeholders Gains consent of those with the
problem and the solution Engendering trust and understanding
of those with the problem
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From Perspectives to Priority
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Prioritizing: A reality
Traditional public health approach as typified by Dever who drew on Hanlon
Utility measures as individual information for planning
Resource allocation as a prioritization
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Prioritizing per Dever (1)
1 Determine size of health problem(s)
•Use health indicators :• mortality, morbidity, utilization,
satisfaction
•Use epidemilogy measures :• rates, proportions
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Prioritizing per Dever (2)
2 Determine seriousness and importance of health problem (s)• Compare epidemiology and normative
data• consider relative risk, odds ratio
• Use utility measures to get at perceived seriousness
• Conduct focus groups or surveys to assess perceived importance
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Prioritizing per Dever (3)
3 Determine intervention effectiveness• Review literature on various possible
interventions, programs, treatments
• Use evidence-based practice guidelines
• Conduct pilot program with intervention
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Logic Model of Public Health Assessment for Planning
Hampering factors(Assets and
INTERVENTIONS)
HelathProblem
HealthIndicators
Risk of:
Determiniant factors ofthe health problem
As demonstrated in
Contributingfactors to the
health problem
Antecedentfactors
Among target audience
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Health Resource Allocation: 8 Step Strategy (Patrick &Erickson)
1. Specify the health decision
2. Classify health outcomes as health states
3. Assign values to health states by using preferences (i.e., utility measures)
4. Measure health related quality of life
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Health resource allocation strategy (continued)
5. Estimate prognosis and healthy years of life
6. Estimate direct and indirect health care costs
7. Rank costs and outcomes
8. Revise ranking of costs and outcomes
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Dever/Hanlon Approach
Implies apolitical and rationality to problem prioritization
Reality is that values, preferences, motive can surface and affect the process
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Ways to objectify the Hanlan/Dever Approach
Educate group using critical or communication approach to planning
Gain consensus on the process and decision rules about numbers
Careful balance in composition of group doing the problem prioritization
Have adequate resources to do all the steps Address data trustworthiness Consider variability in literature being used
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Planning at macro level
Think across the Pyramid (developed by the Maternal and Child Health Bureau)
Health Policy formation is decision making
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Characteristics of Health Policy Decision Making
(1) Innovation within customary and implicit rules such that the new is subsumed within what is already familiar
(2) Mutual adjustment by one department (or such) in response to the decision made by another department
(3) Bargaining either through direct negotiation or using trade-offs to influence the decision
(4) Move and countermove by departments (or such) in the fashion of taking unilateral action that forces the actions of another
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(continued)
(5) Solutions exist and sometimes come before recognizing the problem, just waiting for a window of opportunity to be applied
(6) The unanticipated consequences of one action can lead to the need for other health decisions that were in themselves unintended
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Conclusion
Principles
Challenges
Roles of
Planners
Paradoxes
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Planning Principles
Have visible, powerful sponsor Involve those affected in the planning Constitute a planning board Have well trained and skilled planning staff Be as objective as possible, given the context Use rationality as much as possible as basis
for power
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Challenges in Planning
Change is distasteful to those affected Health perspective does not reflect
social values Politicians prefer cure, health planners
prefer prevention Politicians have short term view, health
planners have long term view Constituents inherently have conflicting
priorities, preference, etc
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(Some) Roles of Planners
Designer of planning technology, Assistor and systems facilitator, Problem solver, Inquirer
Priority setter, Regulator, Decision maker, Builder of futures
Educator, Expander of capabilities, Advocate, Activator, Power modifier
Agency manger
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Planning paradoxes
Planning is shaped by the same forces that created the problems
The “good “ of individuals and society experiencing the prosperity associated with health and well-being is “bad” to the extent that prosperity produces ill health
What may be easier and more effective may be less acceptable
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Public Health Pyramid
Direct Health Care
Services____________________
Enabling Services___________________________
Population-Based Services___________________________________
Infrastructure Services
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Planning across the Pyramid
Individual Level ~ person focused, direct clinical services
Enabling services ~ aggregate focused, indirect care services
Population services ~ population focused, services delivered to entire population
Infrastructure level ~ the health care organization, public health system
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Data for Problem Size, Seriousness, Importance Across the Pyramid
Problem LEVEL
Problem Size Problem Seriousness Problem Importance
Individual Use epi data with an ecological approach
Epidemiologic data, Trends
Utility measures, Survey data, Focus groups
Enabling (services) (aggregate)
Use epi data
Demand data used to infer seriousness
Logic and theory underlying causes and consequences
Population (services)
Use epi data Normative perspective
Trends
Infrastructure Demand and Need data
Trends data relative to HP 2010 objectives, political perspective
Evaluation data