FAMILY AND COMMUNITY MEDICINE III

Problem Identification & Prioritization

Isabelita Samaniego,MD | 20 March 2019
S4T7
OUTLINE 3. Establish criteria
I. Measuring Health and Health Status Indicators o Selection of appropriate prioritization criteria on which to judge
II. Problem Prioritization the merit of potential focus areas
III. Prioritizing Health Problems o To avoid selection based on bias or hidden agendas and
IV. Five Prioritization Process ensure that everyone is on the right track
A. Multi-Voting Technique
B. Strategy Grids
C. Nominal Group Technique III. PRIORITIZING HEALTH PROBLEMS
D. The Hanlon Method A. CRITERIA TO IDENTIFY PRIORITY PROBLEM (C-I-S-U-R-S)
E. Prioritization Matrix • Cost and/or return on investment
• Impact of problem
I. MEASURING HEALTH AND HEALTH STATUS • Availability of solutions
INDICATORS • Urgency of solving problem (measles or air pollution)
• Availability of resources (staff, time, money, equipment) to solve
• Through the definition of health is easy to state, trying to qualify the problem
amount of health an individual or population possesses is not easy • Size of problem (e.g. number of individuals affected)
• Measures of health are expressed using health statistics
• Based on the traditional medical model of describing ill health B. FIVE PRIORITIZATION PROCESS
(injury, disease, and health) instead of well health 1. Multi-Voting Technique
o The higher the presence of injury, diseases, and death 2. Strategy Grids
indicators, the lower the level of health 3. Nominal Group Technique
o The lower the presence of injury, diseases, and death indicators, 4. The Hanlon Method
the higher the level of health 5. Prioritization Matrix
A. WHY MEASURE HEALTH? 1. Multi-Voting Technique
1. To establish priorities • Useful when a long list of health problems must be narrowed
o The collection and evaluation of information about the health
status and health problems of a community is an important a. Round 1 vote
way of identifying needs o Once a list of health problems has been established, each
2. To assist planning participant votes for their highest priority items
o Health promoters need information to assist the planning and b. Update List
evaluation of health promotion programs o Health problems with a vote count equivalent to half the number
3. To justify resources of participants voting remain on the list and all other health
o Health promotes need information on the health status of problems are eliminated
population to make a claim for resources for their activities c. Round 2 Vote
4. To assist the development of the profession o Each participant votes for their highest priority items of this
o Measurements of health gain are important in a community for condensed list
proper funding, resources for benefit of the health promoters d. Repeat the third step until desired no. of priorities is reached
B. MEASURES OF HEALTH AS OBJECTIVE ATTRIBUTE Example of Multi-Voting Technique. In a board meeting, there are 10
• There are number of ways of measuring health as an objective people in the room, they will vote and then the top 5 issues will be
factor: promoted to round 2, and so on until one issue will win the vote.
1. Health measures – health indices (crude mortality rate, birth rate, ISSUE Round 1 Round 2 Round 3
etc.) 1 IIII IIIII IIII
2. Health behavior indicators – control of firework injury, lifestyle
2 II
modification
3 II
3. Environmental indicators – waste management
4. Socio-economic indicators – social status 4 IIIII III
5 IIII IIII IIII
C. MEASURES OF HEALTH AS SUBJECTIVE ATTRIBUTE
1. Measures of physical well-being (indicated by physical function) 2. Strategy Grid
2. Measures of psychological well-being • Strategy grids facilitate agencies in refocusing efforts by shifting
3. Measures of social well-being emphasis towards addressing problems that will yield the greatest
4. Measures of quality of life results
• May assist in transitioning from brainstorming with many
options to a more focused plan of action
II. PROBLEM IDENTIFICATION
A. PURPOSE OF IDENTIFYING PROBLEMS a. Select Criteria
• To understand the health problems and their causes o Choose 2 broad criteria that are currently most relevant to the
• To develop effective countermeasures to reduce or eliminate the agency
problem o Examples of criteria may be importance/urgency, cost/impact,
• To design evaluation mechanisms to measure changes in need/feasibility
problem severity o Competing activities, projects or programs will be evaluated
• To manage the issues that cause them (i.e. use of statistical data against how well this set of criteria is met
to help solve the problem) o The example strategy grid below uses need and feasibility as the
criteria
B. GENERAL PROBLEM IDENTIFICATION PROCEDURE b. Create a grid
1. Community Assessment o Set-up a grid with 4 quadrants and assign 1 broad criteria to
o Conducting assessments will determine the current status and each axis
detect gaps to focus on as potential priority areas (ex. o Create arrows on the axes to indicate ‘high’ or ‘low’
Situational Analysis)
2. Clarify objectives and processes

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 FAMILY AND COMMUNITY MEDICINE III
Problem Identification and Prioritization
c. Label quadrants o Participants also provide clarification for any items that others
o Based on the axes, label each quadrant as either ‘High Need/ find unclear
High Feasibility’, ‘High Need/ Low Feasibility’, ‘Low Need/ High e. Group Discussion
Feasibility’, ‘Low Need/ Low Feasibility’ o The moderator facilitates a group discussion on how well each
d. Categorize and Prioritize listed item measures up to the criteria that was determined by
o Place competing activities, projects or programs in the the team prior to the NGT process.
appropriate quadrant based on the quadrant labels f. Anonymous Ranking
o On a notecard, all participants silently rank each listed health
Example of a Strategy Grid problems on a scale from 1to 10 (can be altered based on needs
HIGH NEED/ of the agency) and the moderator collects, tallies and calculates
LOW FEASIBILITY total scores
• With high demand and high g. Repeat if desired
return on investment, these HIGH NEED/ o Once the results are displayed, the group can vote to repeat the
are the highest priority items HIGH FEASIBILITY process if items on the list receive tied scores or if the results
and should be given sufficient • With high demand and high need to be narrowed down further.
resources to maintain and return on investment, these
continuously improve. are the highest priority items Table 3. Example of NGT
• These are long term projects and should be given sufficient
Priority
which have great deal of resources to maintain and
potential but will require continuously improve Health 1st Choice 2nd Choice 3rd Choice
Total Score
significant investment. Indicat Score = 3 Score = 2 Score = 1
Focusing on too many of these Examples or
LOW NEED → HIGH NEED

items can overwhelm an • TB DOTS, Heart club (2x3) + (4X2)

X 2 4 6
agency. • High blood pressure + 6 = 20
screening program in a (1x3) + (6X2)
Y 1 6 3
Examples community with a rapidly + 3 = 18
• Investing on the environment increasing rates of stroke (4x3) + (6X2)
• Access to dental care in a Z 4 6 6
+ 6 = 30
community with a largely
uninsured population 4. Hanlon Method
LOW NEED/ LOW NEED/ • Complex method but advantageous when the desired outcome is an
LOW FEASIBILITY HIGH FEASIBILITY
objective list of health priorities based on baseline data and
• With minimal return on • Often politically important and
numerical values
investment, these are the difficult to eliminate, these
o A combination of being objective and subjective in prioritizing
lowest priority items and should items may need to be
be phased out allowing for redesigned to reduce health problem, most recommended method
resources to be reallocated to investment while maintaining • Relative framework, not absolute
higher priority items impact
a. Rate against specified criteria
Examples Example o It is important to remember that this step requires the collection
• Dengvaxia, • Sixteen parenting classes in a of baseline data from the community such as from a community
• Investing in a health education primarily aging community health assessment.
material in Spanish in a with a low teen pregnancy o Once a list of health problems has been identified, on a scale
community with <1% non- rate from 0 through 10, rate each health problem on the following
English speaking population • Politics – motivational activity criteria:
LOW FEASIBILITY → HIGH FEASIBILITY 1. Size of health problem
− Should be based on the baseline data collected form
3. Nominal Group Technique individual community
• This method is useful in the early phases of prioritization when 2. Magnitude of health problem
there exists a need to generate a lot of ideas in a short amount of − Seriousness of the problem
time and when input from multiple individuals must be taken into − Answers the following questions: Does it require
consideration immediate attention? Is there a public demand? What is
the economic impact? What is the impact on the Quality of
a. Establish group structure Life (QOL)? Is there a high hospitalization rate?
o Establish a group of, ideally, 6-20 people to participate in the 3. Effectiveness of potential interventions
NGT process − Determine the upper and lower measures of effectiveness
o Designate a moderator to take the lead in implementing the and rate of health problems relative to those limits
process.
o The moderator should clarify the objective and the process
b. Silent brainstorming
o The moderator should state the subject of the brainstorming and
instruct the group to silently generate ideas and list them on a
sheet of paper
c. Generate list on round-robin fashion
o The moderator should solicit one idea from each participant and
list them on a flip chart for the group to view
o Should be repeated until all ideas and recommendations are
listed
d. Simplify and clarify
o The moderator then reads aloud each item in sequence and the
group responds with feedback on how to condense or group
items

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 FAMILY AND COMMUNITY MEDICINE III
Problem Identification and Prioritization
b. Apply the PEARL test SUMMARY
o Once health problems have been rated by criteria, use the
Purpose of identifying health problems
PEARL test to screen out health problems based on the
Ways of prioritizing health problems
following feasibility factors:
1. Propriety – Is a program for the health problem suitable?
− e.g. “Is DOTS Program suitable for TB?” REFERENCE
2. Economics – Does it make economic sense to address the 3B Trans 2019
problem? Are there economic consequences if a problem is Dra. Samaniego’s lecture
not carried out?
3. Acceptability – Will a community accept the program? Is it
wanted?
4. Resources – Is funding available or potentially available for
a program?
5. Legality – Do current laws allow program activities to be
implemented?
o Eliminate any health problems which receive an answer of No to
any of the factors OR
o Proceed with corrective action to ensure that potential health
priorities meet all five of the feasibility factors.

c. Calculate Priority Scores

o The formula for this method is:
D= [A+(2xB)] x C
where:
D = Priority Score
A = Size of health Problem ranking
B = Seriousness/Magnitude of health problem ranking;
C = Effectiveness of intervention ranking
o Note: Seriousness of health problem is multiplied by 2
because according to the Hanlon technique, it is weighted as
being twice as important as size of health problems

d. Rank the Health Problems

o Based on the priority scores calculated in Step 3 of the Hanlon
Method, assign ranks to the health problems with the highest
priority score receiving a rank of ‘1’, the next high priority score
receiving a rank of ‘2’ and so on

5. Prioritization Matrix
• More commonly used tools for prioritization
• Ideal when health problems are considered against a large number
of criteria or when an agency is restricted to focusing on only one
health issue
• Provides a visual method for prioritizing and accounts for criteria
with varying degrees of importance

a. Create a matrix
o List all health issues and criterion so that each row is
represented by a health issue and each column is represented
by a criterion
o Last column is for the priority score

b. Rate against specified criteria

o Fill in cells of the matrix by rating each health issue against each
criterion which should have been established by the team prior to
beginning this process

Table 5. Sample Prioritization Matrix

Criterion Criterion Criterion
Health 1 2 3 Priority
Rank
Concern [Rating x [Rating x [Rating x Score
Weight] Weight] Weight]
2 X0.5 1 X 0.25 3 X 0.25
A 2 2
=1 = 0.25 = 0.75
3 X 0.5 2 X 0.25 2 X 0.25
B 2.5 1
= 1.5 = 0.5 = 0.5
1 X 0.5 1 X 0.25 1 X 0.25
C 1 3
= 0.5 = 0.25 = 0.25

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