Part 2 Options and decisions JwoLeun Lee, PhD, DLSHTM, MSc. Department of Senior Citizen Service Management National Taichung Nursing College

Introduction

Decisions People who dislike decisions should not become public health practitioners. The first decision is whether or not there is a public health problem to be tackled, and not all problems that affect populations are appropriate problems for public health practitioners or departments alone. Is this a public health problem, an economic problem, or a political problem? Or, to be more precise, what should a public health practitioner ro department do?

Coping with multiple realities Public health options have to take into account a wide range of different types of factor such as: The needs of the population and the relative importance of different problems The evidence about cost-effectiveness of different options The values of the population and the ethical basis of those values.

2.1. Scoping public health problems

Eight important scoping questions Identifying the dimensions: What do we know about the problem? What areas are contentious? Which interest groups and academic disciplines have or could be expected to have a useful perspective on this problem? What are the political and structural aspects of the problem?

Eight important scoping questions And setting priorities: Why is this problem on the agenda now? (do not confuse the urgent with the important) What support and resources are likely to be available for tackling the problem? What parts of the problem are already well covered and where are the areas of greatest need? Where can the most effective, strategic interventions be made?

2.2. Turning problems into answerable questions

How to avoid making issues more complex Far better an approximate answer to the right question…than an exact answer to the wrong question. Be aware that different groups will identify totally different problems affecting a given population. One of the most difficult steps in turning many problems into answerable questions is clearly defining what the problem is actually perceived to be.

How to avoid making issues more complex Public health practitioners should never be afraid to use the challenging words—’why’ and ‘what’—both on themselves and on others. Before collecting data, ensure that the data will help you answer one or more of the questions you have. Pursue the questions that you have identified as important Remember the basic rules of traditional planning Unless data are turned into stories that can be understood by all, they are not effective in any process of change

Key steps As pure scientists can remain tentative about the nature of associations. As public health specialists, however, judgements must be made in the absence of final proof in order to reduce the health risks to the pubic. Examples: pp.74-75.

Two kinds of questions Scientific/technical questions: what causes lung cancer? Socio-political questions: who are the key people who will need persuading? The latter can involve such techniques as SWOT analysis and stake-houlder analysis.

Being opportunistic and realistic Problem solvers often complain that they have worked out ideal solutions but that no one will use them…Real problems include not only the specified problem situation but also the ‘person situation’, which includes the people who have to accept and act on the solution.’ A solution is not a solution if it is not possible to implement it. The same is true for a policy. Eg. Edwin Chadwick: p.77

2.3. Finding evidence

2.6. Economic evaluation