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Friday Mar 16, 2018

Want to Solve Problems in Public Health? Here's How

I have many loves in family medicine. I love delivering a newborn directly into a mother's arms. I love excisional biopsies of funny looking moles. I love giving someone hope after a chronic disease diagnosis.  

[group of people sitting around a table]

What I love most, however, is community-based preventive medicine. As such, I wrangled a contract directly out of residency that is 20 percent population medicine. (Lesson No. 1: Ask for what you want. You might actually get it).

As part of this endeavor, I am pursuing a master's degree in public health. I hope to use this training to make connections in the world of public health policy; to learn how to create, implement, message and evaluate programming; and perhaps to eventually break into creation of, or participation in, policy. I will have some required coursework in, for example, biostatistics and epidemiology, but I will also have myriad electives on topics like environmental public health and behavioral economics.

Throughout the course of my program, I hope to distill the most useful-to-the-family-medicine-doc public health pearls from my classes and pass them along. This post is the first in this series. Thus far, I have taken courses on problem-solving in public health and intro to persuasive communication.

The course on problem-solving in public health taught me two things: a remarkably egalitarian way to run a meeting and a systematic approach to solving problems.

The Nominal Group Technique (NGT)

In this setup for running a meeting, start by imagining a group of eight people. During each session, one of them is the moderator, one a notetaker and one a timekeeper. The moderator's job is to decide how long each part of the session ought to take, and the timekeeper's job is to cut people off once time is reached. The notetaker … takes notes.

Each meeting uses the following series of steps, and as participants get used to the process, they get faster and more efficient.

  • Clarify the purpose and goals. The moderator reminds everyone about the specific question or questions for the session, reviews time limits for each ensuing step and allows for adjustments on each of these points.
  • Brainstorm solutions. Group members brainstorm answers to the session's central question, a step that can take place before the meeting.
  • Share ideas in a round robin. Going around in a circle, each person briefly shares one idea, adding more brief ideas -- avoiding duplicates -- when the circle comes back around until time runs out or all ideas have been voiced. In this manner, no one dominates the discussion and everyone is heard.
  • Discuss as a group. Here the group focuses on clarifying, not debating. The goal is to add salient details or reasons for a certain suggestion. This is a time to ask questions rather than make arguments. Some time can also be spent discussing criteria for voting in the next step.
  • Rank the suggestions. Each group member ranks the options based on the set criteria -- perhaps voting for their three favorites, using two votes however they want, or casting one vote each -- and the group ends up with two or three leading suggestions.
  • Wrap up with conclusions and assignments. Participants are assigned roles or tasks to complete before the next meeting, and a new moderator, timekeeper and notetaker are assigned.

The NGT is delightfully efficient and focused. Moreover, it imposes a thoughtful, respectful and inclusive methodology to traditionally explosive or at least controversial topics. By using this technique, you can assure all members of the group that each of their voices will be heard with equal weight, as will also be the case in the problem-solving process below.

The Problem-solving Process

Usually applied to public health problems, this series of steps offers a framework through which one can approach just about any problem that involves groups of people. Whether your problem is developing a group visit program or decreasing smoking in pregnant women, you can approach the problem with success in this way. Notably, this process works well in combination with the NGT.

  • Define the problem. A good problem definition has a specific group, timeframe and outcome of interest. For example, the definition could be, "Childhood obesity rates in the United States among school-aged children have been rising since the 1970s."
  • Identify indicators of the problem. If your problem is childhood obesity, your direct indicators would be things like body mass index, waist circumference or waist-to-hip ratio. Indirect indicators -- things that give you a clue your endpoint might be happening -- would be rates of childhood hypertension, diabetes or obesity-related sleep apnea. Using the NGT would lead your group to brainstorm as many direct and indirect indicators as possible, then you vote on which ones to track and change.
  • Find data for the indicators. Without data, you will have a hard time convincing others to do what you want.
  • Identify stakeholders. Find out who cares about the outcome. A meeting held in the NGT style would come out of brainstorming and round robin with a diverse, inclusive and thorough list of potential stakeholders. For childhood obesity, the stakeholders could be parents, students, educators, elected officials, etc. The ranking step would narrow the list to the stakeholders that your group wants to work with.
  • Identify key determinants. These are the things that might make the outcome of interest more or less likely. For childhood obesity, these factors might be diet, exercise, dangerous neighborhoods that prevent exercise, food deserts, genes, obesity in parents, television watching, school lunches and poverty.
  • Identify intervention strategies. Here is when you brainstorm actions to change the outcome. Some of the group's ideas might be school lunch programs, educational programs for parents, active recess or adjusting food aid programs. All ideas are welcome for discussion and ranking. At the end of the meeting, your group will have decided on an intervention strategy to pursue.
  • Identify implementation strategies. It is all well and good to have an intervention, but the next step is to figure out how to get it off the ground. You need to use all the resources you have -- friends in high places, friends in low places, grants, national organizations, local fundraising, city council meetings and more.
  • Evaluate. All good interventions need to be evaluated. Be sure to figure out how to do so. Is it working? Is it costing too much? Does it have any unintended benefits or consequences?

I already have used each of these techniques to great effect. By addressing problems in this step-by-step fashion, I find myself suddenly more organized, and you know what that means: more time for more projects!

Just kidding. I get to read books for fun these days and go on long runs. It is amazing.

Stewart Decker, M.D., is a family physician practicing in southern Oregon. He focuses on the intersection of public health and primary care. You can follow him on Twitter at @drstewartdecker.(twitter.com)

Posted at 04:36PM Mar 16, 2018 by Stewart Decker, M.D.

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