TOPIC: An Ethical Pause As the director of the local public health

TOPIC: An Ethical Pause
As the director of the local public health department, for this assignment you are creating a logic model to document the rationale for the strategic planning process. This document will be widely reviewed and distributed to your staff and senior advisors, and it will facilitate the planning and implementation of all intended approaches.
While very few persons have viewed the results of the Riverbend City community health needs assessment, the data and final reports will soon be made public. As you are creating the logic model, consider the potential for the community health needs assessment data to be misused. You care about the Riverbend City community where you serve. Remember, “Evaluators, program managers, program staff members, stakeholders, and program participants involved in an evaluation can all be susceptible to a variety of pressures that may result in a less than unbiased evaluation” (Issel & Wells, 2018, p. 397).
As the director of the local public health department, use what you learned in this THE readings to identify two strategies to prevent the misuse of the community health needs assessment data that will be reported. Be sure to identify both the threat/potential for misuse and the strategy to prevent it.
Perovich, L. J., Ohayon, J. L., Cousins, E. M., Morello-Frosch, R., Brown, P., Adamkiewicz, G., & Brody, J. G. (2018). Reporting to parents on children’s exposures to asthma triggers in low-income and public housing, an interview-based case study of ethics, environmental literacy, individual action, and public health benefits. Environmental Health, 17, 1–12.
Include THREE academic references above 2017
Due 8/4/22 at 10am
Riverbend city ( Community Health Needs Assessment)
Martin Lewis, Parent: You know what bugs me? The panhandlers in Ruby Lake are getting so much worse. It was always kind of a problem, but now when I wait for a bus I actually feel kind of unsafe. Some of those people are aggressive and seem kind of unhinged.
Ed Kowalski, Riverbend City Police Department: It’s tough. I can tell you that, on the force, we know it’s a problem. Homelessness all over Riverbend City has gotten a lot worse in the past five years, especially in Ruby Lake.
Nicole Fernandez, Health Care Representative: Well, if we want to talk about public health needs, there you go. Spiking homelessness represents a collision of a bunch of public health issues a lot of the time. The correlation between homelessness and mental health problems is very large, and we know for a fact that access to mental health care is a glaring problem in the city. Across all populations, by the way, not just among the homeless. Same thing for substance abuse- it can be a gateway to homelessness or an endemic condition within it, and either way, we again have real problems.
Victor Maldonado, Community Activist: If we look at the Community Health Needs Assessment, the top needs all seem to pop up here. Mental health- top concern, check. Substance abuse, check. Health care access, big check.
Father Junot Rivera, Faith-Based Representative: Certainly that’s a problem among the homeless, but I think we can agree that it’s a problem throughout the neighborhood and the city. In my parish, there are very few people who feel like they have easy access to healthcare, especially preventative healthcare. And this is both among people who work and people who don’t.
Victor Maldonado, Community Activist: And the other two in the top five concerns are in the same neighborhood, thematically: programs and resources for obesity prevention, and for chronic disease. Add this up, and our citizens overwhelmingly have problems getting health care in a systematic and preventative way.
Martin Lewis, Parent: : And that’s why we need to work out how the city and county can help connect people with these services.
Ed Kowalski, Riverbend City Police Department: Whoa, there. I think that’s way beyond our brief. I’ll grant you that these problems exist, but we’re here to enforce the laws and keep the streets clean, not to hold people’s hands into mental health care.
Father Junot Rivera, Faith-Based Representative: Come on. You know as well as the rest of us that there are real-world benefits that we would see if people in Ruby Lake had better access to mental health care, and other types of long-term medical care. Nobody’s necessarily saying that the city or county needs to provide everything, but they can certainly help empower organizations that are providing services, and reduce structural barriers, and, you know, direct people towards resources that exist. What if you provided a mental health care referral to one of the panhandlers making Martin uncomfortable? What if you, as a police officer, had phone numbers you could give to people when you see obvious chronic disease or substance abuse problems when you’re performing a welfare check?
Ed Kowalski, Riverbend City Police Department: I’m a cop, not a social worker. I want to help people, sure, but I need to spend my time protecting the community from bad guys. This social help stuff would have to be a distant second. It’s not my place to save the world, and it’s not in my power.
Bruce Greenberg, Superintendent of the Riverbend City School District: : Not on your own, sure, but all of us represent organizations or points of view that can do something to reduce barriers. Even if we can’t help everybody—and of course I know we can’t—we *can* help a lot of people in actual, concrete ways. And every single person we help makes our city a little bit better.
Read (pages 14–21)
The Fuzzy Aspects of Planning
We like to think of planning as a rational, linear process, with few ambiguities and only the rare dispute. Unfortunately, this is not the reality of health program planning. Many paradoxes inherently exist in planning as well as implicit assumptions, ambiguities, and the potential for conflict. In addition, it is important to be familiar with the key ethical principles that underlie the decision making that is part of planning.
Several paradoxes pervade health planning (Porter, 2011), which may or may not be resolvable. Those involved can hold assumptions about planning that complicate the act of planning, whether for health systems or programs. Being aware of the paradoxes and assumptions can, however, help program planners understand possible sources of frustration.
One paradox is that planning is shaped by the same forces that created the problems that planning is supposed to correct. Put simply, the healthcare, sociopolitical, and cultural factors that contributed to the health problem or condition are very likely to be same factors that affect the health planning process. The interwoven relationship of health and other aspects of life affects health planning. For example, housing, employment, and social justice affect many health conditions that stimulate planning. This paradox implies that health planning itself is also affected byhousing, employment, and social justice.
Another paradox is that the “good” of individuals and society experiencing the prosperity associated with health and well-being is “bad” to the extent that this prosperity also produces ill health. Prosperity in our modern world has its own associated health risks, such as higher cholesterol levels, increased stress, increased risk of cardiovascular disease, and increased levels of environmental pollutants. Also, as one group prospers, other groups often become disproportionately worse off. So, to the extent that health program planning promotes the prosperity of a society or a group of individuals, health issues for others will arise that require health program planning.
A third paradox is that what may be easier and more effective may be less acceptable. A good example of this paradox stems from decisions about active and passive protective interventions. Active protection and passive protection are both approaches to risk reduction and health promotion. Active protection requires that individuals actively participate in reducing their risks—for example, through diet changes or the use of motorcycle helmets. Passive protection occurs when individuals are protected by virtue of some factor other than their behavior—for example, water fluoridation and mandates for smoke-free workplaces. For many health programs, passive protection in the form of health policy or health regulations may be more effective and efficient. However, ethical and political issues can arise when the emphasis on passive protection, through laws and communitywide mandates, does not take into account cultural trends or preferences.
Another paradox is that those in need ideally, but rarely, trigger the planning of health programs; rather, health professionals initiate the process. This paradox addresses the issue of who knows best and who has the best ideas for how to resolve the “real” problem. The perspective held by health professionals often does not reflect broader, more common health social values (Reinke & Hall, 1988), including the values possessed by those individuals with the “problem.” Because persons in need of health programs are most likely to know what will work for them, community and stakeholder participation becomes not just crucial but, in many instances, is actually mandated by funding agencies. This paradox also calls into question the role of health professionals in developing health programs. Their normative perspective and scientific knowledge need to be weighed against individuals’ choices that may have caused the health problem.
A corollary to the paradox dealing with the sources of the best ideas is the notion that politicians tend to prefer immediate and permanent cures, whereas health planners prefer long-term, strategic, and less visible interventions (Reinke & Hall, 1988). Generally, people want to be cured of existing problems rather than to think probabilistically about preventing problems that may or may not occur in the future. As a consequence, the prevention and long-term solutions that seem obvious to public health practitioners can conflict with the solutions identified by those with the “problem.”
One reason that the best solutions might come from those with the problem is that health professionals can be perceived as blaming those with the health problem for their problem. Blum (1981), for example, identified the practice of “blaming the victim” as a threat to effective planning. When a woman who experiences domestic violence is said to be “asking for it,” the victim is being blamed. During the planning process, blaming the victim can be implicitly and rather subtly manifested in group settings through interpretation of data about needs, thereby affecting decisions related to those needs. Having the attitude that “the victim is to blame” can also create conflict and tension among those involved in the planning process, especially if the “victims” are included as stakeholders. The activities for which the victim is being blamed need to be reframed in terms of the causes of those activities or behaviors.
Yet another paradox is the fact that planning is intended to be successful; no one plans to fail. Because of the bias throughout the program planning cycle in favor of succeeding, unanticipated consequences may not be investigated or recognized. Theunanticipated consequences of one action can lead to the need for other health decisions that were in themselves unintended (Patrick & Erickson, 1993). To overcome this paradox, brainstorming and thinking creatively at key points in the planning process ought to be fostered and appreciated.
A final paradox of planning, not included on Reinke and Hall’s (1988) list, is that most planning is for making changes, not for creating stability. Yet once a change has been achieved, whether in an individual’s health status or a community’s rates of health problems, the achievement needs to be maintained. Many health programs and health improvement initiatives are designed to be accomplished within a limited time frame, with little or no attention to what happens after the program is completed. To address this paradox requires that planning anticipate the conclusion of a health program and include a plan for sustaining the gains achieved.
Assumptions also influence the effectiveness of planning. The first and primary assumption underlying all planning processes is that a solution, remedy, or appropriate intervention can be identified or developed and provided. Without this assumption, planning would be pointless. It is fundamentally an optimistic assumption about the capacity of the planners, the stakeholders, and the state of the science to address the health problem. The assumption of possibilities further presumes that the resources available, whether human or otherwise, are sufficient for the task and are suitable to address the health problem. The assumption of adequate capacity and knowledge is actually tested through the process of planning.
A companion assumption is that planning leads to the allocation of resources needed to address the health problem. This assumption is challenged by the reality that four groups of stakeholders have interests in the decision making regarding health resources (Sloan & Conover, 1996) and each group exists in all program planning. Those with the health problem and who are members of the target audience for the health program are one group. Another group of stakeholders is health payers, such as insurance companies and local, federal, and philanthropic funding agencies. The third group is individual healthcare providers and healthcare organizations and networks. Last, the general public is a stakeholder group because it is affected by how resources are allocated for health programs. This list of stakeholder groups highlights the variety of motives each group has for being involved in health program planning, such as personal gain, visibility for an organization, or acquisition of resources associated with the program.
Another assumption about those involved is that they share similar views on how to plan health programs. During the planning process, their points of view and cultural perspectives will likely come into contrast. Hoch (1994) suggested that planners need to know what is relevant and important for the problem at hand. Planners can believe in one set of community purposes and values yet still recognize the validity and merit of competing purposes. He argues that effective planning requires tolerance, freedom, and fairness and that technical and political values are two bases from which to give planning advice. In other words, stakeholders involved in the planning process need to be guided into appreciating and perhaps applying a variety of perspectives about planning.
Each stakeholder group assumes that there are limited resources to be allocated for addressing the health problem and is receptive or responsive to a different set of strategies for allocating health resources. The resulting conflicts among the stakeholders for the limited resources apply whether they are allocating resources across the healthcare system or among programs for specific health problems. Limitedresources, whether real or not, raise ethical questions of what to do when possible gains from needed health programs or policies are likely to be small, especially when the health program addresses serious health problems.
It is interesting that, the assumption of limited resources parallels the paradox that planning occurs around what is limited rather than what is abundant. Rarely is there a discussion of the abundant or unlimited resources available for health planning. Particularly in the United States, we have an amazing abundance of volunteer hours and interest and of advocacy groups and energy, and recently retired equipment that may be appropriate in some situations. Such resources, while not glamorous or constituting a substantial entry on a balance sheet, deserve to be acknowledged in the planning process.
Another assumption about the planning process is that it occurs in an orderly fashion and that a rational approach is best. To understand the implications of this assumption, one must first acknowledge that four key elements are inherent in planning: uncertainty, ambiguity, risk, and control. The presence of each of these elements contradicts the assumption of a rational approach, and each generates its own paradoxes.
Uncertainty, Ambiguity, Risk, and Control
Despite the orderly approach implied by use of the term planning, this process is affected by the limits of both scientific rationality and the usefulness of data to cope with the uncertainties, ambiguities, and risks being addressed by the planning process (see TABLE 1-3).
TABLE 1-3 Fuzzy Aspects Throughout the Planning and Evaluation Cycle
Stages in the Planning and Evaluation Cycle
Community Assessment
Effect Evaluation
Unknown likelihood of finding key health determinants
Unknown likelihood of selecting an effective intervention, unknown likelihood of the intervention being effective
Unknown likelihood of the intervention being provided as designed and planned
Unknown likelihood of intervention being effective
Unclear about who is being assessed or why
Unclear about the process, who is leading planning process, or what it is intended to accomplish
Unclear about the boundaries of the program, who ought to participate, or who ought to deliver the program
Unclear about meaning of the evaluation results
Unknown possibility of the assessment causing harm
Unknown possibility of planning touching on politically sensitive issues
Unknown possibility of the intervention having an adverse effect on participants
Unknown possibility of adverse effect from the evaluation design, or from misinterpretation of the findings
Directing the process of gathering and interpreting data about the health problem
Directing the decisions about the program
Directing the manner in which the program is provided
Directing the process of data collection, analysis and interpretation
Uncertainty is the unknown likelihood of a possible outcome. Rice, O’Connor, and Pierantozzi (2008) have identified four types of uncertainty: types and amount of resources, technological, market receptivity to the product, and organizational. Each of these uncertainties is present in planning health programs. Ambiguity is doubt about a course of action stemming from awareness that known and unknown factors exist that can decrease the possibility of certainty. In this sense, ambiguity results in uncertainty. Both uncertainty and ambiguity pervade the planning process because it is impossible to know and estimate the effect of all relevant factors—from all possible causes of the health problem, to all possible health effects from program interventions, to all possible acts and intentions of individuals. A rational approach to planning presumes that all relevant factors can be completely accounted for by anticipating the effect of a program, but our experiences as humans tell us otherwise.
Ambiguity is the characteristic of not having a clear or single meaning. Change, or the possibility of change, is a possible source of ambiguity. When ambiguity is ignored, the resulting differences in interpretation can lead to confusion and conflict among stakeholders and planners, among planners and those with the health problem, and among those with various health problems vying for resources. The conflict, whether subtle and friendly or openly hostile, detracts from the planning process by requiring time and personnel resources to address and resolve the conflict. Nonetheless, openly and constructively addressing the ambiguity and any associated conflict can lead to innovations in the program.
Risk is the perceived possibility or uncertain probability of an adverse outcome in a given situation. Health planners need to be aware of the community’s perception and interpretation of probabilities as they relate to health and illness. Risk is not just about taking chances (e.g., bungee jumping or having unprotected sex) but is also about uncertainty and ambiguity (as is the case with estimates of cure rates and projections about future health conditions). Risk is pervasive and inherent throughout the planning process in terms of deciding who to involve and how, which planning approach to use, which intervention to use, and in estimating which health problem deserves attention. The importance of understanding risk as an element both of the program planning process and of the target audience provides planners with a basis from which to be flexible and speculative.
Control, as in being in charge of or managing, is a natural reaction to the presence of ambiguity, conflict, and risk. It can take the form of directing attention and allocating resources or of exerting dominance over others. Control remains a key element of management. In other words, addressing the ambiguity, uncertainty, and risk that might have been the trigger for the planning process requires less—not more—control. Those who preside over and influence the planning process are often thought of as having control over solutions to the health problem or condition. They do not. Instead, effective guidance of the planning process limits the amount of control exerted by any one stakeholder and addresses the anxiety that often accompanies the lack of control.
Introduction to the Types of Evaluation
Several major types of activities are classified as evaluations. Each type of activity requires a specific focus, purpose, and set of skills. The types of evaluations are introduced here as an overview of the field of planning and evaluation.
Community needs assessment (also known as community health assessment) is a type of evaluation that is performed to collect data about the health problems of a particular group. The data collected for this purpose are then used to tailor the health program to the needs and distinctive characteristics of that group. A community needs assessment is a major component of program planning because it is, done at an early stage in the program planning and evaluation cycle. In addition, the regular completion of community assessments may be required. For example, many states do 5-year planning of programs based on state needs assessments.
Another type of evaluation begins at the same time that the program starts. Process evaluations focus on the degree to which the program has been implemented as planned and on the quality of the program implementation. Process evaluations are known by a variety of terms, such as monitoring evaluations, depending on their focus and characteristics. The underlying framework for designing a process evaluation comes from the process theory component of the overall program theory developed during the planning stage. The process theory delineates the logistical activities, resources, and interventions needed to achieve the health change in program participants or recipients. Information from the process evaluation is used to plan, revise, or improve the program.
The third type of evaluation seeks to determine the effect of the program—in other words, to demonstrate or identify the program’s effect on those who participated in the program. Effect evaluations answer a key question: Did the program make a difference? The effect theory component of the program theory is used as the basis for designing this evaluation. Evaluators seek to use the most rigorous and robust designs, methods, and statistics possible and feasible when conducting an effect evaluation. Findings from effect evaluations are used to revise the program and may be used in subsequent initial program planning activities. Effect evaluations may be referred to as outcome or impact evaluations, terms which seem to be used interchangeably in the literature. For clarity, outcome evaluations focus on the more immediate effects of the program, whereas impact evaluations may have a more long-term focus. Program planners and evaluators must be vigilant with regard to how they and others are using terms and should clarify meanings and address misconceptions or misunderstandings.
A fourth type of evaluation focuses on efficiency and the costs associated with the program. Cost evaluations encompass a variety of more specific cost-related evaluations—namely, cost-effectiveness evaluations, cost–benefit evaluations, and cost–utility evaluations. For the most part, cost evaluations are done by researchers because cost–benefit and cost–utility evaluations, in particular, require expertise in economics. Nonetheless, small-scale and simplified cost-effectiveness evaluations can be done if good cost accounting has been maintained by the program and a more sophisticated outcome or impact evaluation has been conducted. The similarities and differences among these three types of cost studies are reviewed in greater detail in the text so that program planners can be, at minimum, savvy consumers of published reports of cost evaluations. Because cost evaluations are performed late in the planning and evaluation cycle, their results are not likely to be available in time to make program improvements or revisions. Instead, such evaluations are generally used during subsequent planning stages to gather information for prioritizing program options.
Comprehensive evaluations, the fifth type of evaluation, involve analyzing needs assessment data, process evaluation data, effect evaluation data, and cost evaluation data as a set of data. Given the resources needed to integrate analysis of various types of data to draw conclusions about the effectiveness and efficiency of the program, comprehensive evaluations are relatively uncommon. A sixth type of evaluation is a meta-evaluation. A meta-evaluation is done by combining the findings from previous outcome evaluations of various programs for the same health problem. The purpose of a meta-evaluation is to gain insights into which of the various programmatic approaches has had the most effect and to determine the maximum effect that a particular programmatic approach has had on the health problem. This type of evaluation relies on the availability of existing information about evaluations and on the use of a specific set of methodological and statistical procedures. For these reasons, meta-evaluations are less likely to be done by program personnel; instead, they are generally carried out by evaluation researchers. Meta-evaluations that are published are extremely useful in program planning because they indicate which programmatic interventions are more likely to succeed in having an effect on the participants. Published meta-evaluations can also be valuable in influencing health policy and health funding decisions.
Summative evaluations, in the strictest sense, are done at the conclusion of a program to provide a conclusive statement regarding program effects. Unfortunately, the term summative evaluation is sometimes used to refer to either an outcome or impact evaluation, adding even more confusion to the evaluation terminology and vernacular language. Summative evaluations are usually contrasted with formative evaluations. The term formative evaluation is used to refer to program assessments that are performed early in the implementation of the program and used to make changes to the program. Formative evaluations might include elements of process evaluation and preliminary effect evaluations.
Mandated and Voluntary Evaluations
Evaluations are not spontaneous events. Rather, they are either mandated or voluntary. A mandate to evaluate a program is always linked in some way to the funding agencies, whether a governmental body or a foundation. If an evaluation is mandated, then the contract for receiving the program funding will include language specifying the parameters and time line for the mandated evaluation. The mandate for an evaluation may specify whether the evaluation will be done by project staff members or external evaluators, or both. For example, the State Child Health Insurance Program (SCHIP), created in 1998, is a federally funded and mandated program to expand insurance coverage to children just above the federal poverty level. Congress has the authority to mandate evaluations of federal programs and did just that with the SCHIP. Mandated evaluations of SCHIP include an overall evaluation study by Wooldridge and associates from the Urban Institute (2003), and an evaluation specifically focused on outcomes for children with special healthcare needs (Zickafoose, Smith, & Dye, 2015).
Other evaluations may be linked to accreditation that is required for reimbursement of services provided, making them de facto mandated evaluations. For example, to receive accreditation from the Joint Commission, a health services organization must collect data over time on patient outcomes. These data are then used to develop ongoing quality improvement efforts. A similar process exists for mental health agencies. The Commission on Accreditation of Rehabilitation Facilities (CARF) requires that provider organizations conduct a self-evaluation as an early step in the accreditation process. These accreditation-related evaluations apply predominantly to direct care providers rather than to specific programs.
Completely voluntary evaluations are initiated, planned, and completed by the project staff members in an effort to make improvements. However, given the relatively low reward from, and cost associated with, doing an evaluation when it is not required, these evaluations are likely to be small with low scientific rigor. Programs that engage voluntarily in evaluations may have good intentions, but they often lack the skills and knowledge required to conduct an appropriate evaluation.
When Not to Evaluate
Situations and circumstances that are not amenable to conducting an evaluation do exist, despite a request or the requirement for having an evaluation. Specifically, it is not advisable to attempt an evaluation under the following four circumstances: when there are no questions about the program, when the program has no clear direction, when stakeholders cannot agree on the program objectives, and when there is not enough money to conduct a sound evaluation (Patton, 2008). In addition to these situations, Weiss (1972) recognized that sometimes evaluations are requested and conducted for less than legitimate purposes, namely, to postpone program or policy decisions, thereby avoiding the responsibility of making the program or policy decision; to make a program look good as a public relations effort; or to fulfill program grant requirements. As these lists suggest, those engaged in program planning and evaluation need to be purposeful in what is done and should be aware that external forces can influence the planning and evaluation processes.
Since Weiss made her observation in 1972, funders have begun to require program process and effect evaluations, and conducting these evaluations to meet that requirement is considered quite legitimate. This change has occurred as techniques for designing and conducting both program process and effect evaluations have improved, and the expectation is that even mandated evaluations will be useful in some way. Nonetheless, it remains critical to consider how to conduct evaluations legitimately, rigorously, inexpensively, and fairly. In addition, if the AEA standards of utility, feasibility, propriety, and accuracy cannot be met, it is not wise to conduct an evaluation (Patton, 2008).
Interests and the degree of influence held by stakeholders can change. Such changes affect not only how the evaluation is conceptualized but also whether evaluation findings are used. In addition, the priorities and responsibilities of the organizations and agencies providing the program can change during the course of delivering the program, which can then lead to changes in the program implementation that have not been taken into account by the evaluation. For example, if withdrawal of resources leads to a shortened or streamlined evaluation, subsequent findings may indicate a failure of the program intervention. However, it will remain unclear whether the apparently ineffective intervention was due to the design of the program or the design of the evaluation. In addition, unanticipated problems in delivering the program interventions and the evaluation will always exist. Even rigorously designed evaluations face challenges in the real world stemming from staff turnover, potential participants’ noninvolvement in the program, bad weather, or any of a host of other factors that might hamper achieving the original evaluation design. Stakeholders will need to understand that the evaluator attempted to address challenges as they arose if they are to have confidence in the evaluation findings.
The Public Health Pyramid
Pyramids tend to be easy to understand and work well to capture tiered concepts. For these reasons, pyramids have been used to depict the tiered nature of primary healthcare, secondary healthcare, and tertiary healthcare services (U.S. Public Health Service, 1994), the inverse relationship of effort needed and health impact of different interventions (Frieden, 2010), and nutrition recommendations (Gil, Ruiz-Lopez, Fernandez-Gonzalez, & de Victoria, 2014).
The public health pyramid is divided into four sections (FIGURE 1-2). The top, or the first, section of the pyramid contains direct healthcare services, such as medical care, psychological counseling, hospital care, and pharmacy services. At this level of the pyramid, programs are delivered to individuals, whether patients, clients, or even students. Generally, programs at the direct services level have a direct, and often relatively immediate, effect on individual participants in the health program. Direct services of these types appear at the tip of the pyramid to reflect that, overall, the smallest proportion of a population receives them. These interventions, according to the Health Impact Pyramid (Frieden, 2010), require considerable effort, with minimal population effects.
FIGURE 1-2 The Public Health Pyramid
At the second level of the pyramid are enabling services, which are those health and social services that support or enhance the health of aggregates. Aggregates are used to distinguish between individuals and populations; they are groups of individuals who share a defining characteristic, such as mental illness or a terminal disease. Examples of enabling services include mental health drop-in centers, hospice programs, financial assistance programs that provide transportation to medical care, community-based case management for patients with acquired immune deficiency syndrome (AIDS), low-income housing, nutrition education programs provided by schools, and workplace child care centers. As this list of programs demonstrates, the services at this level may directly or indirectly contribute to the health of individuals, families, and communities and are provided to aggregates. Enabling services can also be thought of as addressing some of the consequences of social determinants of health.
The next, more encompassing level of the public health pyramid is population-based services. At the population level of the pyramid, services are delivered to an entire population, such as all persons residing in a city, state, or country. Examples of population services include immunization programs for all children in a county, newborn screening for all infants born in a state, food safety inspections carried out under the auspices of state regulations, workplace safety programs, nutrition labeling on food, and the Medicaid program for pregnant women whose incomes fall below the federal poverty guidelines. As this list reflects, the distinction between an aggregate and a population can be blurry. Programs at this level typically are intended to reach an entire population, sometimes without the conscious involvement of individuals. In this sense, individuals receive a population-based health program, such as water fluoridation, rather than participating in the program, as they would in a smoking-cessation class. Interventions and programs aimed at changing the socioeconomic context within which populations live would be included at this population level of the pyramid. Such programs are directed at changing one or more social determinants of health. Population-level programs contribute to the health of individuals and, cumulatively, to the health status of the population.
Supporting the pyramid at its base is the infrastructure of the healthcare system and the public health system. The health services at the other pyramid levels would not be possible unless there were skilled, knowledgeable health professionals; laws and regulations pertinent to the health of the people; quality assurance and improvement programs; leadership and managerial oversight; health planning and program evaluation; information systems; and technological resources. The planning and evaluation of health programs at the direct, enabling, and population services levels is itself a component of the infrastructure; these are infrastructure activities. In addition, planning programs to address problems of the infrastructure, as well as to evaluate the infrastructure itself, are needed to keep the health and public health system infrastructure strong, stable, and supportive of the myriad of health programs.
Use of the Public Health Pyramid in Program Planning and Evaluation
Health programs exist across the pyramid levels, and evaluations of these programs are needed. However, at each level of the pyramid, certain issues unique to that level must be addressed in developing health programs. Accordingly, the types of health professionals and the types of expertise needed vary by pyramid level, reinforcing the need to match program, participants, and providers appropriately. Similarly, each level of the pyramid is characterized by unique challenges for evaluating programs. For this reason, the public health pyramid, as a framework, helps illuminate those differences, issues, and challenges, as well as to reinforces that health programs are needed across the pyramid levels if the Healthy People 2020 goals and objectives are to be achieved.
In a more general sense, the public health pyramid provides reminders that various aggregates of potential audiences exist for any health problem and program and that health programs are needed across the pyramid. Depending on the health discipline and the environment in which the planning is being done, direct service programs may be the natural or only inclination. The public health pyramid, however, provides a framework for balancing the level of the program with meeting the needs of the broadest number of people with a given need. Reaching the same number of persons with a direct services program as with a population services program poses additional expense and logistic challenges.
The pyramid also serves as a reminder that stakeholder alignments and allegiances may be specific to a level of the pyramid. For example, a school health program (an enabling-level program) has a different set of constituents and concerned stakeholders than a highway safety program (a population-level program). The savvy program planner considers not only the potential program participants at each level of the pyramid but also the stakeholders who are likely to make themselves known during the planning process.
The public health pyramid has particular relevance for public health agencies concerned with addressing the three core functions of public health (Institute of Medicine, 1988): assessment, assurance, and policy. These core functions are evident, in varying forms, at each level of the pyramid. Similarly, the pyramid can be applied to the strategic plans of organizations in the private healthcare sector. For optimal health program planning, each health program being developed or implemented ought to be considered in terms of its relationship to services, programs, and health needs at other levels of the pyramid. For all these reasons, the public health pyramid is used throughout this text as a framework for summarizing specific issues and applications of chapter content to each level of the pyramid and to identify and discuss potential or real issues related to the topic of the chapter.
The Public Health Pyramid as an Ecological Model
Individual behavior and health are now understood to be influenced by the social and physical environment of individuals. This recognition is reflected in the growing use of the ecological approach to health services and public health programs. The ecological approach, which stems from systems theory applied to individuals and families (Bronfenbrenner, 1970, 1989), postulates that individuals can be influenced by factors in their immediate social and physical environment. This perspective has been expanded into the social determinants perspective in public health, which has wide acceptance (Frieden, 2010). The individual is viewed as a member of an intimate social network, usually a family, which is a member of a larger social network, such as a neighborhood or community. The way in which individuals are nested within these social networks has consequences for the health of the individual.
Because it distinguishes and recognizes the importance of enabling and population services, the public health pyramid can be integrated with an ecological view of health and health problems. If one were to look down on the pyramid from above, the levels would appear as concentric circles (FIGURE 1-3)—direct services for individuals nested within enabling services for families, aggregates, and neighborhoods, which are in turn nested within population services for all residents of cities, states, or countries. This is similar to individuals being nested within the enabling environment of their family, workplace setting, or neighborhood, all of which are nested within the population environment of factors such as social norms and economic and political environments. The infrastructure of the healthcare system and public health system is the foundation and supporting environment for promoting health and preventing illnesses and diseases.
FIGURE 1-3 The Pyramid as an Ecological Model
The end of the chapter presents a summary of challenges or issues related to applying the chapter content to each level of the pyramid. This feature reinforces the message that each level of the pyramid has value and importance to health program planning and evaluation. In addition, certain unique challenges are specific to each level of the pyramid. The chapter summary by levels offers an opportunity to acknowledge and address the issues related to the levels.