Bobby Milstein

Codebook Development for Team-Based Qualitative Analysis

One of the key elements in qualitative data analysis is the systematic coding of text (Strauss and Corbin 1990:57%60; Miles and Huberman 1994:56). Codes are the building blocks for theory or model building and the foundation on which the analyst’s arguments rest. Implicitly or explicitly, they embody the assumptions underlying the analysis. Given the context of the interdisciplinary nature of research at the Centers for Disease Control and Prevention (CDC), we have sought to develop explicit guidelines for all aspects of qualitative data analysis, including codebook development.

Practical Challenges of Systems Thinking and Modeling in Public Health

OBJECTIVES Awareness of and support for systems thinking and modeling in the public health field are growing, yet there are many practical challenges to implementation. We sought to identify and describe these challenges from the perspectives of practicing public health professionals. METHODS A systems-based methodology, concept mapping, was used in a study of 133 participants from 2 systems-based public health initiatives (the Initiative for the Study and Implementation of Systems and the Syndemics Prevention Network). This method identified 100 key challenges to implementation of systems thinking and modeling in public health work. RESULTS The project resulted in a map identifying 8 categories of challenges and the dynamic interactions among them. CONCLUSIONS Implementation by public health professionals of the 8 simple rules we derived from the clusters in the map identified here will help to address challenges and improve the organization of systems that protect the publics health.

Systems thinking and modeling for public health practice

Many public health workers will regard this issue of the Journal, devoted to the theme of systems thinking and modeling, as a welcome affirmation that our endeavors to protect the public’s health do indeed depend on more than the sum of their parts. As Midgley observes, “The whole concept of public health is founded on the insight that health and illness have causes or conditions that go beyond the biology and behavior of the individual human being.”1(p466) Animated by this systemic insight, public health leaders have worked for more than a century to identify and transform the processes that leave people vulnerable to afflictions of all sorts. As this work has evolved, our understanding of population health dynamics—and of our power to navigate change—has improved through innovations in the concepts, methods, and moral frameworks that shape the field. The present exploration of systems thinking and modeling, therefore, springs from the very core of our discipline, adding to our repertoire novel and far-reaching tools that the pioneers of public health work could scarcely have imagined.

Understanding Diabetes Population Dynamics Through Simulation Modeling and Experimentation

Health planners in the Division of Diabetes Translation and others from the National Center for Chronic Disease Prevention and Health Promotion of the Centers for Disease Control and Prevention used system dynamics simulation modeling to gain a better understanding of diabetes population dynamics and to explore implications for public health strategy. A model was developed to explain the growth of diabetes since 1980 and portray possible futures through 2050. The model simulations suggest characteristic dynamics of the diabetes population, including unintended increases in diabetes prevalence due to diabetes control, the inability of diabetes control efforts alone to reduce diabetes-related deaths in the long term, and significant delays between primary prevention efforts and downstream improvements in diabetes outcomes.

Analyzing National Health Reform Strategies With a Dynamic Simulation Model

Proposals to improve the US health system are commonly supported by models that have only a few variables and overlook certain processes that may delay, dilute, or defeat intervention effects. We use an evidence-based dynamic simulation model with a broad national scope to analyze 5 policy proposals. Our results suggest that expanding insurance coverage and improving health care quality would likely improve health status but would also raise costs and worsen health inequity, whereas a strategy that also strengthens primary care capacity and emphasizes health protection would improve health status, reduce inequities, and lower costs. A software interface allows diverse stakeholders to interact with the model through a policy simulation game called HealthBound.

Setting Objectives for Community and Systems Change: An Application of Concept Mapping for Planning a Statewide Health Improvement Initiative

The Hawaii Department of Health (HDOH) used concept mapping techniques to engage local stakeholders and national subject area experts in defining the community and system factors that affect individuals’ behaviors related to tobacco, nutrition, and physical activity. Over eight working days, project participants brainstormed 496 statements (edited to a final set of 90), which were then sorted and rated for their importance and feasibility. A sequence of multivariate statistical analyses, including multidimensional scaling and hierarchical cluster analysis, generated maps and figures that were then interpreted by project stakeholders. The results were immediately incorporated into an official plan, approved by the governor and state legislature, recommending how Hawaii’s tobacco settlement resources could be used to create sustainable changes in population health. The results also provide empirical support for the premise that both community and systems factors ought to be considered when planning comprehensive health improvement initiatives.

Why Behavioral And Environmental Interventions Are Needed To Improve Health At Lower Cost

We used a dynamic simulation model of the US health system to test three proposed strategies to reduce deaths and improve the cost-effectiveness of interventions: expanding health insurance coverage, delivering better preventive and chronic care, and protecting health by enabling healthier behavior and improving environmental conditions. We found that each alone could save lives and provide good economic value, but they are likely to be more effective in combination. Although coverage and care save lives quickly, they tend to increase costs. The impact of protection grows more gradually, but it is a critical ingredient over time for lowering both the number of deaths and reducing costs. Only protection slows the growth in the prevalence of disease and injury and thereby alleviates rather than exacerbates demand on limited primary care capacity. When added to a simulated scenario with coverage and care, protection could save 90 percent more lives and reduce costs by 30 percent in year 10; by year 25, that same investment in protection could save about 140 percent more lives and reduce costs by 62 percent.

Promoting condom use with main partners: A behavioral intervention trial for women

The Stages of Change (SOC) model was used to implement and evaluate a condom promotion intervention for HIV-positive and at-risk women who were recruited from clinic and community settings in Baltimore and Philadelphia. Participants were assigned to receive standard reproductive health services or enhanced services (standard plus SOC peer advocate intervention). Women who had a main partner at baseline and at a 6-month follow-up were included in the analysis (70 HIV positive, 471 at risk). Compared with the standard group, HIV-positive women in the enhanced group were significantly more likely to have progressed in the SOC model or to have maintained consistent condom use, and less likely to have relapsed or stayed in the precontemplation stage. Among the at-risk women, exposure to the intervention was associated with being at a higher SOC and being less likely to relapse relative to the standard group. The SOC model has promise for use in social and public health service settings that serve women at risk or living with HIV.

From Model to Action: Using a System Dynamics Model of Chronic Disease Risks to Align Community Action

Health planners in Austin, Texas, are using a System Dynamics Model of Cardiovascular Disease Risks (SD model) to align prevention efforts and maximize the effect of limited resources. The SD model was developed using available evidence of disease prevalence, risk factors, local contextual factors, resulting health conditions, and their impact on population health. Given an interest in understanding opportunities for upstream health protection, the SD model focused on the portion of the population that has never had a cardiovascular event. Leaders in Austin used this interactive simulation model as a catalyst for convening diverse stakeholders in thinking about their strategic directions and policy priorities. Health officials shared insights from the model with a range of organizations in an effort to align actions and leverage assets in the community to promote healthier conditions for all. This article summarizes the results from several simulated intervention scenarios focusing specifically on conditions in East Travis County, an area marked by higher prevalence of adverse living conditions and related chronic diseases. The article also describes the formation of a new Chronic Disease Prevention Coalition in Austin, along with shifts in its members’ perceived priorities for intervention both before and after interactions with the SD model.

A Framework Featuring Steps and Standards for Program Evaluation

Every day, the Centers for Disease Control and Pre vention (CDC) focuses the world’s attention on issues that deserve to be in the public health spotlight. Visitors to the CDC Web site 2 know that this spotlighting is not only a metaphor but also a prominent physical feature on the agency’s Internet home page. Through its Spot light section, the CDC summarizes at a glance the most important things happening in public health each day. During the week of September 17, 1999, that spotlight shone on program evaluation. The CDC’s attention to program evaluation confirmed what most practitioners have experienced in their own workplaces—that evaluation activities are becoming an inseparable part of public health practice. The Spotlight feature also coincided with the publication of a “Framework for Program Evaluation in Public Health” (CDC, 1999). This framework was written to help the public health workforce gain a common under standing of evaluation concepts and to promote further integration of evaluation into the routine activities of public health organizations. The changing circumstances of public health de mand that all practitioners make better use of what evaluation has to offer. With its focus on making evalu ation more understandable and accessible, the frame work helps build evaluation literacy and competency. It is a practical, timely tool that many practitioners have already found applicable and helpful. This article pro vides a synopsis of the framework along with exam ples of how it is being disseminated, understood, and used by practitioners throughout the public health system.