# Guide for Establishing Public Health Priorities

(Modified from CDC Case Study: Translating Science into Practice)

Establishing priorities from the multitude of public health problems facing communities today is a necessary and increasingly difficult task. Public health administrators and managers often are faced with an increasing range of pressing problems in light of decreasing resources. A method to establish priorities that is fair, reasonable, and easy to calculate is a necessary management tool.

The method described here provides means to compare different health problems in a relative, not absolute, framework, as equally as possible, and in a somewhat objective manner.

This method, which has been called both the Hanlon Method and the Basic Priority Rating System (BPRS), is described in Public Health: Administration and Practice (Hanlon and Pickett, Times Mirror/Mosby College Publishing) and Basic Health Planning (Spiegel and Hyman, Aspen Publishers).

The method has three major objectives:

• to allow decision-makers to identify explicit factors to be considered in setting priorities
• to organize the factors into groups that are weighted relative to each other
• to allow the factors to be modified as needed and scored individually.

## Basic Priority Rating Formula

Based on review of repeated trials conducted in identifying health problems, a consistent pattern of criteria became apparent. This pattern is reflected in the components of this system.

Component A = Size of the problem

Component B = Seriousness of the problem

Component C = Estimated effectiveness of the solution

Component D = PEARL factors (propriety, economic feasibility, acceptability, resource availability, legality)

These components translate into two formulas that provide a numerical score that gives highest priority to those diseases/conditions with the highest scores.

Basic Priority Rating (BPR) > BPR = (A+B)C/3

Overall Priority Rating (OPR) > OPR = [(A+B)C/3] x D

The difference in the two formulas will become apparent as Component D (PEARL) is described.

It is important to recognize and accept that, as with many such processes, a large amount of subjectivity will be present. The choice, definition, and relative weights assigned to the components are a group decision and flexible. Further, the ratings are the judgments of the individual raters. However, some scientific control can be achieved by using precise definitions of terms, and using appropriate and accurate statistical data.

## Components

Component A – Size of the Problem

This component is one in which the factors are few in number. Choices usually are limited to a percentage of population directly affected by the problem, i.e. incidence, prevalence, or mortality rates and numbers.

Size can also be considered in more than one way. Both the entire population and potential target populations can be considered. Also, diseases with common risk factors that are amenable to a common solution might be considered together. For example, if tobacco-related cancers were considered, lung, esophagus, and oral cancers might be considered as one. If more diseases were also being considered, cardiovascular diseases might also be considered. The maximum value of this component is 10. The decision of how to define size is usually a group consensus.

Component B – Seriousness

The group should consider possible factors that define the seriousness of the problem; however, the number of factors should be kept reasonable. The group should be careful not to bring the issues of size or preventability into the discussion, as they fit elsewhere into the equation.

The maximum score in this component is 20. The factors must be weighted and carefully defined. By using this number (20), Seriousness is considered to be twice as important as Size.

Factors that could be used are:

• Urgency: emergent nature of the problem; trends in incidence, mortality, or risk factors; importance relative to the public; current access to needed service.
• Severity: survival rates, average age at death, disability, relative premature mortality.
• Economic loss: to the community (city/county/State), to the individual.

Each of the factors must be weighted. As an example using four factors, the weights could be 0-5 or any combination that would equal a maximum of 20. It is usually helpful to establish what would be considered minimum and maximum in each factor. This will help to establish boundaries to keep some perspective in establishing a numerical rating. A way to consider this is to use as scale such as:

0 = none

1 = some

2 = more

3 = most

For example, if premature mortality is being used to define severity, then infant mortality would probably be a 5 and gonorrhea would be a 0.

Component C – Effectiveness of Intervention

This component should be considered as "How well this problem can be solved, if at all." The factor is scored from 0 – 10. This may be the most subjective component of the formula. There is a large amount of data that is available from studies that document how successful interventions have been.

The effectiveness rating, based on known success rates from the literature, is multiplies by the percent of the target population expected to be reached.

Example: Smoking cessation

Target population 45,000 smokers

Total attempting to stop 13,500

Effectiveness of smoking cessation classes 32% or 0.32

Target population x effectiveness 0.30 x 0.32 = 0.096 or 0.1 or 1

Example: Immunization

Target population 200,000

Expected number immunized 193,000

Percent of total 97% or 0.97

Effectiveness 94% or 0.94

Population reached x effectiveness 0.97 x 0.94 = 0.91 or 9.1

An advantage in considering the target population and the number expected to be reached is getting a realistic feel for resources needed and expected ability to meet set objectives.

Component D – PEARL

The PEARL is a group of factors that, although not directly related to the health problem, have a high degree of influence in determining whether a particular problem can be addressed.

P – Propriety Is the problem one that falls within the agencies’ overall missions?

E – Economic Feasibility Does it make economic sense to address the problem? Are there economic consequences if the problem is not addressed?

A – Acceptability Will the community and/or target population accept the problem being addressed?

R – Resources Are resources available to address the problem?

L – Legality Do current laws allow the problem to be addressed?

Each of these qualifying factors is considered, and the scoring for each factor of the PEARL is 1 if the answer is "yes" and 0 if the answer is "no." When scoring is complete, all of the numbers are multiplied to obtain a final answer. Since together these factors represent a product and not a sum, if any of the five factors is "no’, then D will equal 0. Because D is the final multiplier in the formula, if D=0, then the health problem will not be addressed in the OPR regardless of how high the problem ranks in BPR. However, part of the total planning effort might include addressing the intermediate steps needed to address the PEARL positively in the future. For example, if the intervention is just not acceptable to the population, steps might be taken gradually to educate the population as to the potential benefits of the intervention so that it can be considered in the future.

Basic Priority System last revised April 19, 2004 (epowell)