Quantify the Problem

Once a problem area is defined, a related consideration is to quantify the scope of the problem. This involves identifying its prevalence and impact. The targeted problem area may affect a significant portion of a population such that it warrants intervention attention. Alternatively, the targeted problem area may affect only a small number of individuals; yet, it is the driver of significant personal and societal costs and thus important to address through intervention development.

The impact of the problem may include the number of persons affected; its associated sequelae on families, communities, or society at large; or its personal, community, or societal costs. The impact of the problem is one of the most important factors to consider when evaluating whether an investment of time and resources to develop and evaluate an intervention is warranted. The potential impact of an intervention proposed in a grant application will be heavily weighed by review committees of funding agencies. There are many clinical and/or localized concerns of interest to particular professional groups or practice settings for which an intervention could be developed. However, these important yet “small” clinical problems may not rise to the level of public health import necessary for obtaining funding to support intervention development, because they do not affect a significant number of persons, result in societal harm or costs, nor are associated with pernicious sequelae of events warranting investment in intervention development, or considered a public health priority.

Quantifying the prevalence and impact of the targeted issue using existing evidence is important for several reasons. First, it is important to build a strong case that the problem is a public health issue to secure funding from federal agencies and foundations (see Chapter 23 on grant writing). Second, quantifying the problem can provide a basis for understanding the potential impact of an intervention and resultant personal and societal cost savings. For the ABLE Program, it was documented that an estimated 38 million older adults by 2030 would be living in the community with significant functional limitations and that a greater portion of Medicare dollars compared to older adults without disabilities were being spent on this group. As this group is at high risk for falls and hospitalizations, the magnitude

TABLE 3.1 Key Considerations in Discovery Prephase

Key Consideration

Explanation

Exemplar—ABLE Program

Define problem

On the basis of epidemiological studies and/or needs assessments, identify problem and extent to which it represents a public health problem. Quantifying problem can demonstrate its impact.

Functional limitations place older adults at risk for relocation, health care utilization, hospitalizations, poor quality of life, social isolation, morbidity, and mortality.

Quantify problem

Determine prevalence of problem, cost of problem, or other indicators of its impact.

By 2030, 38 million older adults will have one or more functional limitations.

Specify populations at most risk

Within designated population, identify those most at risk who may need intervention.

Most at risk are minority and low-income, representing fastest growing segment of aging population. Also, older adults living in poor housing stock, those with multiple chronic comorbidities, the oldest old, those living alone and lacking resources are also at high risk.

Determine

pathway(s)

Identify theoretical basis for an intervention that addresses the problem.

Disablement Model provides overarching framework for understanding pathways between functional limitations, disability, and poor outcomes. It suggests that a mismatch between capabilities (intrinsic) and home environments (extrinsic) heightens disability or ability to perform desired activities including self-care. Life-Span Theory of Control suggests that mismatch can be minimized through control-oriented strategies (e.g., compensatory techniques, seeking help and environmental adjustments).

Determine if pathways amenable to change

Evaluate whether hypothesized pathways are modifiable and what measures will be sensitive to change.

Although underlying impairment may not be amenable to change, it can mitigate disability caused from mismatch between capabilities and environments. Providing "control" enhancing strategies and modifying home environment may reduce impact of functional limitations, negative psychosocial consequences, and risk for relocation.

Specify potential outcomes

Identify potential proximal (immediate), primary (main), secondary, distal, and mediating outcomes and their measurement.

Proximal outcome was home safety and use of control-oriented strategies; primary outcomes included reduction in functional difficulties and improved self-efficacy; distal outcomes were improved

TABLE 3.1 Key Considerations in Discovery Prephase (Continued)

Key Consideration

Explanation

Exemplar—ABLE Program

quality of life and reduction of risk for mortality. Measures sensitive to change might include subjective appraisals of functional difficulty, self-efficacy, strategy use; objective measures of health care utilization, functional performance, depressive symptoms might also be relevant.

Quantify potential for improvement

Evaluate whether improvements will reflect small, medium, or large changes. Effect sizes will influence sample size considerations.

Reducing disability can minimize depression, morbidity, mortality, nursing home placement, hospitalization, risk of other types of relocations. Reductions in functional difficulties will be small but clinically significant.

Determine how problem is currently addressed

Through literature review, determine if there is an existing intervention and if it is effective for the targeted population. If not, then new intervention development will be warranted. Also, determine if there are proven protocols that may be useful.

There were no interventions developed or tested. Although there was previous evidence for role of home modifications, there were no proven protocols that could be combined into an intervention. Thus, ABLE had to be developed from the ground up.

of the problem and its personal and societal impact warrant moving forward with intervention development.

 
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