# Principles of Public Health Practice/The desirability and feasibility of interventions

We have covered a great deal of the conceptual, ethic and legal aspects of the Principles of Public health. We are now beginning to move towards some of the critical issues in public health practice. You needed the background; now we need to foreground more practical issues.

## Learning activity instructions

Each week we hold a lectorial and a tutorial. A lectorial is a short lecture followed by a group activity, and the tutorials are for discussion and practising group activities.
Lectorial
* View this topic's (review the learning outcomes) playlist here.
* Review the introductory and background material for this topic and obtain copies of key resources here.
* Review the topic learning outcomes and attend the lectorial after doing your preparatory work.
Tutorial
* Download the tutorial sheet here and prepare as instructed.
* Progress your group-based assignment through your communication channels.
* Attend the tutorial and be prepared to work out your research, analysis and evaluation and writing roles and responsibilities for your group. The criteria and format instructions are available under the rubric for the second assessment.

## What are the typical means available to public health practitioners to assess both the desirability and feasibility of interventions?

Have you ever thought, "Gee, it would be really nice if we could do that!" Your friend says, "Do what?" You repeat what you said and they look at you as if you have just said the dumbest thing possible. When you patiently talk everything through, your friend finally admits that it would be nice to do that; but, there is no way that you will be able to do that. It's frustrating to find yourself in that sort of situation.
Sometimes people are so focused on what they think could not happen that they never wonder whether it would be desirable to do the thing in question. While the two are related, we need to keep them somewhat separate in our thinking. What is not feasible or doable now, just might become doable under the right conditions. All we need to do is to change the conditions. But, to do that, we require sufficient motivation. We will never work hard to achieve something that we think is of little value.
We have now revealed something important. We have highlighted the difference between value (desirability) and means (feasibility).
Let's do a thought experiment. I say to you, "If we can get people to engage in more physical activity, then we can significantly change the likelihood of premature mortality." You think that this would be valuable. You begin to think of all the people at immediate risk of premature death. Then, you realise, "My goodness; it is going to be very difficult to get them to become more active. We do not have the means of getting them prepared to undertake the sort of program the might be required."
I would suggest to you that you might be looking at the thing the wrong way round.
We may not have the means to get the really sick to increase their activity. But, we do have the means to get those with the potential for becoming ill more active. This might prevent them from declining further. For instance, it may be the case that all we need for them to do is to walk briskly for five minutes in one direction at work and, then, return briskly to their desk. If they do this three times in a day, they will have shifted from being more sedentary to being less sedentary. Across a large population and through time, that may well mean significantly reduced rates of morbidity and premature mortality.
Notice that what is considered to be both valuable and feasible may not be the most obvious thing. We needed to know some very specific things about health and illness to create potential interventions that might be engaged across a whole population. But, what about the participation of the various groups of people? In other words, a "population" of people is not really totally homogeneous, or the same in all respects. There will always be outliers, people at the edge, in a population. It is often that case that those people who a similar in may ways when considered from one point of view will have very different factors that motivate them to act. We not only have to understand health and illness; we also have to understand people.

## Background

We often hear of desirability and feastibility mention in the same conversation even when quite different stakeholders are involved (e.g., debates over health insurance (Rannan-Eliya, Irava & Saleem 2013)). Why? The reason that we have to ask questions about desirability (value) and feasibility (means) is the limitation of resources and the possibility of unintended consequences (Rogowski 2010). When we speak of desirability, we want to know that the benefits might be for the various stakeholders and what perceptions of benefit may or may not be held by these stakeholders (Lehoux 2008). Each type of stakeholder and each level in which they encounter the issue will, most likely, have a different set of standards by which they judge what is desirable (Halpin, Morales-Suarez-Varela, Martin-Moreno 2010). Desirability can be discussed in terms of acceptability, accessibility and affordability. These later concepts can be considered desirable. Something that makes the situation better and scores highly on the three A's is more likely to be enacted.
But, not everyone will be worried about the three A's. Some people will be more concerned about the relative effectiveness of the intervention. This is often balanced with the resources costs. We have a number of ways of considering either a cost/benefit or a cost/effectiveness analysis (Asare-Marfo, Birol, Fielder, Ha, Lividini, Moursi, Meenakshi, Stein & Zeller n.d.). And, we do not necessarily need to forget about equity (Jack 2000). In some ways, this is just another way of discussing the three A's which are important considerations even for Randomized Control Trials (Walji, Wahoush & Atkinson 2013). However, the language game is usually a little bit different (Prakongsai, Patcharanarumol & Tangcharoensathien (2008). Additionally, what counts as evidence of effectiveness is also different. If you wish for people to see the potential intervention as desirable, it is important to know your audience and to ensure that you have answered their questions. What might be desireable to one set of stakeholders may look quite different to another. We are often required to engage in what is called social marketing or social persuasion to gain adherence during the various phases of assessing, planning, implementing and evaluating an intervention (Lefebvre & Flora 1988).
Where does feasibility fit in in the terms of public health interventions. Well, we are back to the idea of efficacy and effectiveness. What might work in ideal conditions, may not work in the normal circumstances of life. What might work for one group of people in one context may not even get a start with another group of people or the same sorts of people in a new context (Judd, Frankish & Moulton 2001). Again, it is a matter of resources and motivation. This time, it is less about the perceived value of an action or activity and the practical issues involved in trying to implement the activity (Hunt, Fagan, Lederman, Stoddard, Frazier, Girod & Sorensen 2003). It might be a good idea to use community gardens to interest young children in eating vegetables; yet, this might be impossible to enact in the middle of a war zone or a zone of chronic inclement weather (say among Laplanders). Yet, even in the most unpromising of places, motivation and interest can have strong impacts on feasibility (Mendelson, Greenberg, Dariotis, Gould, Rhoades & Leaf 2010).
You should probably obtain, store and scan the following resources:
   * Evidence-based Methodologies for Public Health
   * Public Health Planning and Practice Improvement: Deciding and specifying an intervention portfolio
   * Evidence Summary: Public health interventions to support mental health
References and resources
    Asare-Marfo, D., Birol, E., Fielder, J. Ha, B., Lividini, K., Moursi, M., Meenakshi, J.V., Stein, A.J. and Zeller, M. (n.d.) Cost-effectiveness of Biofortification. The 2nd Global Conferfence of Biofortification: Getting Nutritious Foods to People. Conference Brief #17 (Nutrition & Impact).
    ECDC (2011) Evidence-based Methodologies for Public Health: How to assess the best available evidence when time is limited and there is a lack of sound Evidence. Stockholm: European Centre for Disease Prevention and Control.
    Hunt, M.K., Fagan, P., Lederman, R., Stoddard, A., Frazier, L., Girod, K. & Sorensen, G. (2003) Feasibility of implementing intervention methods in an adolescent worksite tobacco control study. Tobacco Control 12(Suppl IV):iv40-iv45.
    Jack, William (2000) Public spending on health care: How are different criteria related? A second opinion. Health Policy 53:61-67.
    Judd, J., Frankish, C.J. and Moulton, G. (2001) Setting standards in the evaluation of community-based health promotion programmes--A unifying approach. Health Promotion International 16(4):367-380.
    Lefebvre, R.C. and Flora, J. A. (1988) Social Marketing and Public Health Intervention. Health Education Quarterly 15(3):299-315.
    Lehoux, P. (2008) Why Examining the Desirability of Health Technology Matters/L'importance d'examiner dans quelle mesure les technologies de la sante sont souhaitables. Healthcare Policy 3(3):29-39.
    Mendelson, T., Greenberg, M., Dariotis, J.K., Gould, L.F., Rhoades, B.L. and Leaf, P.J. (2010) Feasibility and preliminary outcomes of a school-based mindfulness intervention for urban youth. Journal of Abnormal and Child Psychology. [Published online: 04 May 2010 at 10.1108/JCS-07-2013-0024]
    NHSHS (2012)Evidence Summary: Public health interventions to support mental health. Glasgow: National Health Service Health Scotland.
    NPHP (2000) Public Health Planning and Practice Improvement: Deciding and specifying an intervention portfolio. Melbourne: National Public Health Partnerships.
    Prakongsai, P., Patcharanarumol, W. & Tangcharoensathien, V. (2008) Can earmarking mobilize and sustain resource to the health sector? Bulletin of the World Health Organization 86(11):898-901.
    Rannan-Eliya, R.P., Irava, W. & Saleem, S. (2013) Assessment of Social Health Insurance Feasibility and Desirability in Fiji. Fiji Ministry of Health and WHO.
    Rogowski, W.H. (2010) What should public health research focus on? Comments from a decision analytice perspective (editorial) European Journal of Public Health 20(5):484-485.
    Walji, R., Wahoush, O. and Atkinson, S.A. (2013) Feasibility and acceptance of a novel nutrition and exercise intervention to manage excess gestational weight gain: Focus group student in Ontario, Canada. Primary Health Care 3(2):n.p. [open access journal accessed at http://dx.doi.org/10.4172/2167-1079.1000134]

## Learning Outcomes

What are the typical means available to public health practitioners to assess both the desirability and feasibility of interventions?
Upon completion of this topic, through your own investigations, group preparation, tutorial participation and lectorial explorations, you should be able to:
   * Reproduce the typical aims of of public health interventions in terms of the various levels and scope of intervention (e.g., primary, secondary, tertiary).
   * Compare and contrast various factors involved in and ways of assessing the health of a population and their relative risk.
   * Summarize the elements and importance of logic models in outlining the various aspects of assessing, planning, implementing an intervention.
   * Discuss the various ethical issues involved in considering a public health intervention from the point of view of autonomy, justice and equity.