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Scoping public health problems 

Scoping public health problems
Chapter:
Scoping public health problems
Author(s):

Gabriele Bammer

DOI:
10.1093/med/9780199586301.003.0001
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Objectives

This chapter aims to help you figure out what you can most effectively do, within the constraints of the resources you have, to address the public health problem you are concerned with.

What does scoping mean?

Scoping is the process of identifying all the aspects of the problem that are important before setting priorities for the approach that we will take to it. This allows us to use available resources most effectively. Aims include making the needs of the problem central (rather than our own expertise), ensuring that contentious issues are recognized and addressed, and focusing beyond individual behaviours to political, social, environmental, business, and other influences.

Scoping is the preparatory stage of a project where we systematically think about what we can best do with the time, money, and people we have at our disposal in order to use those resources most effectively. It involves considering:

  • What is most important for addressing the problem?

  • What needs to be done to get there?

  • Who needs to be on-side?

  • What are the likely blocks and how can they be overcome?

Why is scoping an important public health skill?

Scoping is particularly important as it helps us:

  • broaden our view of the problem beyond what we know and understand, recognizing and respecting different points of view

  • decide if we want to challenge the way in which the problem is generally dealt with, by paying more attention to something society sees as marginal or has excluded

  • consider issues of legitimacy

  • set boundaries.

A central aspect of scoping is to start by broadening the view of the problem, to move us beyond our own outlook and to help us see the problem through the eyes of others. The aim is to appreciate what various disciplines and stakeholders can contribute. The approach taken is then not limited to what we know. In this way, the problem becomes central, rather than our own expertise.

This process involves recognizing and respecting different points of view, giving us a rich understanding of the problem and an array of possible responses. Interestingly, in controversial areas, paying attention to the range of arguments also often smooths the path to compromise. Views may soften once people feel they have been respectfully heard. In addition, if people know that all reasonable alternatives have been considered, they will usually be more satisfied with the choice that is made. Therefore, starting off with a broad approach can help get people on-side for the action that is eventually decided upon (see Box 1.1.1).

In addition, by considering a range of perspectives, scoping helps us decide whether a fresh approach is needed to the problem, perhaps even one that challenges conventional thinking. Are there aspects of the problem that are currently not taken into account or that are on the periphery, which should be more central?

When the status quo is challenged or controversial issues tackled, issues of legitimacy often come into play. Who is funding the project? Which organizations, researchers, and stakeholders are involved? These are important in helping determine whether the project is attempting to be even-handed or is pushing a particular point of view.

The end product of scoping is to consciously set effective boundaries around how we will address the problem. Scoping helps us get to the nub of an issue, rather than tinkering at the margins or reinventing the wheel. There is always a limit to what any project can attempt, but we often do not realize the extent to which we have control over what we undertake. We can decide what is central, what is marginalized and what can be ignored in our project.

This is particularly important when resources are very limited. It helps us plan ahead, so that we can finish the project, rather than running out of money or time halfway through. Scoping may also be able to identify a way to proceed that is most likely to lead to more resources later.

Eight questions useful for scoping

  • What is already known about the problem?

  • What can different stakeholders and academic disciplines contribute to addressing this problem?

  • Which areas are contentious?

  • What are the big-picture issues? In other words, what are the political, social, and cultural aspects of the problem?

and

  • Why is this problem on the agenda now?

  • What support and resources are likely to be available for tackling the problem?

  • Which parts of the problem are already well covered and where are the areas of greatest need?

  • Where can the most strategic interventions be made?

The first four questions help identify the dimensions of the problem, while the last four help set priorities.

Addressing the scoping questions

Finding out what is already known about the problem

A key issue here is to systematically review the literature about previous research on the problem. Scoping public health problems Chapter 2.7provides guides for how to do this. Other sources of existing information may also be relevant, such as government white papers, non-government organization position papers, and business group statements.

Working with stakeholders and disciplines

In terms of figuring out how existing knowledge might best be built on, liaison with a range of stakeholders and academic disciplines is critical. Key steps include:

  • identifying which stakeholders and disciplines are relevant

  • finding appropriate representatives

  • getting their input

  • rewarding them.

It is useful to cast the net widely to identify relevant players. As well as using the review of existing knowledge, we should think laterally and use our contacts and networks. It may be useful to identify two categories of stakeholders—those affected by the problem and those in a position to influence the problem—and to ensure that both are adequately included.

Scoping public health problems Chapter 3.4takes us through the issues of representativeness and input from consumers, who are usually those affected by the problem. In terms of those who can influence the problem, representativeness tends to be less of an issue. Instead, targeting the most appropriate decision makers and practitioners may be more critical. For example, there is little point involving local government officials if the decision-making power rests with the national government.

Targetting is also important in terms of disciplinary input, as disciplines are usually quite heterogeneous in terms of what they cover. Finding the right kind of expertise for the problem is therefore the challenge. For instance, a sociologist with ethnographic skills is not particularly useful if a national survey will provide the most pertinent data.

Key questions to ask ourselves before seeking input from stakeholders and disciplinary experts are:

  • How can they make a meaningful contribution?

  • How can we ensure they will be listened to respectfully?

  • Will what they say actually be taken into account?

This will guide how we seek input and is also a critical aspect of reward. Recognition involves being included and taken seriously, as well as being kept informed about how their input was used and, eventually, what outcomes were achieved.

Dealing with areas of contention

While it can be tempting to avoid areas of contention, it is generally advisable to deal with them explicitly and early. It helps greatly to be dispassionate and sincerely open to hearing all arguments, as well as to identify the basis of the controversy—for example, is it a clash of egos, a misunderstanding resulting from poor communication, a conflict of interests, or a difference in values? This helps us think about how we want to position our approach to the public health issue and if we want to try to resolve the disagreement.

There are a number of participatory methods that can help people understand why others think differently.2 In general, people respond positively if they feel confident that their views are being heard and taken seriously. Then, even if they disagree with the final approach that is taken, they will often think it is fair.

Legitimacy particularly comes into play here (see Box 1.1.2). Taking a dispassionate stance only works if it is genuine and demonstrable.

What can we do if we are not disinterested, but are pushing for a particular outcome? Read the chapters on advocacy and activism (Scoping public health problems Chapters 4.5 and 6.8)! The issue becomes one of understanding the opposition and being able to counter it—both through being able to draw on a wide range of allies and being able to effectively frame our argument.

Tackling big-picture issues

Tackling the big picture issues is specifically linked to the stakeholders who can influence the problem. The point here is to move beyond considering the problem just in terms of individual behaviours to also take into account, for example, the influence of government policy, advertising, and business practice. Changes here can be more far-reaching and effective.

On the one hand, we should view these perspectives as we would those of any other stakeholder, i.e. something that we need to respectfully take into account. Steps include finding out who the key actors are, if there is any formal level of co-ordination, and what level of authority the actors and the co-ordinating group carry. We should attempt to involve players who can represent big-picture issues and not just assume that they will not be interested. They may well be aware of the problem and welcome an opportunity to be involved in dealing with it.

On the other hand, we need to recognize the power imbalance and that the key players may not see the problem under consideration as being of any consequence or may not wish to legitimize our activity by participating in it, especially if it threatens their interests. We must exercise extra caution, so that these stakeholders do not hijack the agenda, bog the process down or stymie action.

Setting priorities

The same processes of discussions with key players and lateral thinking are also key to setting priorities. Understanding the big-picture context of the problem is particularly useful for figuring out why the problem is on the agenda now and the points of strategic intervention. Clarifying what is already known about the problem will point to what is well covered and give some ideas about the areas of greatest need. The latter will be enhanced by discussions with a wide range of disciplinary experts and stakeholders. Such discussions will also highlight the level of support available for tackling the problem and possibly identify additional resources.

An iterative process

An iterative, rather than a linear, process in addressing the eight scoping questions will most probably work best and reduces the danger of getting bogged down, especially when charting unfamiliar territory.

The judicious use of experts is crucial to saving time and maintaining momentum. The challenge is to discern what is needed to put together an understanding of the problem, what we know and don’t know, and who to bring in to fill the gaps. As new players are brought into the picture, their contributions may lead us to revisit our understandings of what is known or the areas of disagreement or the priorities. We must be open to this, but we also need a clear sense of direction so that we are not diverted by less relevant agendas which other players may have.

Back-to-back spirals are illustrative of the process—the outward expansion of the top spiral indicates the build-up of knowledge and perspectives, whereas the inward direction of the second shows the knowledge and perspectives being used to set priorities (Figure 1.1.1). The loops illustrate revisiting what is known, bringing in other people who might have a useful perspective, and so on. As the figure illustrates, the starting point may be somewhat off centre; in other words, our own knowledge and expertise may be limited, but the end point of scoping is an action plan that addresses central issues.


Figure 1.1.1 Broadening, aligning, and focusing perspectives.

Figure 1.1.1
Broadening, aligning, and focusing perspectives.

‘Reality testing’ can profitably be undertaken at several points. The aim here is to find holes in the knowledge base or the arguments on which priorities are based and, from this, to highlight where further data gathering or consultation is required. This is where advisory and reference groups can be invaluable, as they can be asked to comment along the way.

What are the competencies needed for effective scoping?

Key competencies include:

  • integrity (including being clear about whether or not we are dispassionate)

  • credibility in terms of acknowledged expertise about the problem and/or the scoping process

  • possession of a wide-ranging network of contacts, so that we know the key players or an intermediary who can provide access to them

  • skill in facilitating meetings and interactions, including encouraging open debate and the challenging of ideas, handling negotiations and conflict, and creating a positive atmosphere

  • management skills

  • an open mind to ideas from others

  • the ability to think laterally and creatively

  • understanding the ‘cultures’ of different stakeholders and the ability to empathize with different concerns, without being captured by them

  • the ability to identify which disciplines are relevant and enough knowledge about the disciplines to know what they can offer, to identify experts, and to involve experts in working on the problem

  • understanding the relevant policies and other big-picture issues, their history, the key players, and the political sensitivities

  • the ability to integrate a range of knowledge and expertise, to cut through to the essentials, and to lead a priority-setting process

  • the ability to build alliances with those we need to have on-side in order to move forward.

What are the potential pitfalls in the scoping process?

Potential pitfalls include:

  • Not having enough resources: including time, to undertake an adequate process

  • No real commitment: by those in a position to act to understanding and dealing with the problem. For example, a process can be set in train for reasons of political expediency and the plug may be pulled as soon as the political heat dies down

  • Not being the right person for the job: for example, if we are not interested in this process, not experienced enough to keep control, or if we cannot deal with a diverse range of views respectfully

  • Getting bogged down: losing momentum and timeliness can be fatal. Beware of wallowing in factual detail, meetings without a clear purpose, and red herrings. We should not feel that we have to be on top of all the material, but instead rely on experts who understand the stakeholder or disciplinary perspectives.

  • Choosing inappropriate representatives of stakeholders: involving people in a process helps legitimize their point of view and we should think carefully about including fringe groups. If people who are not well-regarded are included in the process, respected players may pull out or not participate fully

  • An inappropriate balance: the problem has to be seen in perspective, so that the process involves an appropriate mix of stakeholders and academic disciplines, the powerful and the powerless, and, for a dispassionate approach to contentious issues, different points of view

  • Avoiding the contentious issues: ignoring particular groups in an attempt to avoid controversial issues will often backfire, with their exclusion providing them with an additional opportunity to further their cause and even undermining the outcomes of the process

  • Exhausting key players: stakeholder representatives and experts from particular disciplines usually have a substantive job to do and they may get no recognition or credit for being involved in our scoping process. Use their time wisely, sparingly, and efficiently

  • Promoting conflict: scoping processes that involve contentious issues usually seek to find compromise, but if the players are not chosen carefully and the process is not handled appropriately, conflict can be escalated, rather than reduced

  • Not showing leadership: if we do not show leadership when we are in charge of the scoping process, it is open to being hijacked by the more powerful participants. This can also be a factor in the promotion of conflict

  • Avoiding decisions: never underestimate the temptation not to make a decision when the problem is difficult or contentious. Yield not to temptation!

  • Not being prepared to combat the wrath of the powerful: when scoping processes involve challenging entrenched power bases, provoking a reaction could well be a measure of success. The challenge is not to be naïve and to be prepared to counter these forces

  • Not learning from our mistakes

  • Inexperience: this can be overcome by finding mentors, powerful allies, and supportive colleagues.

How will you know when you have been successful?

Markers of success are an approach to the problem that has:

  • broad-based support

  • clear and implementable steps for increasing understanding and moving to a solution

  • commitment from the key players and the stakeholders they represent to stay involved in seeking a solution

  • respect between opponents.

For issues where a major power base has been challenged and where the power base is seeking to protect its interests, measures of success include:

  • a coalition that includes people of influence, which will stand up to the power base and continue to fight for the solution

  • openings for negotiation.

A successful scoping process lays a strong foundation for effectively tackling a problem, and increases the chances of developing a solution on budget and on time.

Further resources

Arksey H, O’Malley L. (2005). Scoping studies: towards a methodological framework. International Journal of Social Research Methodolgy, 7, 19–32.Find this resource:

Executive Office of the President, Council on Environmental Quality (1981). Memorandum for general counsels, NEPA liaisons and participants in scoping. Available at: Scoping public health problems http://ceq.hss.doe.gov/nepa/regs/scope/scoping.htm (accessed 19 August 2010).Find this resource:

    Mulvihill PR. (2003). Expanding the scoping community. Environmental Impact Assessment Review, 23, 39–49.Find this resource:

    Wood G, Glasson J, Becker J. (2006). EIA scoping in England and Wales: practitioner approaches, perspectives and constraints. Environmental Impact Assessment Review, 26, 221–41.Find this resource:

    References

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    2 McDonald D, Bammer G, Deane P. (2009). Research integration using dialogue methods. Australian National University E Press, Canberra. Available at: Scoping public health problems http://epress.anu.edu.au/dialogue_methods_citation.html.Find this resource:

      3 World Commission on Dams. (2000). Dams and development: a new framework for decision-making. Earthscan, London. Available at: Scoping public health problems http://pubs.iied.org/pdfs/9126IIED.pdfFind this resource: