Scheirer and Dearing’s article proposing an agenda for research on the sustainability of public health programs suggested that the characteristics of an intervention might usefully be assessed according to whether
[t]he intervention is (1) flexible or adaptable from its original form, (2) inexpensive or can be delivered by volunteers, and (3) supported by evidence for its effectiveness.1(p2062)
I would like to propose the hierarchy of risk controls (a model from the risk management literature) as a supplement to this approach (see box on this page).
Although it comes in a variety of forms, all versions of the hierarchy of risk controls share the same purpose: to rank potential actions in terms of their effectiveness and guide practitioners in considering first those that are most robust.2 A key feature of this model is that risk controls higher up in the hierarchy are not only more effective but also less dependent upon humans continuing to take the prescribed action. Once implemented, such interventions may therefore be more likely to be sustained despite the fact that the upfront costs are often higher. Indeed, frontloading the cost and effort required for sustainment may be an important approach for sustainable public health interventions supported by temporary funding.
In my own work,3 I have used a simplified three-tier version (see the box on this page) of the five-tier National Institute for Occupational Safety and Health (NIOSH) model.4
HIERARCHY OF RISK CONTROLS
| 1. Elimination |
| Eliminate the hazard entirely. |
| 2. Design Controls (known as “engineering controls”) |
| With a focus on physical barriers, isolation, forcing functions, human factors, and failsafe design, engineering controls improve safety “independent of worker interactions.” |
| 3. Administrative Controls |
| Policies, procedures, training, and other controls that depend on people taking the correct actions. |
Source. This simplified model is an adaptation of the NIOSH model.4
The hospice volunteers at the Louisiana State Penitentiary at Angola must go through a difficult process to bury their own regrets and fears, and unearth their capacity to love. The exhibition, “Grace Before Dying” looks at how, through hospice, inmates assert and affirm their humanity in an environment designed to isolate and punish. Photograph by Lori Waselchuk. Printed with permission.
It is readily apparent that maintaining interventions in the top two rungs of the hierarchy will often require less in the way of continuous effort because these interventions do not rely to the same extent on voluntary behavior. For instance, if a brackish tidal pool is breeding mosquitoes that serve as a vector for malaria, the intervention of filling it in (elimination) or building a drainage ditch to the ocean to increase the salinity (design control) may be far more likely to continue reducing the incidence of malaria five years after funding has run out than an administrative control (e.g., expecting local community members to continue regular applications of larvicide).
References
- 1.Scheirer MA, Dearing JW. An Agenda for research on the sustainability of public health programs. Am J Public Health. 2011;101(11):2059–2067 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Manuele FA. Risk assessment & hierarchies of control: their growing importance to the SH&E profession. Prof Saf. 2005;50(5):33–39 [Google Scholar]
- 3.Card AJ, Ward JR, Clarkson PJ. Successful risk assessment may not always lead to successful risk control: a systematic literature review of risk control after root cause analysis. J Healthc Risk Manag. 2012;31(3):6–12 [DOI] [PubMed] [Google Scholar]
- 4. NIOSH. Engineering Controls. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/niosh/topics/engcontrols. Accessed February 13, 2012.