Step

 3:  Overview
1) Create  a  Determinants  Selection  Matrix  with  
all  determinants  (direct  and  indirect)  from  
the  PAC

2) Select  one  determinant  (from  high/high  

category)  for  intervention

3) Write  a  performance  objective  for  each  

determinant  selected  for  intervention
 Determinants  Selection  Matrix
• Facilitates  selection  of  determinants  (direct  
and  indirect  causes)  for  intervention

• Determinants  are  classified  by  how  

“changeable” and  “important” they  are

• Determinants  from  high/high  category  are  

usually  chosen  for  intervention
 Determinants  Selection  Matrix

High  I  /High  C High  I/Low  C

High
Importance

Low

Low  I/High  C Low  I/Low  C

High Low
Changeability
 Determinants  Selection

• Which  determinant?  
– Ideally  from  high/high—but  at  least  high  
importance
– Use  literature,  theory,  common  sense
– How  many  arrows/how  connected  is  the  
determinant?
– Can  prioritize  an  upstream/root  cause  if  resources  
allow  (tend  to  be  low  changeable)
– How  well-­‐equipped  are  you  to  intervene?
 CVD  among  sedentary  adults  in  rural  Maine
8.  Winter  rural  roads  are  unsafe  for   11.  little  community  resources  for   12.  not  a  
walking  or  running extra  wide  roads/  complete  streets Legislative  
priority

13.  Lack  of  community   14.  Low  tax  

2.  Lack  of   9.  Few  YMCAs  or  facilities 15.  town  
resources base
convenient  and   independence  
affordable  options   versus  sharing  
for  PA  after  work 10.  High  cost  of  using  a  facility 16.  High  cost  of  building  and  
statewide
running  the  facility
17.  Child  care  not  after  
3.  Little  time   19.  not  subsidized  by  
working  hours 18.  High  cost  of  labor  
without  children state  or  community  
1.  CVD 20.  High  cost  of  quality  
childcare 21.  No  social  
sedentary
infrastructure   22.  Funding  cuts  to  Fund  
rural   4.  Lack  of  knowledge   component  whose   for  Healthy  Maine
Maine   of  existing  options  for   23.  Options  (e.g.  
responsibility  it  is  to  
adults PA schools  gyms  after  
do  this
school)  not  advertised
25.  School  curricula  
26.  Low  perceived   24.  Inadequate  educational   lack  components
5.  Few  Perceived  Benefits
threat:   opportunities
susceptibility/severity  of  
6.  Little  opportunity  for  PA   27.  Non-­‐PA  culture/social   28.  Screen  time  
CVD
during  working  hours support  for  PA preferences  and  
modeling
29.  Few  flextime  
policies 30.  Employers  don’t  understand  
7.  Few  fresh  F&V  in  diet Sources  (AMA):
benefits  and  cost  savings
1.
31.  Lack  of  insurance  incentives 2.
etc.
HIGH
2.  Lack  of   8.  Winter  rural  roads  are  unsafe  for  
convenient  and   walking  or  running
affordable  options  
for  PA  after  work
9.  Few  YMCAs  or  facilities 31.  Lack  of  insurance  incentives
4.  Lack  of  knowledge  
of  existing  options  for   11.  little  community  resources  for  
PA extra  wide  roads/  complete  streets
19.  not  subsidized  by  
state  or  community  
13.  Lack  of  community  
Importance

5.  Few  Perceived  Benefits resources

27.  Non-­‐PA  culture/social  

6.  Little  opportunity  for  PA   10.  High  cost  of  using  a  facility support  for  PA
during  working  hours
26.  Low  perceived   28.  Screen  time  
3.  Little  time   threat:   preferences  and  
7.  Few  fresh  F&V  in  diet without  children susceptibility/severity  of   modeling
CVD

29.  Few  flextime   23.  Options  (e.g.   12.  not  a  

22.  Funding  cuts  to  Fund  
policies schools  gyms  after   Legislative  
for  Healthy  Maine
school)  not  advertised priority

21.  No  social  

18.  High   30.  Employers  don’t   17.  Child  care  not  after   14.  Low  tax  
infrastructure  
cost  of  labor   understand  benefits  and   working  hours base
component  whose  
cost  savings
LOW 24.  
responsibility  it  is  
15.  town  
to  do  this 16.  High  cost  of  building  
Inadequate   20.  High  cost  of  quality   independence  
educational   versus  sharing   and  running  the  facility
25.  School  curricula   childcare
opportunities lack  components statewide

HIGH Changeability LOW

HIGH
2.  Lack  of   8.  Winter  rural  roads  are  unsafe  for  
convenient  and   walking  or  running
affordable  options  
for  PA  after  work
9.  Few  YMCAs  or  facilities 31.  Lack  of  insurance  incentives
4.  Lack  of  knowledge  
of  existing  options  for   11.  little  community  resources  for  
PA extra  wide  roads/  complete  streets
19.  not  subsidized  by  
state  or  community  
13.  Lack  of  community  
Importance

5.  Few  Perceived  Benefits resources

27.  Non-­‐PA  culture/social  

6.  Little  opportunity  for  PA   10.  High  cost  of  using  a  facility support  for  PA
during  working  hours
26.  Low  perceived   28.  Screen  time  
3.  Little  time   threat:   preferences  and  
7.  Few  fresh  F&V  in  diet without  children susceptibility/severity  of   modeling
CVD

29.  Few  flextime   23.  Options  (e.g.   12.  not  a  

22.  Funding  cuts  to  Fund  
policies schools  gyms  after   Legislative  
for  Healthy  Maine
school)  not  advertised priority

21.  No  social  

18.  High   30.  Employers  don’t   17.  Child  care  not  after   14.  Low  tax  
infrastructure  
cost  of  labor   understand  benefits  and   working  hours base
component  whose  
cost  savings
LOW 24.  
responsibility  it  is  
15.  town  
to  do  this 16.  High  cost  of  building  
Inadequate   20.  High  cost  of  quality   independence  
educational   versus  sharing   and  running  the  facility
25.  School  curricula   childcare
opportunities lack  components statewide

HIGH Changeability LOW

Childhood  Obesity/  new  mothers  not  following  BF  guidelines
18.  Little  regulation  of  
5.OB/GYN 11.  Lentiginous  culture litigation
fear  of  
litigation 12.  Medical  insurance   19.  Little  regulation  of  
policies insurance
6.  OB  and   20.  Lack  of  
2.  High   13.  Lack  of  
mothers’  desire   education  
C-­‐ understanding  of   21.  societal  
for  control  of   about  risk
section   risk attitudes  and  
birth  timing
rates culture  
14.  negative   around  BF 22.  Lack  of  
Child 7.  lack  of   partner  attitudes
partner   reimburse-­‐
Obesity: support  for  BF 23.  Not  all   ment
new   3.  Low  BF   15.  Hospitals   Hospitals  in   incentives  
Maine   initiation   allow  formula   Maine  have   among  
right  after   8.Introductio companies   “baby  friendly”   insurance  
mothers   n  of  formula  
birth giveaways designation   companies  
not   at  hospital and  compliance   for  “baby  
following   friendly”
BF   9.  little  
4.  Low   preparation   16.  OB/GYN  field  
guidelines
compliance   for  this   does  not  prepare   24.  Not  part  of   25.  Not  a  
with  6   during   physicians  to   medical  school   priority  for  the  
month  BF   prenatal   prepare  women  for   or  residency   national  
guideline visits  ay   “after  birth”   training association
OB/GYN behaviors

10.  Low  rate  

26.  hospital  
of  women   17.  midwife  
hiring  
seeing   shortage
practices
midwives
HIGH 6.  OB  and  
mothers’  
desire  for  
control  of  
birth  timing 14.  negative   11.  Lentiginous  culture
partner   3.  Low  BF  
attitudes 5.OB/GYN 12.  Medical  insurance   initiation  
7.  lack  of   fear  of   policies right  after  
partner   litigation birth
support  for  BF 15.  Hospitals  
allow  formula  
8.Introductio
Importance

companies  
n  of  formula   giveaways 10.  Low  rate   20.  Lack  of  
21.  societal  
at  hospital of  women   education  
attitudes  and   22.  Lack  of  
seeing   about  risk
culture   reimburse-­‐
9.  little   23.  Not  all   midwives
around  BF ment
preparation   Hospitals  in   incentives  
for  this   Maine  have   24.  Not  part  of   among  
2.  High  
during   “baby  friendly”   medical  school   insurance  
C-­‐
prenatal   designation   or  residency   4.  Low   companies  
section  
visits  ay   and  compliance   training compliance   for  “baby  
rates
OB/GYN with  6   friendly”
month  BF  
13.  Lack  of   17.  midwife   guideline
understanding  of   shortage
risk

16.  OB/GYN  field   26.  hospital  

25.  Not  a  
does  not  prepare   hiring  
priority  for  the  
physicians  to   practices
LOW prepare  women  for  
national  
association
“after  birth”   18.  Little  regulation  of  
behaviors litigation

HIGH Changeability LOW

HIGH 6.  OB  and  
mothers’  
desire  for  
control  of  
birth  timing 14.  negative   11.  Lentiginous  culture
partner   3.  Low  BF  
attitudes 5.OB/GYN 12.  Medical  insurance   initiation  
7.  lack  of   fear  of   policies right  after  
partner   litigation birth
support  for  BF 15.  Hospitals  
allow  formula  
8.Introductio
Importance

companies  
n  of  formula   giveaways 10.  Low  rate   20.  Lack  of  
21.  societal  
at  hospital of  women   education  
attitudes  and   22.  Lack  of  
seeing   about  risk
culture   reimburse-­‐
9.  little   23.  Not  all   midwives
around  BF ment
preparation   Hospitals  in   incentives  
for  this   Maine  have   24.  Not  part  of   among  
2.  High  
during   “baby  friendly”   medical  school   insurance  
C-­‐
prenatal   designation   or  residency   4.  Low   companies  
section  
visits  ay   and  compliance   training compliance   for  “baby  
rates
OB/GYN with  6   friendly”
month  BF  
13.  Lack  of   17.  midwife   guideline
understanding  of   shortage
risk

16.  OB/GYN  field   26.  hospital  

25.  Not  a  
does  not  prepare   hiring  
priority  for  the  
physicians  to   practices
LOW prepare  women  for  
national  
association
“after  birth”   18.  Little  regulation  of  
behaviors litigation

HIGH Changeability LOW

 Write  a  Performance  Objective  for  each  
determinant  chosen  for  intervention

• Who?

• What?

• How  Much?

• By  when?
Performance  Objectives  should  be  SMART

• Specific
• Measurable
• Achievable SMART
• Realistic
• Time-­‐Sensitive
 SMART  Objectives
1.   Specific – Objectives  should  specify  what  
they  want  to  achieve.
2.   Measurable – You  should  be  able  to  
measure  whether  you  are  meeting  the  
objectives  or  not.
3.   Achievable -­‐ Are  the  objectives  you  set,  
achievable  and  attainable?
4.   Realistic – Can  you  realistically  achieve  the  
objectives  with  the  resources  you  have?
5.   Time  – By  when  do  you  want  to  achieve  
the  set  objectives?
 Flextime  Policy  Objective

• Determinant:  Few  flextime  policies

There  will  be  a  5%  increase  (how  much)  in  the  
number  of  small  businesses  (who) with  
Flextime  for  PA  policies  in  greater  Portland  
(what)  by  December  1,  2019 (By  When).

Baseline:  Currently  only  10%  of  small  businesses  

(with  less  than  50  employees)  have  flextime  
policies.
 Baby-­‐Friendly  Hospital  Objective
• Determinant:  Not  all  Hospitals  in  Cumberland  
County  have  “Baby-­‐Friendly”  designation

By  June  2019  (by  when),  All (how  much)

hospitals  in  Cumberland  County  (who) will  be  
designated  “Baby-­‐Friendly”(what).

Baseline:  Currently  only  2  of  6  (one-­‐third)  hospitals  in  Cumberland  

County  currently  have  a  ‘Baby-­‐Friendly”  designation.
 Other  Examples  of  SMART  Objectives
• By  December  31st,  10  practitioners  will  be  trained  to  use  the  Centering  Pregnancy®  
model.
• By  December  31st,  participants  in  the  program  will  demonstrate  an  80%  increase  in  
awareness  of  the  signs  and  symptoms  of  preterm  labor.  
• By  December  31st,  there  will  be  a  70%  decrease  in  the  number  of  babies  born  
prematurely  or  of  low  birth  weight  to  program  participants.
• By  May  31st,  all  clinic  staff  will  have  completed  training  on  the  components  of  
perinatal  care.
• By  December  31st,  the  clinic  will  report  an  80%  increase  in  the  number  of  participants  
completing  all  prenatal  visits
• By  December  30,  increase  from  baseline  to  65%  the  percentage  of  hypertension  
patients  at  community  health  centers  whose  blood  pressure  is  under  control.
• By  June  28,  increase  from  2  to  10  the  number  of  community  health  centers  that  have  
implemented  use  of  electronic  medical  records  with  provider  reminders  of  high  blood  
pressure  treatment  guidelines.  
• By  June  28,  increase  from  2  to  5  the  number  of  community  health  centers  that  have  
provided  staff  training  on  the  (JNC7)  guidelines.
 Written  Assignment
1) Create  a  Determinants  Selection  Matrix  with  
all  determinants  (direct  and  indirect)  from  
the  PAC
2) Select  one  (from  high/high  category)  for  
intervention
3) Write  a  performance  objective  for  the  
determinant  selected  for  intervention  
(answer  4  questions  and  name  a  baseline)
4) Provide  references  for  choices  made  in  PAC,  
matrix  and  performance  objective  baseline.