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Improving Speaking Skills
Betsabé Navarro Romero
This article examines the different circumstances under which infant and adult learners develop speaking skills. We will see the facilities or difficulties in both cases in order to focus on the real possibilities of adults to develop a high level of speaking proficiency. We will see what the role of the teacher is in order to improve the learners’ skills, the features of oral communication that need to be improved and which strategies can be used to overcome the difficulties. Key words : speaking skills, adult learning, oral communication, teaching strategies.
Este artículo analiza las diferentes circunstancias en las que niños y adultos desarrollan las destrezas orales. Veremos las facilidades y dificultades en ambos casos para así centrarnos en las posibilidades reales que tienen los adultos de alcanzar un alto nivel de competencia oral. Veremos también cual es el papel del profesor en este contexto, para mejorar las capacidades de los alumnos, y ver cuáles son los elementos de la comunicación oral que hay que mejorar y qué estrategias se pueden aplicar para superar las dificultades. Palabras clave : destrezas orales, aprendizaje de adultos, comunicación verbal, estrategias de enseñanza.
If we think of the period in our lives when we learned to speak our first language, and the moment in which we started to make huge efforts to speak our second/foreign language we find significant differences. In the former case, we may have fond memories of what our parents told us; and in the latter, it suddenly becomes a frustrating experience that seems to bring imperfect results. For adults, learning to speak a new language is in many cases far from satisfactory simply because they feel they need to cope with many different aspects at one time, and that seems to be impossible in real conversations. I wonder if it is possible to acquire a high level of speaking proficiency in adults; I wonder if it is possible to make adult learners improve their speaking skills, and the most important thing for teachers: how?
The first question we have to consider in order to reach a conclusion is whether learning at infancy is different from learning at adulthood; which are the circumstances that differentiate them and if those conditions inevitably lead to obvious and hopeless results. Only bearing in mind what we can expect of a particular type of learner, we can focus on how to improve their speaking skills.
It is obvious that there are marked differences between children learners and adult learners and that they cannot acquire the second language under the same circumstances. Consequently, the results will be also different. Concerning children and the early age at which they learn to speak, we can say that they enjoy certain advantages that make them outstanding learners. They have surprising linguistic abilities due to optimal moment in which they find themselves for language learning, this is to say, at this moment their brain is characterized by a certain plasticity that allows some abilities to develop with ease during a period of time, after which it becomes really difficult for these abilities to be developed (Fleta, 2006: 53), or using
Improving Speaking Skills Betsabé Navarro Romero Encuentro, 18, pp. 86-90
Klein’s words ‘between the age of two and puberty the human brain shows the plasticity which allows a child to acquire his first language’ (Klein, 1986: 9). Therefore, children are special learners for their natural and innate abilities to acquire a language. According to Fleta, one of these special abilities is ‘filtering sophisticated information about language properties from birth’ (Fleta, 2006: 49), in other words, children have an enormous ability to integrate difficult information in an easy and unconscious way from the beginning of their development. They are able to acquire and integrate complex data without being aware of it, whereas other learners, at other ages, would find it arduous to achieve. Moreover, apart from this special gift children have for assimilating difficult information, we can mention some of their other qualities, such as their capacity for perceiving and imitating sounds. Some studies have showed that ‘young infants are especially sensitive to acoustic changes at the phonetic boundaries between categories’ (Kuhl, 2004: 832). Also, children are especially good at predicting syllable chunks: ‘infants are sensitive to the sequential probabilities between adjacent syllables’ (Kuhl, 2004: 834) which makes children with a surprising instinct as far as language knowledge is concerned . Finally, students also acquire the ability of ordering words within a sentence (grammar rules) unconsciously: ‘there is some evidence that young children can detect non-adjacencies such as those required to learn grammar’ (Kuhl, 2004: 836). All in all, we can say that children learn the language without being aware of it when they ‘are exposed to the right kind of auditory information’ (Kuhl, 2004: 836), this is, children learn the language through communication and interaction and thanks to that they acquire all the abilities they can potentially develop.
On the other hand, concerning adults we observe how difficult is that they can acquire certain native sounds; their pronunciation will be, on many occasions, foreign-like which is due to their difficulty in distinguishing and producing some sounds after the so called ‘critical period’. In that respect, some authors claim that adult learners cannot acquire a phonological development (Lightbown and Spada, 2006: 69). However, other researchers defend the opposite. Wolfgang Klein, in his book Second Language Acquisition (1986) stated that ‘the apparent facility with which children learn a second language is often attributed to biological factors, but an alternative explanation might be that, unlike adults, children have no need to fear the loss of their social identity’ (Klein, 1986: 6). Authors such as Klein argue that phonological facilities of children are not bound to biological reasons, but to psychological ones. In that respect, adults feel attached to their native identities, to their original social identities, which is what prevent them from achieving perfection in L2 pronunciation. Klein confirmed that ‘suitably motivated adults are capable of mastering to perfection the pronunciation of the most exotic languages’ (Klein, 1986: 10). Therefore, we conclude that although the cases of adults speaking a second language without any accent are not very common, this does not mean that it is impossible to acquire a native-like pronunciation. Also, besides phonological issues, we can talk about the capacity of adults to acquire any other kind of linguistic faculties, more related to structural relations (UG). In that sense, there are authors that doubt the validity of Lenneberg’s Critical Period Hypothesis (CPH) by assuring that even adults have access to the well known Universal Grammar. While Lenneberg claimed that only before puberty learners had UG available, authors such as S. W. Felix defended by evidence that adult L2 learners also benefit from the UG principles: ‘If child and adult learners use different modules for the purpose of language acquisition, then we would expect adult learners to be unable to attain grammatical knowledge that arises only through the mediation of UG. If, in contrast, adults do attain this type of knowledge, then, we have reason to believe that UG continues to be active even after puberty’ (Felix, 1988: 279). Therefore, we can conclude that adults are also able to master a proficient use of the second/foreign language, not only in grammatical issues but also in phonological ones, which makes us believe that we can improve adult learners’ speaking skills.
Improving Speaking Skills Betsabé Navarro Romero Encuentro, 18, pp. 86-90
Once we know that adults can be biologically and psychologically prepared to have a native-like proficiency in the second language, we should move on to the second language teaching context in order to achieve our aim of improving adult learners’ skills. In that respect, we should reflect on the teachers’ role in this situation and what they can do to be successful with their learners. Teachers therefore need to analyse the students’ needs, face their problems and find fruitful solutions that help them develop their speaking abilities. S. Pit Corder, in his chapter called ‘Applied Linguistics and Language Teaching’, in Introducing Applied Linguistics (1973) defended the important role of linguists who identify the problems of the learners and find solutions for them. Corder added that specialists’ role is to formulate the appropriate questions in order to define problems that need to be faced. Using his words, ‘the formulation of the questions, the identification of the problems and the specification of their nature presupposes linguistic theory. The nature of the problem is defined by the theory which is applied to it. The solution to a problem is only as good as the theory which has been used to solve it’ (Corder, 1973: 138). In this direction he said that in language teaching there are two appropriate questions teachers should make: what to teach and how to teach, ‘these are the problems of content and method, or, using an industrial analogy, the problem of product and process design respectively’ (Corder, 1973: 139). Therefore, if teachers wish to know how to improve speaking skills, what they need to ask themselves first is what they are going to teach, and how.
On the one hand, let us consider the first question: what . If we need to improve speaking skills we need to know which skills or which features learners need to develop. In that respect, there are several authors that stated different goals or different dimensions that speakers needed to achieve. Goodwin, for instance, established several goals for a proper pronunciation. She called them ‘functional intelligibility, functional communicability, increased self-confidence, and speech-monitoring abilities’ (Goodwin, 2001: 118). She argued that learners should be able to speak an intelligible foreign language, that is to say, listeners need to understand the learner’s message without huge efforts; learners also need to be successful in a ‘specific communicative situation’ (Goodwin, 2001: 118); they need to ‘gain confidence in their ability to speak and be understood’ (Goodwin, 2001: 118); and finally, they need to monitor and control their own production by paying attention to their own speech. Goodwin specified those abilities that learners need to acquire through certain linguistic features that can be practiced: Intonation, rhythm, reduced speech, linking words, consonants and vowel sounds, word stress, etc. These are concrete speaking aspects in which learners should be trained in order to improve their speaking skills.
Similarly, other authors such as Anne Lazaraton suggest that oral communication is based on four dimensions or competences: grammatical competence (phonology, vocabulary, word and sentence formation…); sociolinguistic competence (rules for interaction, social meanings); discourse competence (cohesion and how sentences are liked together); and finally, strategic competence (compensatory strategies to use in difficult situations), (Lazaraton, 2001: 104). According to Lazaraton learners should develop all these abilities to acquire a high oral level of the foreign language, but she adds that in recent years, with the influence of the communicative approach, more importance is given to fluency, trying to achieve a balance with the traditional accuracy.
Moreover, apart from what pedagogically and theoretically should be taught, many researchers are presently analysing real problems that learners face: ‘fluent speech contains reduced forms, such as contractions, vowel reduction, and elision, where learners do not get sufficient practice’ (Lazaraton, 2001: 103); use of slang and idioms in speech since students tend to sound ‘bookish’ (Lazaraton, 2001: 103), stress, rhythm, intonation, lack of active vocabulary, lack of interaction pattern rules…
Improving Speaking Skills Betsabé Navarro Romero Encuentro, 18, pp. 86-90
Once speaking goals have been determined, next step consists of questioning how they are going to be achieved. For designing a concrete methodology teachers need to adopt a theoretical perspective, they need to reflect on the linguistic approach that will be used in their teaching. Many authors, following the up-to- date trend of the Communicative approach, defend the interactive role of speaking and promote its teaching from a communicative perspective stressing meaning and context. In Goodwin’s words: ‘In “Teaching Pronunciation” the goal of instruction is threefold: to enable our learners to understand and be understood, to build their confidence in entering communicative situations, and to enable them to monitor their speech’ (Goodwin, 2001: 131), also ‘pronunciation is never an end in itself but a means of negotiating meaning in discourse, embedded in specific sociocultural and interpersonal contexts’ (Goodwin,2001: 117).
If we think of how this theoretical background will be applied in real teaching, we find that in traditional classes they focused speaking practice on the production of single and isolated sounds, whereas within the communicative approach, ‘the focus shifted to fluency rather than accuracy, encouraging an almost exclusive emphasis on suprasegmentals’ (Goodwin, 2001: 117). There is the key word, when communication is the main goal linguistic practice turns into longer structures, at the suprasegmental level; therefore, the training on individual sounds makes way for macro structures that affect interaction directly.
The second part of how to teach, moves away from theory to approach real problems and their solutions. Several authors have stated that when learners face problems in speaking they need practical and concrete solutions to know how to behave and respond in order to overcome those difficulties. Mariani, in his article ‘Developing Strategic Competence: Towards Autonomy in Oral Interaction’ , recalls L1 strategies that native speakers use when they encounter communication problems, and suggests teaching those strategies to L2 learners: ‘just think of how often, in L1 communication, we cannot find the words to say something and have to adjust our message, or to ask our interlocutor to help us, or to use synonyms or general words to make ourselves understood’ (Mariani, 1994: 1). Mariani classifies those strategies according to the speakers’ behaviour: learners can either avoid certain messages because they don’t feel confident with their speaking skills (‘reduction strategies’), or make the most out of their knowledge and modify their message bearing in mind their weaknesses and strengths (‘achievement strategies’: borrowing, foreignizing, translating…(Mariani, 1994: 3). The author praises the latter by saying that achievement strategies are a very interesting way of developing learners’ language domain. Speakers who opt for this option make huge efforts to transmit a message by playing with the language to the extreme, which only brings beneficial consequences.
In the second or foreign language classroom context, teachers should train learners to use and practice the different strategies that can help them face difficult situations. The only way of training students in this direction is by means of a bank of activities in which they become aware of the different possibilities that they can put into practice. Authors such as Goodwin or Lazaraton offer a varied list of exercises to be used in class: poems, rhymes, dialogues, monologues, role plays, debates, interviews, simulations, drama scenes, discussions, conversations…
Therefore, coming back to the initial question proposed above, I think it is absolutely feasible to teach adults strategies to improve their speaking skills. Of course, that objective depends on many different factors that will affect the degree of acquisition, let us think of age, motivation, or even the context in which the language is learned: ESL versus EFL. In that respect, learners in a second language context will have numberless occasions to practice the language and that will undoubtedly influence their skills development. With reference to the foreign language context, authors such as Lazaraton admitted the difficulties learners
Improving Speaking Skills Betsabé Navarro Romero Encuentro, 18, pp. 86-90
normally face: ‘homogeneous EFL classes, where all students speak the same first language and English is not used outside the classroom, present certain additional challenges for the teacher’ (Lazaraton, 2001: 110). As she said, teachers have considerable limitations in EFL classes such as lack of opportunities to use the language, lack of motivation in the learners, the number of students in the class, curriculum restrictions…(Lazaraton, 2001: 110), but there are solutions and strategies, as the ones previously mentioned, that should be put into practice.
Mariani, in his article mentioned above , also makes a reflection on whether communication strategies should be teachable or not. He states the pros and cons by saying that training students on specific strategies can provide them with certain limitations and consequently hamper fluent communication: ‘we can hardly force them into a straightjacket of pre-selected strategies […] Most of us would agree that we should encourage spontaneity, creativity and originality in language use’ (Mariani, 1994: 7). However, on the other hand, he argues that if learners become aware of the different strategies they can flexibly use, they will finally integrate them either consciously or unconsciously, which will stretch their possibilities for communication.
To sum up, as teachers can, and should, improve learners’ speaking skills and communication strategies, the only thing they need to do is to plan their teaching around two main questions: what they want to teach, which specific speaking features they want to develop in their learners; and how they want to do it.
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Sampai di sana saya beristirahat untuk perjalanan jauh. Setelah beristirahat Saya berdoa dan makan siang bersama. Setelah itu saya bermain PS. Selanjutnya aku tidur dikamar 13:00. Dan bangun jam 5 sore. Keesokan harinya aku pergi ke darat Bongko. Ada tempat yang sangat indah tapi banyak sampah berserakan. Di sana saya dan saudaraku foto bersama. Dan kemudian minum kelapa muda, itu sangat segar.
Setelah ke pantai aku pulang ke Pati. Kira-kira aku pulang jam 2 p.m . Karena besoknya aku harus bersekolah lagi. Aku sampai dirumah jam 4 p.m. Dan aku segera mandi. Karena perjalanannya jauh aku harus beristirahat. Ini adalah pengalaman liburan yang menurutku terbaik
A Priority Rating System
for Public Health Programs
DOUGLAS VILNIUS, MS, MPA
SUZANNE DANDOY, MD, MPH
The authors are with the Utah Department of Health. Mr. Vilnius is
Director, Division of Community Health Services, and Dr. Dandoy is
Executive Director of the Department. She is also Adjunct Professor,
Department of Family and Preventive Medicine, University of Utah.
The authors are indebted to George E. Pickett, MD, MPH, Univer-sity of Michigan, who initially developed the Basic Priority Rating
(BPR), and Denise Basse, Utah Department of Health, who suggested
the application and adaptation of the model.
Tearsheet requests to Douglas Vilnius, Division of Community
Health Services, Utah Department of Health, P.O. 16660, Salt Lake
City, Utah 84116-0660.
When resources are limited, decisions must be made
regarding which public health activities to undertake. A
priority rating system, which incorporates various data
sources, can be used to quantify disease problems or
risk factors, or both.
The model described in this paper ranks public
health issues according to size, urgency, severity of the
problem, economic loss, impact on others, effective-ness, propriety, economics, acceptability, legality of
solutions, and availability of resources. As examples of
how one State can use the model, rankings have been
applied to the following health issues: acquired immu-nodeficiency syndrome, coronary heart disease, injuries
from motor vehicle accidents, and cigarette smoking as
a risk factor. In this exercise, smoking is the issue with
the highest overall priority rating.
The model is sensitive to the precision of the data
used to develop the rankings and works best for health
issues that are not undergoing rapid change. Cost-ben-efit and cost-effectiveness analyses can be incorporated
into the model or used independently in the priority-set-ting process. Ideally, the model is used in a group set-ting with six to eight decision makers who represent the
primary agency as well as external organizations.
Using this method, health agencies, program directors,
or community groups can identify the most critical
issues or problems requiring intervention programs.
PUBLIC HEALTH AGENCIES, like all governmental
services, never have adequate resources to address the
needs of all constituents. Over time, the resource pen-dulum may swing, but most who pursue public health
funding through the political process would agree that
major distinctions between the good and bad times are
based on relative degrees of "lean," "leaner," or
"devastating.'" Such is the environment in which
scarce public resources must be competed for among
vast and growing social needs.
The competition for resources mandates that public
health decision makers seek methods and apply skills
that produce efficient and effective outcomes. State leg-islators, local boards of health, city and county com-missioners, and taxpayers occasionally demand and
certainly deserve public health programs and services
which maximize cost-effective and cost-beneficial pub-lic health outcomes. What methods and tools are avail-able to public health administrators and managers that
enable them not only to do things right but, even more
important, to do the right things?
There seems to be reasonable consensus within the
public health community that prolonging productive life
is a societal value that has been adopted as part of the
public health mission. The reduction of pain and suffer-ing is another generally accepted goal of public health.
However, further clarification of the mission and goals
may become clouded by politics, ethics, economics,
and public opinion. Life satisfaction, quality of care,
confidentiality, access to care, blaming the victim, the
right to die, and cost containment are issues tied to
societal values that affect health decision making in the
1990s. What, if any, effect do these issues have on
public health's mission, and how are their implications
translated into information upon which decisions and
priorities can be based?
A Decision Making Model
There is no "one best way" to set public health pri-orities. What is essential, however, is that a process or
method be adopted that is systematic, objective, and
allows for a standardized comparison of problems or
alternatives that incorporate the scrutiny of science and
the realities of the environment. One approach to this
challenge is a methodology which attempts to consoli-Soptomber-October 1990, Vol. 105 No. 5 463
Table 1. Problem size ratings for selected health problems on a
scale of 1-10
Problem Rate, Scale Rate' Scale BPR score
AIDS .......... 11.2 2 3.9 0 1
CHD .......... 3,058 6 313.4 4 5
MVI .......... 176 4 18.0 2 3
Smoking ....... 10,006 8 44.1 2 5
I per 100,000 population.
NOTE: AIDS = acquired immunodeficiency syndrome; CHD = coronary heart dis-ease; MVI = motor vehicle injury requiring hospitalization.
date these factors into a process having a quantifiable
outcome. That model, Basic Priority Rating (BPR),
(1, 2) applies a defined problem or issue to a set of cri-teria that rate the size and seriousness of the problem,
the effectiveness of potential interventions, and a reality
test of miscellaneous items. The resulting process pro-duces a quantifiable value for each problem being ana-lyzed, thus providing a basis for priority setting. The
BPR formula is as follows:
[(A+B) C]÷3xD =
where A equals the size of the problem, B the serious-ness of the problem; C the effectiveness of intervention,
and D equals propriety, economics, acceptability, and
legality, known as "P.E.A.R.L." We shall now
describe the model and its use with specific examples.
Defining the problem. Decision makers who engage in
problem solving can conserve considerable energy by
constructing clear statements of problems. Many frus-trating hours and lost opportunities have resulted from
an imprecise definition of a problem. Is the problem a
dysentery outbreak or a contaminated water supply? Is
the problem that people are dying from heart failure at
an old age or prematurely, or is the problem better
defined by lifestyle practices that lead to heart disease?
A clear statement of the problem will not only provide a
consensus for direction among those engaged in the pri-ority-setting process, but it will also establish a basis
for concise objective setting if, and when, the problem
is identified as a priority for which planning, interven-tion, and evaluation are necessary.
If the link between risk factors, health status condi-tions, and mortality is recognized, each risk factor or
each cause of illness may be considered as a problem.
Four potential problems-the incidence of acquired
immunodeficiency syndrome (AIDS), motor vehicle
injuries requiring hospitalization (MVI), coronary heart
disease (CHD), and cigarette smoking (smoking)-will
be analyzed to illustrate the application of BPR. The
nature of priority setting and decision making often
involves choices among a variety of conditions requir-ing a public health response, thus further complicating
the decision making process. Consequently, care should
be taken to arrange problems by category, such as dis-ease and accidents, risk factors, and target populations,
before the analysis begins. In our example, we will, for
illustration only, be comparing three direct causes of
morbidity and mortality (AIDS, MVI, and CHD) and
one risk factor (smoking), using both national and Utah
Size of the problem. The size of a health problem is
most often represented by incidence or prevalence rates
in 100,000 population segments. These rates are spe-cific to disease and nondisease conditions, such as 176
motor vehicle injuries per 100,000; 10,006 cigarette
smokers per 100,000; 11.2 AIDS cases per 100,000;
3,058 heart disease cases per 100,000.
Disease specific morbidity data are often difficult to
obtain compared with the relative ease of acquiring
cause of death information. Most information on dis-ease incidence emanates from hospitals and physicians
as a record of treatment and payment. Few States have
a morbidity registry that provides a centralized source
for disease and injury data, unless the diseases are con-sidered communicable. Therefore, finding reliable data
to compare relative problem incidence-prevalence may
prove to be a difficult task. Lifestyle risk factor data, on
the other hand, are being collected on a regular basis by
the majority of States through the Behavioral Risk Fac-tor Survey (3).
Mortality rates may also be applied to the process of
rating the problem size and, like the incidence and
prevalence rates, are presented per 100,000 population,
for example, 313.4 CHD deaths per 100,000. These
data are easily obtained from State health department
offices of vital records and traditionally play a major
role in determining public health priorities.
The BPR model suggests the following scale for
scoring relative rate ranges:
Incidence or prevalence per 100,000 population Score (1)
50,000 or more ............... 10
5,000 to 49,999 ............... 8
500 to 4,999 ............... 6
SOto 499 ............... 4
S to 49 ............... 2
0.5 to 4.9 ............... 0
Depending on the magnitude of problems being consid-ered, the scale may require adjustment to compensate
for lower incidence or prevalence rates.
In table 1 we apply this rating scale to the four prob-lem conditions being analyzed. Smoking and CHD war-rant the highest ratings for problem size, while AIDS
scores the lowest.
464 Public Halth Reports
Seriousness of the problem. A health problem's
seriousness is defined by four factors in the BPR model:
(a) urgency, (b) severity, (c) economic loss, and
(d) impact on others. Each factor should be evaluated
on a per case basis only. Readily identifiable and acces-sible data sources are not available for ranking problem
seriousness. The analysis of each seriousness factor will
require a considerable degree of investigation in order
to obtain quantifiable data. Some factors related to the
problem under consideration may require literature
searches, while other factors may require the decision
making group's best guess.
As each seriousness factor is applied, it is important
to keep its analyses independent of the other factors,
both within the seriousness category as well as the other
categories. For example, when assessing the severity of
AIDS, the analysis should be undertaken without regard
for the size or economic loss of the AIDS problem .
This principle of independent assessment within criteria
and factor should be applied throughout the process.
Each of the four problems is rated according to the four
factors that define seriousness in the model.
1. Urgency. Some problems require a rapid response
in order to prevent the spread of the problem or death
as, for example, in a spill of radioactive waste, con-taminated food, or a rabies outbreak. In BPR we use a
0-5 scale for each factor within the seriousness cate-gory. Since there is no clearly defined data source for
these ratings, one must rely on a combination of scien-tific knowledge and public opinion. The four problem
areas under consideration and their relative urgency rat-ings, using a scale of 0-5, are:
AIDS .... 3
Smoking ..... 0
AIDS receives the highest urgency rating, while smok-ing rates lowest of the four problems.
2. Severity. Severity is a major factor which fre-quently drives public health programs. Hence, the
severity of a disease, injury, outcome, or event is often
the key to health program decision making. AIDS,
chronic obstructive pulmonary disease, diarrhea from
Salmonella, measles, spinal cord injuries, and low birth
weight babies present varying levels of severity. How
should one rate these conditions on a scale ranging from
1 to 5?
What factors determine severity? Certainly the case
fatality rate (CFR), which measures the proportion of
those with a disease who die from it, would be the ulti-Table 2. Problem severity ratings by averaging case fatality rate
(CFR) and years of potential life lost (YPLL) for selected health
problems, on a scale of 0-5
Problem CFR Rating YPLL per case Rating ratbng
AIDS ....... 1.00 5 35.0 5 5
CHD ....... .06 3 13.3 3 3
MVI ....... . 10 3 43.7 5 4
Smoking ... . .004 1 1.9 0 0.5
NOTE: AIDS = acquired immunodeficiency syndrome; CHD = coronary heart dis-ease; MVI = motor vehicle injury requiring hospitalization.
mate measure of severity. Rabies, for instance, has a
CFR of 100 percent.
An additional severity index important to priority-set-ting is based on deaths which are deemed premature,
that is, before age 65. Premature mortality is repre-sented by years of potential life lost (YPLL) for persons
dying before age 65 within a specific disease category
(4). Hence, motor vehicle fatalities generate more years
of potential life lost per case than heart disease because
motor vehicle deaths generally occur at younger ages.
For the purpose of severity assessment, consideration of
YPLL should be limited to its face value and not
include aspects of economics related to productivity, a
subject to be addressed at another juncture in BPR.
In addition to CFR and YPLL, there are certain
"'conditions" or "states of being" which warrant
severity consideration because they affect the quality of
life. Arthritis, blindness, and spinal cord injury would
be examples of such conditions. Because hard data to
measure the severity of a disability or condition are fre-quently nonexistent, the information and experience of
the decision making group and their personal assess-ments of the problem often determine the ranking of
Risk factors may also be considered legitimate meas-ures of severity. Considering the fact that the risk of
dying from lung -cancer is 23 times greater for males
who smoke 40 cigarettes per day than for male non-smokers (5), does cigarette smoking warrant a severity
rating? Is its rating higher because smoking is also asso-ciated with other cancers, chronic obstructive pulmo-nary disease, and vascular disease? How should one
rate smoking versus unsafe sex versus sedentary life-style?
Because quality of life conditions and risk factors are
difficult to quantify with respect to seriousness, we
have limited our severity ratings to CFR and YPLL
(table 2). Thus, AIDS is the most severe problem and
smoking the least severe.
A decision making group may choose to weight these
subfactors differently. Note that the scale considered for
September-October 1990, Vol. 105 No. 5 465
each subfactor can greatly influence the outcome of the
ratings. Should AIDS, with a CFR nearly six times that
of CHD, proportionally establish the subfactor scale,
thus relegating all other problems proportional to AIDS
and resulting in CHD perhaps receiving a score of 0 or
1? The application of a scale with a range based more
on a pre-determined standard, versus relative com-parisons, as indicated previously, is another option.
There is no hard and fast rule as to what procedure to
follow. If the relative scale is used, it is possible to
achieve a total score for seriousness of 20 points. If the
problem size score warranted a 10, a seriousness score
of 20 implies that seriousness warrants twice the weight
of problem size, which may or may not be valid.
3. Economic costs. The economic aspects of a prob-lem should include the costs of medical expenses, pub-lic services, and prevention programs to the
community, to the person or the family or all three.
Although these costs can, and later will, be applied to
the aggregate problem as identified in problem size, at
this point the costs should be addressed on an individual
There is no one central source for average case costs,
although some publications provide cost information
that could be used in the absence of State or local data
(6-8). If at all possible, costs should be adjusted to a
given year's dollar value if cost data are based on dif-ferent years for different problems.
Both direct and indirect costs, if available, should be
Cost estimates by case for each study problem, using
a scale of 0-5, would be
Case cost per year
Again, the decision to use a standard versus a relative
scale arises. Based on the cost information considered,
AIDS and MVI warrant the highest rating and smoking
4. Impact on others. A basic principle upon which
public health was established is that society has legiti-mate concern over individual actions or conditions that
may affect many. Communicable disease control
remains an important agenda for public health today,
but the concept of effect on others has been expanded to
include water and air pollution, toxic waste spills, pas-sive smoking, and alcohol use by pregnant women.
Economic loss and the cost to society also may be
considered as impacts on others, even when the out-come of one person's disease or behavior may not
directly affect others. Legislation mandating use of seat
belts and motorcycle helmets has been passed partially
because of high insurance rates and increased Medicaid
costs for injuries.
The BPR attempts to capture the effect of health
problems on other persons in a quantifiable manner.
The decision maker is asked to consider the problem's
potential and its actual effect on others, as in the case,
for example, of the effect of suicide on a family, or the
transmission of AIDS, or drinking while driving.
Data for this category may be found in a variety of
sources, based on probability of infection per exposure,
such as, for example, measles exposure in an 80-per-cent immunized school population; the probability of
contracting lung cancer over time as a result of
exposure to cigarette smoke; or the probability of
spouse abuse in a given population of alcoholic men.
These data are not easily linked, however, in the midst
of a variety of public health problems and may require
considerable interpretation and assumption. Once again,
the process requires consideration of the problem on a
case basis. The preferred scale is 0-5, but the decision
maker may chose a standard or relative scale. The fol-lowing ratings, using a scale of 0-5, indicate that AIDS
has the greatest impact on others, while CHD has the
AIDS .... 5
Summary of seriousness criteria. The ratings of each
of the four factors comprising the seriousness category
are totalled in table 3. Based on the factors considered
in the process, AIDS is rated most serious, followed by
motor vehicle injuries, coronary heart disease, and
Effectiveness of interventions. Some public health
466 Public Halth Reports
problems seem more easily resolved than others, such
as, for example, measles versus AIDS, or smoking
versus obesity. The difficulty of educating intravenous
drug users, combined with the lack of a vaccine or
curative drugs, places AIDS in a less favorable inter-vention position than dental cavities, for instance. An
effective intervention, like measles vaccine, may not
eliminate a local disease outbreak if less than 80 percent
of the targeted child population receive the vaccine. A
proven worksite blood pressure control program may be
poorly attended if the workers have confidentiality con-cerns. Thus, the BPR model recognizes effectiveness of
intervention at two levels: (a) the overall success of the
method to be employed and (b) the degree to which the
targeted population will respond.
Locating information concerning effectiveness of
programs and receptivity of a target audience requires
an extensive literature search. Occasionally, reports or
journals present research summaries for select pro-grams, such as school health (9), smoking cessation
(5), or worksite health promotion (10). The pursuit of
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