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Using a Concept Map as a Tool for Strategic Planning: The Healthy Brain Initiative

Using a Concept Map as a Tool for Strategic Planning: The Healthy Brain Initiative assist in assessing what has been done and what can and should be done. In 2005, Congress appropriated funds to Concept mapping is a tool to assist in strategic planning the Centers for Disease Control and Prevention (CDC) to that allows planners to work through a sequence of phases address cognitive health (2). That same year, the Centers to produce a conceptual framework. Although several for Disease Control and Prevention and the Alzheimer’s studies describe how concept mapping is applied to vari- Association formed a new partnership, The Healthy Brain ous public health problems, the flexibility of the methods Initiative, to examine how best to bring a public health used in each phase of the process is often overlooked. If perspective to the promotion of cognitive health. The practitioners were more aware of the flexibility, more partnership recognized a need to develop a strategic plan public health endeavors could benefit from using concept to identify public health priorities, create a unified vision mapping as a tool for strategic planning. among stakeholders, and guide activities over a 3- to 5- year period. The objective of this article is to describe how the 6 concept-mapping phases originally outlined by William Concept mapping is a tool that helps with strategic plan- Trochim guided our strategic planning process and how ning. It consists of a sequence of phases that result in a we adjusted the specific methods in the first 2 phases to conceptual framework (3). A concept map provides a visual meet the specialized needs and requirements to create The picture of strategic planning ideas; the ideas are clustered Healthy Brain Initiative: A National Public Health Road in groups so that a complex set of ideas can be more read- Map to Maintaining Cognitive Health. In the first stage ily understood. Concept mapping has taken various forms, (phases 1 and 2 of concept mapping), we formed a steer- such as “idea mapping” or “mind mapping,” to enhance ing committee, convened 4 work groups over a period of creative thinking or improve the organization of ideas (4). 3 months, and generated an initial set of 42 action items Concept mapping for public health, a process introduced grounded in science. In the second stage (phases 3 and 4), by William Trochim (3), involves a group of stakeholders we engaged stakeholders in sorting and rating the action who have an interest in a given area (eg, researchers, items and constructed a series of concept maps. In the practitioners) or may be affected by the outcomes (eg, com- third and final stage (phases 5 and 6), we examined and munity members, program participants). Concept map- refined the action items and generated a final concept map ping has been applied to create logic models for a national consisting of 44 action items. We then selected the top program (5), develop various state plans (6,7), and design 10 action items, and in 2007, we published The Healthy chronic disease competencies (8). Articles describing these The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. www.cdc.gov/pcd/issues/2011/sep/10_0255.htm • Centers for Disease Control and Prevention 1 VOLUME 8: NO. 5 SEPTEMBER 2011 concept maps focus on the outcome of the mapping process Box. Phases of Concept Mapping as Originally Conceptualized by and often, as a result, overlook the flexibility of the meth- Trochim (3) ods at each phase (9). More public health endeavors could Phase 1: Preparation benefit from concept mapping as a strategic planning tool Planning group identifies a single focal question or prompt that will best if practitioners were more aware of the flexibility of the serve the goal of the project. methods at each phase of the process. Planning group identifies participants to generate ideas through brain- storming. The objective of this article is to present an overview of concept mapping to public health practitioners and to show Phase 2: Generation of Ideas how phases of the concept-mapping process can be altered Participants brainstorm ideas in a single in-person session or online. or tailored to meet special requirements. To illustrate con- Planning group selects core group of ideas from ideas generated by par- cept mapping in concrete terms, we show how the tool was ticipants (no more than 100). applied to create a conceptual framework for The Healthy Brain Initiative: A National Public Health Road Map to Phase 3: Structuring of Statements Maintaining Cognitive Health (10), hereafter referred to Planning group identifies and invites external participants to sort and rate as the Road Map. In creating the Road Map, we altered the core group of items. the first 2 phases of Trochim’s original phases to meet our Participants sort and rate the core group of items. own requirements. One requirement was to align action Phase 4: Representation of Statements items in the Road Map with current science. Another was to incorporate input from a broad group of stakeholders, Consultants or staff compute a series of maps using concept-mapping including content experts, practitioners, and policy mak- software (multidimensional scaling and cluster analysis). ers. A participatory process was important because a Phase 5: Interpretation of Maps broad group of stakeholders enhances the perceived valid- Planning group examines the point and cluster maps, generates a final ity of a framework (11). Another modification was the use cluster map, and agrees on a descriptive phrase or word that captures of multiple modes of communication over several months the meaning or essence of each cluster. instead of a single brainstorming session. Phase 6: Use of Maps Planning group relates maps and associated materials to the original goal Development of the Concept Map of the project and produces plan for further action. The state of the science of cognitive health (12) and grow- structuring and representation of action items, including ing concerns about cognitive impairment shaped the sorting and rating action items and constructing a series strategic planning process for bringing a public health of concept maps. The third phase (including Trochim’s perspective to the promotion of cognitive health (13). In phases 5 and 6), finalizing the framework, consisted of May 2006, The Healthy Brain Initiative hosted a meeting the interpretation and use of maps. In this final phase, of national experts to review research and discuss recom- the steering committee examined and refined the concept mendations for promoting cognitive health; participants maps, labeled the clusters, created 2 new items, and focused on vascular risk factors and physical activity (14). selected the top 10 action items for the Road Map. Findings from this meeting provided a foundation for The Healthy Brain Initiative’s next step: developing a strategic Stage 1: Project planning plan. Phase 1: Preparation. We formed a 12-member steering We organized the strategic planning process into 3 committee and established 4 work groups. Steering overarching stages using Trochim’s 6 concept-mapping committee members represented varied disciplines phases (Box) as a guide. The first stage (including and sectors in public health and cognitive health. The Trochim’s phases 1 and 2), project planning, consisted of steering committee guided the overall concept-mapping the formation of a steering committee and work groups process, assisted with identifying and recruiting members and preparation and generation of statements, or action of work groups, helped define the charge to the work groups, items. The second stage (including Trochim’s phases participated in generating the concept maps, helped to 3 and 4), generating concept maps, consisted of the interpret and finalize the concept map, and determined The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. 2 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2011/sep/10_0255.htm VOLUME 8: NO. 5 SEPTEMBER 2011 the final set of 10 priority action items. The CDC co- Before finalizing its list of action items, each work group leader of the steering committee (L.A.A.) took primary sent its list to a group of external reviewers to determine responsibility for formulating the planning process, and whether items were understandable and to identify any CDC hired a project manager (K.L.D.) who coordinated missing items. Finalized lists were submitted to the steer- logistics for the work groups and communication between ing committee. The prevention research work group gener- the work groups and steering committee. ated 18 action items (eg, “Conduct controlled clinical trials to determine the effect of physical activity on reducing Consistent with a typical concept-mapping process, the the risk of cognitive decline and improving cognitive func- steering committee developed a charge, similar to a “focus tions”). The policy work group generated 9 action items prompt,”’ to articulate the goal of the concept-mapping (eg, “Include cognitive health in Healthy People 2020, a set process. The charge was to “develop a set of recommended of health objectives for the nation that will serve as the actions for moving the nation forward over the next 3 to foundation for state and community health plans”). The 5 years toward the long-term goals of maintaining and communication work group generated 8 action items (eg, improving the cognitive function of adults.” “Determine how diverse audiences think about cognitive health and its associated risk factors”). The surveillance Also consistent with a typical concept-mapping process, work group generated 7 action items (eg, “Determine a the steering committee identified and recruited people population-based surveillance system with longitudinal to work groups, which served as vehicles for generating follow-up that is dedicated to measuring the public health ideas. Work groups were established for 4 content areas: burden of cognitive impairment in the United States”). prevention research, surveillance, communication, and policy. The Healthy Brain Initiative required that ideas Stage 2: Generating concept maps and action items be grounded in science, so the steering committee developed criteria to identify eligible par- Throughout the first stage, the work groups worked inde- ticipants. For example, the criteria for the prevention pendently of one another. This second stage of the process research work group included people with experience in allowed a larger group of participants to work collectively phase 2 translational research (from clinical studies to to unite the varied action items into a cohesive framework community-level interventions), translational research or common vision. It also allowed the steering committee from other successful areas (eg, diabetes, physical activ- to understand how the entire group of stakeholders col- ity, cardiovascular health), community-based interven- lectively rated the importance and action potential of the tions, research measurement, study design, and commu- items. nity-based participatory research. Work group members represented varied sectors (eg, nonprofit, government, Phase 3: Structuring of statements. The first step in academia), disciplines (eg, epidemiology, gerontology, Phase 3 was to recruit a larger group of people to sort and social work), and perspectives (eg, aging, public health, rate all the action items identified by the work groups. The policy). Each work group consisted of no more than 20 steering committee enlisted a contractor, Concept Systems participants, and each group was asked to develop an Incorporated, which restructured the 42 items for their initial set of action items. proprietary software tool. The tool allowed participants independently and anonymously to sort and rate the items Phase 2: Generation of statements, or ideas. Using an on the project website. We invited 31 people, including iterative process, the 4 work groups worked independently steering committee members and 19 additional people over 3 months to generate a set of action items. Each representing the fields of cognition, aging, and public work group selected 2 members to facilitate discussions health, to participate in sorting. Using the software online, and draft the rationale statements that accompanied each participants were asked to create their own categories. action item. In addition, each work group developed a They were instructed to place each statement into only definition for its content area (eg, prevention research) and 1 category. The instructions also stated that the sorting identified key principles and audiences. In a departure process should result in more than 1 category but fewer from the typical concept-mapping process, which relies categories than the total number of statements. on a single online or in-person brainstorming session, each group participated in multiple conference calls and The steering committee asked a second larger group of 141 corresponded through e-mail between calls. people, including 21 from the sorting task, to rate the items. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. www.cdc.gov/pcd/issues/2011/sep/10_0255.htm • Centers for Disease Control and Prevention  VOLUME 8: NO. 5 SEPTEMBER 2011 Participants included members of the steering committee Stage 3: Finalizing the framework and work groups and external reviewers. Participants rated each item on 2 dimensions: importance (“How impor- Phase 5: Interpretation of maps. As in a typical concept- tant the item was to a cognitive public health agenda”) and mapping process, the steering committee examined the action potential (“How feasible the implementation of the maps and made several changes. The committee created 2 idea would be”). The items appeared in random order on new action items by reconstructing existing items, and it the project website. Because participation was anonymous, moved several action items from 1 cluster to another. The we could not calculate exact response rates. However, on software consultants subsequently reran the analyses, the basis of unique identifiers, we estimated that 83% of moved additional items, and produced a final concept the 31 stakeholders participated in sorting, and about 49% map with 8 clusters and 44 action items (Figure 1). The of the 141 rated the items. These rates are comparable to steering committee agreed upon cluster names. The other concept-mapping projects (5). cluster “Developing Capacity” originated exclusively from action items from the prevention research work group. Phase 4: Representation of statements. This phase “Implementing Policy” items originated exclusively from involves the computation of a series of concept maps. the policy work group, “Conducting Surveillance” items We generated the concept maps using Concept Systems originated exclusively from the surveillance work group, software 4.0 (Concept Systems Incorporated, Ithaca, New and “Intervention Research” items originated exclusively York) using methods developed by Trochim (3). First, the from the prevention research work group. All other software assigns a unique number to each action item, clusters were formed from various action items derived assesses the number of sorting participants who catego- from several work groups. This final concept map served rized action items similarly, and then generates an aggre- as the organizational framework for the Road Map. gate similarity matrix. Second, the software analyzes the aggregate similarity matrix by using multidimensional scaling analysis and for each action item, generates x and y coordinates in 2-dimensional space (15). Third, the software combines action items into clusters using hier- archical cluster analysis (16). Next, the software super- imposes the results of the hierarchical cluster analysis on the multidimensional scaling analysis, creating a point map. Finally, the software creates an initial cluster map by placing boundaries around the items that make up a cluster. Clusters are initially made up of about 5 items, but the software allows for fewer or greater numbers of items in each cluster. This concept map should be consid- ered the initial solution, however, because it is the starting point for reviewing the findings and determining the final Figure 1. Final concept map that served as the framework for The Healthy cluster map (4). Brain Initiative: A National Public Health Road Map to Maintaining Cognitive Health (10). Points on the map represent the items as entered in the Action items depicted together in cluster are more similar concept-mapping software. Items within a cluster are more similar to one to one another than they are to items in other clusters. another than they are to items in other clusters. The number of action items in a cluster and their similarity determine the shape, boundaries, and size of Items that appear closer together in a cluster are more each cluster. similar to one another than they are to items farther apart. Likewise, clusters that are closer together on the map contain items that are more similar to the items in Phase 6: Use of maps. In this phase, as in a typical near clusters than they are to clusters farther apart. The concept-mapping process, we accomplished the original overall size of a cluster reflects how similar or correlated goal of the project, which was to create a strategic plan, a the items are to each other as well as the number of items set of recommended actions for the next 3 to 5 years. We in a cluster. Concept maps have no top or bottom. In other identified this set of actions by using data from the rating words, the orientation of the clusters relative to the top or process to construct go-zones, a visual display of action bottom of the map has no particular meaning. items rated as most actionable and important. The go-zone The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2011/sep/10_0255.htm VOLUME 8: NO. 5 SEPTEMBER 2011 for the cluster “Implementing Policy” includes 2 priority items (Figure 2). The steering committee reviewed the go-zone analysis for each of the 8 clusters, identified potential prior- ity items, revised some wording, and selected a final set of 10 priority action items from 6 clusters: • Disseminate the latest science to increase public understanding of cognitive health and to dispel com- mon misconceptions (from the clus- ter “Disseminating Information”). • Determine how diverse audiences think about cognitive health and its associations with lifestyle factors (“Translating Knowledge”). Item • Help people understand the con- Number Items Included in the Rating Process From the Cluster “Implementing Policy” nection between risk and protec- tive factors and cognitive health 1 Develop creative and replicable means for raising public awareness about and engaging the public in promoting the importance of cognitive health through policy. (“Translating Knowledge”). • Conduct systematic literature 15 Develop and implement a strategy to have cognitive health included in Healthy People reviews on proposed risk factors (vascular risk and physical activ- 20 Identify and promote appropriate strategic partnerships among associations, government ity) and related interventions for agencies, insurers and payers, private industry, public organizations, elected officials to relationships with cognitive health, support and advance policy related to cognitive health. harms, gaps and effectiveness 21 Educate federal, state, and local officials responsible for addressing issues concerning (“Moving Research Into Practice”). the older population, lifestyle factors, or diseases/conditions related to cognitive health to • Conduct controlled clinical trials initiate and support policy changes to promote cognitive health. to determine the effect of reducing 28 Engage national organizations/agencies that focus on the older populations, and educate vascular risk factors on lowering the these agencies about cognitive health and its connection to the mission of their organiza- risk of cognitive decline and improv- tion. ing cognitive function (“Conducting 6 Develop and implement a strategy to include subjects related to cognitive health in curri- Intervention Research”). cula for continuing professional education of health and human services professionals. • Conduct controlled clinical trials to determine the effect of physi- 0 Convene policy experts to identify and examine current policies (eg, national policy, state cal activity on reducing the risk policy, private sector policy) that could be modified, modernized, or broadened to include cognitive health. of cognitive decline and improv- ing cognitive function (“Conducting Include cognitive decline in the State of Aging and Health in America report when popula- Intervention Research”). tion-level data are available. • Conduct research on other areas 5 Promote the modification of existing national and state public health plans that address potentially affecting cognitive key health issues related to cognitive health to include cognitive health in their strategies health such as nutrition, men- or recommendations where appropriate. tal activity, and social engage- ment (“Conducting Intervention Figure 2. A sample go-zone analysis for 1 of the clusters, “Implementing Policy,” in the final concept map for The Healthy Brain Initiative: A National Public Health Road Map to Maintaining Cognitive Health Research”). (10). Each dot represents an action item and is identified by a unique number. Items were scored for • Develop a population-based importance (from 1, relatively unimportant, to 5, extremely important) and action potential (from 1, no surveillance system with action potential, to , high action potential) during a rating process. The upper right quadrant, or go- zone, highlighted in green, displays items rated as most actionable and important. longitudinal follow-up that is The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. www.cdc.gov/pcd/issues/2011/sep/10_0255.htm • Centers for Disease Control and Prevention 5 VOLUME 8: NO. 5 SEPTEMBER 2011 dedicated to measuring the public health burden of and refined several action items that could not be included cognitive impairment in the United States (from the in the final map because the items were not included in the cluster “Conducting Surveillance”). sorting and rating process. Despite these challenges, con- • Initiate policy changes at the federal, state, and local cept mapping provided a structured process that allowed levels to promote cognitive health by engaging public for flexibility in a way that best suited our needs. We were officials (“Implementing Policy”). able to engage a diverse group of stakeholders, manage a • Include cognitive health in Healthy People 2020, a large amount of information, and frame a complex set of set of health objectives for the nation (“Implementing interrelated ideas. Policy”). The process allowed for different types of participants, On the basis of results of the concept-mapping process, numbers, and types of focus questions, ways of sorting we designed the Road Map (10) and disseminated it to and rating, and interpretations and uses. As Trochim indi- more than 1,000 dementia experts at the 2007 Alzheimer’s cated, “The uses of the map are limited only by the creativ- Association International Conference on Prevention of ity and motivation of the group” (3). Future research on Dementia in Washington, DC. The Road Map appears on concept maps could help to articulate the complete range CDC’s Healthy Aging website (http://www.cdc.gov/aging/ of options for methods, measures, and analyses. healthybrain/index.htm), on many partner websites, and it has been cited in numerous publications and grants. The Acknowledgments Healthy Brain Initiative relies on the Road Map to identify what actions to pursue and how to best collaborate with other partners that share an interest in those actions (17). We acknowledge the contributions of Mary Kane, Catherine CDC uses the 10 priority actions as a means to communi- VanBrunschot, and Brenda K. Pepe for their outstanding cate and support activities (18). work on implementing the concept-mapping components used in the Road Map project. We also thank Akiko Wilson for designing the figures. A Flexible Process Author Information A chief advantage of concept mapping is its flexibility, which allows users to refine ideas and the process itself. This flexibility allowed us to tailor the process to com- Corresponding Author: Lynda A. Anderson, PhD, Healthy bine 2 separate but equally important approaches. One Aging Program, Division of Adult and Community Health, approach was to elicit action items from content experts Centers for Disease Control and Prevention, 4770 Buford independently. Independent submission of ideas across Hwy, NE, MS K-38, Atlanta, GA 30341. Telephone: 770- the areas of research, surveillance, policy, and communi- 488-5998. E-mail: [email protected]. Dr Anderson is also cation strengthened the validity of the action items. The affiliated with the Department of Behavioral Sciences and second approach was participatory: a diverse group of Health Education, Rollins School of Public Health, Emory stakeholders collectively rated and sorted all action items University, Atlanta, Georgia. to develop a cohesive framework. In an additional modifi- cation, we generated initial ideas through 4 work groups Author Affiliations: Kristine L. Day and Anna E. that communicated by e-mail and conference call over 3 Vandenberg, Healthy Aging Program, Division of Adult months instead of relying on a single brainstorming ses- and Community Health, Centers for Disease Control and sion. The entire process — from the formation of the steer- Prevention, Atlanta, Georgia. ing committee to the publishing of the Road Map — took approximately 18 months. References We encountered 2 major challenges in developing the Road Map. First, it took more work than expected to 1. Committee on Assuring the Health of the Public in structure the action items submitted by the work groups the 21st Century. The future of the public’s health into a form that was acceptable for the concept-mapping in the 21st century. Washington (DC): The National software. Second, steering committee members identified Academies Press; 2002. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. 6 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2011/sep/10_0255.htm VOLUME 8: NO. 5 SEPTEMBER 2011 2. Anderson LA, McConnell SR. Cognitive health: an 13. Anderson LA, Day KD, Beard RL, Reed PS, Wu B. emerging public health issue. Alzheimers Dement The public’s perceptions about cognitive health and 2007;3:S70-3. Alzheimer’s disease among the U.S. population: a 3. Trochim W. An introduction to concept map- national review. Gerontologist 2009;49(Suppl 1):S3- ping for planning and evaluation. Eval Program S11. Plann 1989;12(special issue):1-16. http://www. 14. Albert MS, Brown DR, Buchner D, Laditka J, Launer socialresearchmethods.net/research/epp1/epp1.htm. LJ, Scherr P, et al. The healthy brain and our aging Accessed June 24, 2011. population: translating science to public health prac- 4. Trochim W, Kane M. Concept mapping: an introduc- tice. Alzheimers Dement 2007;3(2 Suppl):S3-5. tion to structured conceptualization in health care. Int 15. Davidson ML. Multidimensional scaling. New York J Qual Health Care 2005;17(3):187-91. (NY): John Wiley and Sons; 1983. 5. Anderson LA, Gwaltney MK, Sundra DL, Brownson 16. Aldenderfer MS, Blashfield RK. Cluster analysis. RC, Kane M, Cross AW, et al. Using concept mapping Beverly Hills (CA): Sage Publications; 1984. to develop a logic model for the Prevention Research 17. Day KL, McGuire LC, Anderson LA. The Centers Centers Program. Prev Chronic Dis 2006;3(1). http:// for Disease Control and Prevention’s Healthy Brain www.cdc.gov/pcd/issues/2006/jan/05_0153.htm. Initiative: emerging implications of cognitive impair- Accessed February 20, 2011. ment. Generations 2009;33(1):11-17 6. Trochim W, Milstein B, Wood BJ, Jackson S, Pressler 18. Anderson L, Logsdon RG, Hochhalter AK, Sharkey V. Setting objectives for community and systems JR. Introduction to the special issue on promoting change: an application of concept mapping for planning cognitive health in diverse populations of older adults. a statewide health improvement initiative. Health Gerontologist 2009;49 Suppl 1:S1-2. Promot Pract 2004;5:8-19. 7. Wheeler FC, Anderson LA, Boddie-Willis C, Price PH, Kane M. The role of state public health agen- cies in addressing less prevalent chronic conditions. Prev Chronic Dis 2005;2(3). http://www.cdc.gov/pcd/ issues/2005/jul/04_0129.htm. Accessed February 20, 8. Slonim A, Wheeler FC, Quinlan KM, Smith SM. Designing competencies for chronic disease practice. Prev Chronic Dis 2010:7(2). http://www.cdc.gov/pcd/ issues/2010/mar/08_0114.htm. Accessed February 20, 9. Johnson JA, Biegel DE, Shafran R. Concept mapping in mental health: uses and adaptations. Eval Program Plan 2000;23:67-75. 10. The Healthy Brain Initiative: A National Public Health Road Map to Maintaining Cognitive Health. Chicago (IL): Alzheimer’s Association; 2007. http:// www.cdc.gov/aging/pdf/TheHealthyBrainInitiative. pdf and http://www.alz.org/national/documents/report_ healthybraininitiative.pdf. 11. Milstein R, Wetterhall S, and CDC Evaluation Working Group. A framework featuring steps and standards for program evaluation. Health Promot Pract 2000;1(2):221-8. 12. Hendrie HC, Albert MS, Butters MA, Gao S, Knopman DS, Launer LJ, et al. The NIH Cognitive and Emotional Health Project: Report of the Critical Evaluation Study Committee. Alzheimers Dement 2006;2(1):12–32. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. www.cdc.gov/pcd/issues/2011/sep/10_0255.htm • Centers for Disease Control and Prevention http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Preventing Chronic Disease Pubmed Central

Using a Concept Map as a Tool for Strategic Planning: The Healthy Brain Initiative

Preventing Chronic Disease , Volume 8 (5) – Aug 15, 2011

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Abstract

assist in assessing what has been done and what can and should be done. In 2005, Congress appropriated funds to Concept mapping is a tool to assist in strategic planning the Centers for Disease Control and Prevention (CDC) to that allows planners to work through a sequence of phases address cognitive health (2). That same year, the Centers to produce a conceptual framework. Although several for Disease Control and Prevention and the Alzheimer’s studies describe how concept mapping is applied to vari- Association formed a new partnership, The Healthy Brain ous public health problems, the flexibility of the methods Initiative, to examine how best to bring a public health used in each phase of the process is often overlooked. If perspective to the promotion of cognitive health. The practitioners were more aware of the flexibility, more partnership recognized a need to develop a strategic plan public health endeavors could benefit from using concept to identify public health priorities, create a unified vision mapping as a tool for strategic planning. among stakeholders, and guide activities over a 3- to 5- year period. The objective of this article is to describe how the 6 concept-mapping phases originally outlined by William Concept mapping is a tool that helps with strategic plan- Trochim guided our strategic planning process and how ning. It consists of a sequence of phases that result in a we adjusted the specific methods in the first 2 phases to conceptual framework (3). A concept map provides a visual meet the specialized needs and requirements to create The picture of strategic planning ideas; the ideas are clustered Healthy Brain Initiative: A National Public Health Road in groups so that a complex set of ideas can be more read- Map to Maintaining Cognitive Health. In the first stage ily understood. Concept mapping has taken various forms, (phases 1 and 2 of concept mapping), we formed a steer- such as “idea mapping” or “mind mapping,” to enhance ing committee, convened 4 work groups over a period of creative thinking or improve the organization of ideas (4). 3 months, and generated an initial set of 42 action items Concept mapping for public health, a process introduced grounded in science. In the second stage (phases 3 and 4), by William Trochim (3), involves a group of stakeholders we engaged stakeholders in sorting and rating the action who have an interest in a given area (eg, researchers, items and constructed a series of concept maps. In the practitioners) or may be affected by the outcomes (eg, com- third and final stage (phases 5 and 6), we examined and munity members, program participants). Concept map- refined the action items and generated a final concept map ping has been applied to create logic models for a national consisting of 44 action items. We then selected the top program (5), develop various state plans (6,7), and design 10 action items, and in 2007, we published The Healthy chronic disease competencies (8). Articles describing these The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. www.cdc.gov/pcd/issues/2011/sep/10_0255.htm • Centers for Disease Control and Prevention 1 VOLUME 8: NO. 5 SEPTEMBER 2011 concept maps focus on the outcome of the mapping process Box. Phases of Concept Mapping as Originally Conceptualized by and often, as a result, overlook the flexibility of the meth- Trochim (3) ods at each phase (9). More public health endeavors could Phase 1: Preparation benefit from concept mapping as a strategic planning tool Planning group identifies a single focal question or prompt that will best if practitioners were more aware of the flexibility of the serve the goal of the project. methods at each phase of the process. Planning group identifies participants to generate ideas through brain- storming. The objective of this article is to present an overview of concept mapping to public health practitioners and to show Phase 2: Generation of Ideas how phases of the concept-mapping process can be altered Participants brainstorm ideas in a single in-person session or online. or tailored to meet special requirements. To illustrate con- Planning group selects core group of ideas from ideas generated by par- cept mapping in concrete terms, we show how the tool was ticipants (no more than 100). applied to create a conceptual framework for The Healthy Brain Initiative: A National Public Health Road Map to Phase 3: Structuring of Statements Maintaining Cognitive Health (10), hereafter referred to Planning group identifies and invites external participants to sort and rate as the Road Map. In creating the Road Map, we altered the core group of items. the first 2 phases of Trochim’s original phases to meet our Participants sort and rate the core group of items. own requirements. One requirement was to align action Phase 4: Representation of Statements items in the Road Map with current science. Another was to incorporate input from a broad group of stakeholders, Consultants or staff compute a series of maps using concept-mapping including content experts, practitioners, and policy mak- software (multidimensional scaling and cluster analysis). ers. A participatory process was important because a Phase 5: Interpretation of Maps broad group of stakeholders enhances the perceived valid- Planning group examines the point and cluster maps, generates a final ity of a framework (11). Another modification was the use cluster map, and agrees on a descriptive phrase or word that captures of multiple modes of communication over several months the meaning or essence of each cluster. instead of a single brainstorming session. Phase 6: Use of Maps Planning group relates maps and associated materials to the original goal Development of the Concept Map of the project and produces plan for further action. The state of the science of cognitive health (12) and grow- structuring and representation of action items, including ing concerns about cognitive impairment shaped the sorting and rating action items and constructing a series strategic planning process for bringing a public health of concept maps. The third phase (including Trochim’s perspective to the promotion of cognitive health (13). In phases 5 and 6), finalizing the framework, consisted of May 2006, The Healthy Brain Initiative hosted a meeting the interpretation and use of maps. In this final phase, of national experts to review research and discuss recom- the steering committee examined and refined the concept mendations for promoting cognitive health; participants maps, labeled the clusters, created 2 new items, and focused on vascular risk factors and physical activity (14). selected the top 10 action items for the Road Map. Findings from this meeting provided a foundation for The Healthy Brain Initiative’s next step: developing a strategic Stage 1: Project planning plan. Phase 1: Preparation. We formed a 12-member steering We organized the strategic planning process into 3 committee and established 4 work groups. Steering overarching stages using Trochim’s 6 concept-mapping committee members represented varied disciplines phases (Box) as a guide. The first stage (including and sectors in public health and cognitive health. The Trochim’s phases 1 and 2), project planning, consisted of steering committee guided the overall concept-mapping the formation of a steering committee and work groups process, assisted with identifying and recruiting members and preparation and generation of statements, or action of work groups, helped define the charge to the work groups, items. The second stage (including Trochim’s phases participated in generating the concept maps, helped to 3 and 4), generating concept maps, consisted of the interpret and finalize the concept map, and determined The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. 2 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2011/sep/10_0255.htm VOLUME 8: NO. 5 SEPTEMBER 2011 the final set of 10 priority action items. The CDC co- Before finalizing its list of action items, each work group leader of the steering committee (L.A.A.) took primary sent its list to a group of external reviewers to determine responsibility for formulating the planning process, and whether items were understandable and to identify any CDC hired a project manager (K.L.D.) who coordinated missing items. Finalized lists were submitted to the steer- logistics for the work groups and communication between ing committee. The prevention research work group gener- the work groups and steering committee. ated 18 action items (eg, “Conduct controlled clinical trials to determine the effect of physical activity on reducing Consistent with a typical concept-mapping process, the the risk of cognitive decline and improving cognitive func- steering committee developed a charge, similar to a “focus tions”). The policy work group generated 9 action items prompt,”’ to articulate the goal of the concept-mapping (eg, “Include cognitive health in Healthy People 2020, a set process. The charge was to “develop a set of recommended of health objectives for the nation that will serve as the actions for moving the nation forward over the next 3 to foundation for state and community health plans”). The 5 years toward the long-term goals of maintaining and communication work group generated 8 action items (eg, improving the cognitive function of adults.” “Determine how diverse audiences think about cognitive health and its associated risk factors”). The surveillance Also consistent with a typical concept-mapping process, work group generated 7 action items (eg, “Determine a the steering committee identified and recruited people population-based surveillance system with longitudinal to work groups, which served as vehicles for generating follow-up that is dedicated to measuring the public health ideas. Work groups were established for 4 content areas: burden of cognitive impairment in the United States”). prevention research, surveillance, communication, and policy. The Healthy Brain Initiative required that ideas Stage 2: Generating concept maps and action items be grounded in science, so the steering committee developed criteria to identify eligible par- Throughout the first stage, the work groups worked inde- ticipants. For example, the criteria for the prevention pendently of one another. This second stage of the process research work group included people with experience in allowed a larger group of participants to work collectively phase 2 translational research (from clinical studies to to unite the varied action items into a cohesive framework community-level interventions), translational research or common vision. It also allowed the steering committee from other successful areas (eg, diabetes, physical activ- to understand how the entire group of stakeholders col- ity, cardiovascular health), community-based interven- lectively rated the importance and action potential of the tions, research measurement, study design, and commu- items. nity-based participatory research. Work group members represented varied sectors (eg, nonprofit, government, Phase 3: Structuring of statements. The first step in academia), disciplines (eg, epidemiology, gerontology, Phase 3 was to recruit a larger group of people to sort and social work), and perspectives (eg, aging, public health, rate all the action items identified by the work groups. The policy). Each work group consisted of no more than 20 steering committee enlisted a contractor, Concept Systems participants, and each group was asked to develop an Incorporated, which restructured the 42 items for their initial set of action items. proprietary software tool. The tool allowed participants independently and anonymously to sort and rate the items Phase 2: Generation of statements, or ideas. Using an on the project website. We invited 31 people, including iterative process, the 4 work groups worked independently steering committee members and 19 additional people over 3 months to generate a set of action items. Each representing the fields of cognition, aging, and public work group selected 2 members to facilitate discussions health, to participate in sorting. Using the software online, and draft the rationale statements that accompanied each participants were asked to create their own categories. action item. In addition, each work group developed a They were instructed to place each statement into only definition for its content area (eg, prevention research) and 1 category. The instructions also stated that the sorting identified key principles and audiences. In a departure process should result in more than 1 category but fewer from the typical concept-mapping process, which relies categories than the total number of statements. on a single online or in-person brainstorming session, each group participated in multiple conference calls and The steering committee asked a second larger group of 141 corresponded through e-mail between calls. people, including 21 from the sorting task, to rate the items. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. www.cdc.gov/pcd/issues/2011/sep/10_0255.htm • Centers for Disease Control and Prevention  VOLUME 8: NO. 5 SEPTEMBER 2011 Participants included members of the steering committee Stage 3: Finalizing the framework and work groups and external reviewers. Participants rated each item on 2 dimensions: importance (“How impor- Phase 5: Interpretation of maps. As in a typical concept- tant the item was to a cognitive public health agenda”) and mapping process, the steering committee examined the action potential (“How feasible the implementation of the maps and made several changes. The committee created 2 idea would be”). The items appeared in random order on new action items by reconstructing existing items, and it the project website. Because participation was anonymous, moved several action items from 1 cluster to another. The we could not calculate exact response rates. However, on software consultants subsequently reran the analyses, the basis of unique identifiers, we estimated that 83% of moved additional items, and produced a final concept the 31 stakeholders participated in sorting, and about 49% map with 8 clusters and 44 action items (Figure 1). The of the 141 rated the items. These rates are comparable to steering committee agreed upon cluster names. The other concept-mapping projects (5). cluster “Developing Capacity” originated exclusively from action items from the prevention research work group. Phase 4: Representation of statements. This phase “Implementing Policy” items originated exclusively from involves the computation of a series of concept maps. the policy work group, “Conducting Surveillance” items We generated the concept maps using Concept Systems originated exclusively from the surveillance work group, software 4.0 (Concept Systems Incorporated, Ithaca, New and “Intervention Research” items originated exclusively York) using methods developed by Trochim (3). First, the from the prevention research work group. All other software assigns a unique number to each action item, clusters were formed from various action items derived assesses the number of sorting participants who catego- from several work groups. This final concept map served rized action items similarly, and then generates an aggre- as the organizational framework for the Road Map. gate similarity matrix. Second, the software analyzes the aggregate similarity matrix by using multidimensional scaling analysis and for each action item, generates x and y coordinates in 2-dimensional space (15). Third, the software combines action items into clusters using hier- archical cluster analysis (16). Next, the software super- imposes the results of the hierarchical cluster analysis on the multidimensional scaling analysis, creating a point map. Finally, the software creates an initial cluster map by placing boundaries around the items that make up a cluster. Clusters are initially made up of about 5 items, but the software allows for fewer or greater numbers of items in each cluster. This concept map should be consid- ered the initial solution, however, because it is the starting point for reviewing the findings and determining the final Figure 1. Final concept map that served as the framework for The Healthy cluster map (4). Brain Initiative: A National Public Health Road Map to Maintaining Cognitive Health (10). Points on the map represent the items as entered in the Action items depicted together in cluster are more similar concept-mapping software. Items within a cluster are more similar to one to one another than they are to items in other clusters. another than they are to items in other clusters. The number of action items in a cluster and their similarity determine the shape, boundaries, and size of Items that appear closer together in a cluster are more each cluster. similar to one another than they are to items farther apart. Likewise, clusters that are closer together on the map contain items that are more similar to the items in Phase 6: Use of maps. In this phase, as in a typical near clusters than they are to clusters farther apart. The concept-mapping process, we accomplished the original overall size of a cluster reflects how similar or correlated goal of the project, which was to create a strategic plan, a the items are to each other as well as the number of items set of recommended actions for the next 3 to 5 years. We in a cluster. Concept maps have no top or bottom. In other identified this set of actions by using data from the rating words, the orientation of the clusters relative to the top or process to construct go-zones, a visual display of action bottom of the map has no particular meaning. items rated as most actionable and important. The go-zone The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2011/sep/10_0255.htm VOLUME 8: NO. 5 SEPTEMBER 2011 for the cluster “Implementing Policy” includes 2 priority items (Figure 2). The steering committee reviewed the go-zone analysis for each of the 8 clusters, identified potential prior- ity items, revised some wording, and selected a final set of 10 priority action items from 6 clusters: • Disseminate the latest science to increase public understanding of cognitive health and to dispel com- mon misconceptions (from the clus- ter “Disseminating Information”). • Determine how diverse audiences think about cognitive health and its associations with lifestyle factors (“Translating Knowledge”). Item • Help people understand the con- Number Items Included in the Rating Process From the Cluster “Implementing Policy” nection between risk and protec- tive factors and cognitive health 1 Develop creative and replicable means for raising public awareness about and engaging the public in promoting the importance of cognitive health through policy. (“Translating Knowledge”). • Conduct systematic literature 15 Develop and implement a strategy to have cognitive health included in Healthy People reviews on proposed risk factors (vascular risk and physical activ- 20 Identify and promote appropriate strategic partnerships among associations, government ity) and related interventions for agencies, insurers and payers, private industry, public organizations, elected officials to relationships with cognitive health, support and advance policy related to cognitive health. harms, gaps and effectiveness 21 Educate federal, state, and local officials responsible for addressing issues concerning (“Moving Research Into Practice”). the older population, lifestyle factors, or diseases/conditions related to cognitive health to • Conduct controlled clinical trials initiate and support policy changes to promote cognitive health. to determine the effect of reducing 28 Engage national organizations/agencies that focus on the older populations, and educate vascular risk factors on lowering the these agencies about cognitive health and its connection to the mission of their organiza- risk of cognitive decline and improv- tion. ing cognitive function (“Conducting 6 Develop and implement a strategy to include subjects related to cognitive health in curri- Intervention Research”). cula for continuing professional education of health and human services professionals. • Conduct controlled clinical trials to determine the effect of physi- 0 Convene policy experts to identify and examine current policies (eg, national policy, state cal activity on reducing the risk policy, private sector policy) that could be modified, modernized, or broadened to include cognitive health. of cognitive decline and improv- ing cognitive function (“Conducting Include cognitive decline in the State of Aging and Health in America report when popula- Intervention Research”). tion-level data are available. • Conduct research on other areas 5 Promote the modification of existing national and state public health plans that address potentially affecting cognitive key health issues related to cognitive health to include cognitive health in their strategies health such as nutrition, men- or recommendations where appropriate. tal activity, and social engage- ment (“Conducting Intervention Figure 2. A sample go-zone analysis for 1 of the clusters, “Implementing Policy,” in the final concept map for The Healthy Brain Initiative: A National Public Health Road Map to Maintaining Cognitive Health Research”). (10). Each dot represents an action item and is identified by a unique number. Items were scored for • Develop a population-based importance (from 1, relatively unimportant, to 5, extremely important) and action potential (from 1, no surveillance system with action potential, to , high action potential) during a rating process. The upper right quadrant, or go- zone, highlighted in green, displays items rated as most actionable and important. longitudinal follow-up that is The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. www.cdc.gov/pcd/issues/2011/sep/10_0255.htm • Centers for Disease Control and Prevention 5 VOLUME 8: NO. 5 SEPTEMBER 2011 dedicated to measuring the public health burden of and refined several action items that could not be included cognitive impairment in the United States (from the in the final map because the items were not included in the cluster “Conducting Surveillance”). sorting and rating process. Despite these challenges, con- • Initiate policy changes at the federal, state, and local cept mapping provided a structured process that allowed levels to promote cognitive health by engaging public for flexibility in a way that best suited our needs. We were officials (“Implementing Policy”). able to engage a diverse group of stakeholders, manage a • Include cognitive health in Healthy People 2020, a large amount of information, and frame a complex set of set of health objectives for the nation (“Implementing interrelated ideas. Policy”). The process allowed for different types of participants, On the basis of results of the concept-mapping process, numbers, and types of focus questions, ways of sorting we designed the Road Map (10) and disseminated it to and rating, and interpretations and uses. As Trochim indi- more than 1,000 dementia experts at the 2007 Alzheimer’s cated, “The uses of the map are limited only by the creativ- Association International Conference on Prevention of ity and motivation of the group” (3). Future research on Dementia in Washington, DC. The Road Map appears on concept maps could help to articulate the complete range CDC’s Healthy Aging website (http://www.cdc.gov/aging/ of options for methods, measures, and analyses. healthybrain/index.htm), on many partner websites, and it has been cited in numerous publications and grants. The Acknowledgments Healthy Brain Initiative relies on the Road Map to identify what actions to pursue and how to best collaborate with other partners that share an interest in those actions (17). We acknowledge the contributions of Mary Kane, Catherine CDC uses the 10 priority actions as a means to communi- VanBrunschot, and Brenda K. Pepe for their outstanding cate and support activities (18). work on implementing the concept-mapping components used in the Road Map project. We also thank Akiko Wilson for designing the figures. A Flexible Process Author Information A chief advantage of concept mapping is its flexibility, which allows users to refine ideas and the process itself. This flexibility allowed us to tailor the process to com- Corresponding Author: Lynda A. Anderson, PhD, Healthy bine 2 separate but equally important approaches. One Aging Program, Division of Adult and Community Health, approach was to elicit action items from content experts Centers for Disease Control and Prevention, 4770 Buford independently. Independent submission of ideas across Hwy, NE, MS K-38, Atlanta, GA 30341. Telephone: 770- the areas of research, surveillance, policy, and communi- 488-5998. E-mail: [email protected]. Dr Anderson is also cation strengthened the validity of the action items. The affiliated with the Department of Behavioral Sciences and second approach was participatory: a diverse group of Health Education, Rollins School of Public Health, Emory stakeholders collectively rated and sorted all action items University, Atlanta, Georgia. to develop a cohesive framework. In an additional modifi- cation, we generated initial ideas through 4 work groups Author Affiliations: Kristine L. Day and Anna E. that communicated by e-mail and conference call over 3 Vandenberg, Healthy Aging Program, Division of Adult months instead of relying on a single brainstorming ses- and Community Health, Centers for Disease Control and sion. The entire process — from the formation of the steer- Prevention, Atlanta, Georgia. ing committee to the publishing of the Road Map — took approximately 18 months. References We encountered 2 major challenges in developing the Road Map. First, it took more work than expected to 1. Committee on Assuring the Health of the Public in structure the action items submitted by the work groups the 21st Century. The future of the public’s health into a form that was acceptable for the concept-mapping in the 21st century. Washington (DC): The National software. Second, steering committee members identified Academies Press; 2002. 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Introduction to the special issue on promoting change: an application of concept mapping for planning cognitive health in diverse populations of older adults. a statewide health improvement initiative. Health Gerontologist 2009;49 Suppl 1:S1-2. Promot Pract 2004;5:8-19. 7. Wheeler FC, Anderson LA, Boddie-Willis C, Price PH, Kane M. The role of state public health agen- cies in addressing less prevalent chronic conditions. Prev Chronic Dis 2005;2(3). http://www.cdc.gov/pcd/ issues/2005/jul/04_0129.htm. Accessed February 20, 8. Slonim A, Wheeler FC, Quinlan KM, Smith SM. Designing competencies for chronic disease practice. Prev Chronic Dis 2010:7(2). http://www.cdc.gov/pcd/ issues/2010/mar/08_0114.htm. Accessed February 20, 9. Johnson JA, Biegel DE, Shafran R. Concept mapping in mental health: uses and adaptations. Eval Program Plan 2000;23:67-75. 10. The Healthy Brain Initiative: A National Public Health Road Map to Maintaining Cognitive Health. Chicago (IL): Alzheimer’s Association; 2007. http:// www.cdc.gov/aging/pdf/TheHealthyBrainInitiative. pdf and http://www.alz.org/national/documents/report_ healthybraininitiative.pdf. 11. Milstein R, Wetterhall S, and CDC Evaluation Working Group. A framework featuring steps and standards for program evaluation. Health Promot Pract 2000;1(2):221-8. 12. Hendrie HC, Albert MS, Butters MA, Gao S, Knopman DS, Launer LJ, et al. The NIH Cognitive and Emotional Health Project: Report of the Critical Evaluation Study Committee. Alzheimers Dement 2006;2(1):12–32. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. www.cdc.gov/pcd/issues/2011/sep/10_0255.htm • Centers for Disease Control and Prevention

Journal

Preventing Chronic DiseasePubmed Central

Published: Aug 15, 2011

References