Sunday, April 24, 2016

Leading public health: A competency framework (book review)

What are the competencies of effective public health leaders? I have had the opportunity to participate in several health leadership fellowships (UCSF/California HealthCare Foundation, NACCHO, and Kresge Foundation). All of them have been great! I have learned a tremendous amount. Leadership training curricula start by identifying desired competencies (knowledge, skills, and abilities) for the participants.

As part of my project in the Kresge Foundation fellowship (Emerging Leaders in Public Health) I discovered, and highly recommend, the book by James Begun and Jan Malcolm: Leading Public Health---A Competency Framework (Springer, 2014). Leadership development is a lifelong, continuous improvement endeavor, and this book has become my competency road map. There are 25 competencies clustered into five sets, which I will summarize here.

Begun & Malcolm define public health leadership as the practice of mobilizing people, organizations, and communities to effectively tackle tough public health challenges.

An overview

Here is useful way to categorize leadership:
  1. How to be
  2. What to know
  3. What to do

How to be---public health values and character traits

“[O]ur framework separates values, traits, knowledge, and competencies. … [W]e call out specific values (beliefs about what ought to be) and traits (patterns of personal characteristics) that are particularly helpful to developing public health leadership.”

Public health values: From Begun and Malcolm: “Personal values are broad preferences concerning appropriate courses of action or outcomes. They represent a person’s sense of right and wrong or what ought to be. They are strongly affected by what we learn from parents, teachers, religious traditions, and peers, as well as life experiences. While deeply ingrained, we can examine and redefine personal values. Indeed, we often carry them subconsciously, unless circumstances allow us or force us to examine or test them.”
  • Social justice
  • Reliance on evidence
  • Interdependence
  • Respect
  • Community self-determination
  • Requisite role of government
  • Transparency

Character traits: From Begun and Malcolm: “[Character] traits … are distinguishing features of the behavioral and mental characteristics that make us unique. Traits are fairly hard-wired and may be harder to change than values—at least they would be hard to change in an authentic manner …”
  • Integrity
  • Initiative
  • Empathy
  • Comfort with ambiguity
  • Passion
  • Courage
  • Persistence

From Begun and Malcolm: “[O]ur framework separates values, traits, knowledge, and competencies. ... [W]e call out specific values (beliefs about what ought to be) and traits (patterns of personal characteristics) that are particularly helpful to developing public health leadership.”

What to know—knowledge areas

  1. Public health science
  2. Understanding people
  3. Understanding complex systems
  4. Changing people, organizations, and communities

What to do—five competency sets

  1. Invigorate bold(er) pursuit of population health
  2. Engage diverse others in public health initiatives
  3. Effectively wield power to increase the influence and impact of public health
  4. Prepare for surprise in public health work
  5. Drive for execution and continuous improvement in public health

Here are some details (mostly definitions)

How to be---public health values and character traits

Public health values
  • Social justice: Acceptance of health as a universal, fundamental human right for all, and a strong commitment to correcting patterns of systematic disadvantage to population subgroups
  • Reliance on evidence: Requirement that evidence informs and challenges decision making, accompanied by a healthy skepticism about existing practices, mindsets, and outcomes; helps mitigate groupthink among like-minded public health practitioners
  • Interdependence: Recognition of the need to work with and in collaboration with diverse individuals and communities rather than independent pursuits; enhanced by the impact of social determinants on population health
  • Respect: At the personal level, a way of regarding another individual that denotes the individual is important; manifested in soliciting input from the individual, listening, and doing so in a way that is sensitive to the individual’s culture and individuality
  • Community self-determination: Respect for the right and ability of communities to define their own issues and interventions; serve as a coalition builder rather than the agenda-setter
  • Requisite role of government: Belief in the value of public service and the role of government action to protect the public’s health
  • Transparency: Public and other stakeholders have the right to information; develops trust and promotes constructive politics

Character traits
  • Integrity: Honesty, truthfulness, and consistent action in accord with one’s values; key to credibility and strength in the face of attack
  • Initiative: Drive to change; willingness to take charge and take risks when necessary
  • Empathy: Interest in and ability to relate to people
  • Comfort with ambiguity: Comfort with lack of clear boundaries and hierarchy in work settings
  • Passion: Deep commitment to values of public health, profession of public health, and service
  • Courage: Willingness to take unpopular stands on high-visibility issues and to push harder, to insist more vigorously, more effectively, and over a longer period of time
  • Persistence: Patience with long-term cultural, social, and multi-generational change

What to know---knowledge areas (a) and key characteristics (b)

a) Knowledge areas

  • Public health science
    • Analytic / assessment
    • Basic public health sciences (biostatistics, epidemiology, environmental health, health policy and management, social and behavioral sciences)
    • Cultural competency
    • Communication
    • Community dimensions of practice
    • Financial planning and management
    • Leadership and systems thinking
    • Policy development / Program planning
  • Understanding people
    • Motivation
    • Social and emotional intelligence
  • Understanding complex systems
    • Systems thinking
    • Focusing on complex adaptive systems
  • Changing people, organizations, and communities
    • Change management
    • Culture of innovation
    • Positive deviance

b) Key characteristics of public health knowledge
  • Evidence-based
    • Correlates with an emphasis on science and scientific research
    • Uses evidence as a key weapon in tackling public health challenges in political arenas
    • Grows largely through the accumulation of scientific evidence-based
    • Empowers societal influence of public health leaders and the field
  • Dynamic
    • Changes frequently, particularly knowledge connected to scientific disciplines
    • Invites an attitude of learning by public health leaders
    • Demands the push for new evidence where it is needed
    • Requires leaders’ openness to change their minds where compelling evidence is identified
  • Prevention-focused
    • Directs most public health knowledge toward preventing the emergence of health problems
    • Compels focus on addressing the root causes of health problems to prevent them
    • Enables a “return-on-investment” mindset that reflects the shard belief in the value of prevention
  • Transdisciplinary
    • Driven by problems rather than traditional boundaries of scientific disciplines
    • Welcomes acceptance of relevant information from other fields and disciplines, as well as their potential limitations
    • Encourages cross-sector collaboration within and outside clinical and scientific fields
  • Value-laden
    • Characterized by strongly political nature of field due to value conflict inherent in most population health issues
    • Raises questions about the allocation of public resources relative to government regulation and intervention, legal and ethical concerns, and political influences
    • Requires political debate over both the means and ends for improving population health

What to do---five competency sets (25 competencies)

  1. Invigorate bold(er) pursuit of population health
    1. Critically assess the current state of your program or organization
    2. Articulate a more compelling agenda
    3. Enlist others in the vision and invigorate them to drive toward it
    4. Pursue the vision with rigor and flexibility
    5. Marshal the needed resources
  2. Engage diverse others in public health initiatives
    1. Assess local conditions, in ways relevant and credible to the local stakeholders
    2. Search widely for the right partners
    3. Apply a social determinants perspective to planning
    4. Take time to build relationships, teamwork, and common understanding
    5. Clarify roles and governance
  3. Effectively wield power to increase the influence and impact of public health
    1. Understand and strategically use both positional authority and informal influence
    2. Analyze a given public health problem and proposed solution in “campaign” terms
    3. Build coalitions of core supporters, new partners, and issue-specific allies
    4. Deal effectively with opponents
    5. Be strategically agile
  4. Prepare for surprise in public health work
    1. Promote resilience in individuals and communities
    2. Develop and critique an emergency response plan
    3. Communicate effectively during surprises
    4. Execute an emergency response plan with flexibility and learning
    5. Learn and improve after surprises
  5. Drive for execution and continuous improvement in public health programs and organizations
    1. Build accountability into public health teams, programs, and organizations
    2. Establish metrics, set targets, monitor progress, and take action
    3. Proactively demonstrate financial stewardship of public health funds
    4. Employ the methods and tools of quality improvement
    5. Encourage innovation and risk-taking


Leading Public Health provides 25 competencies associated with effective public health leadership. The authors reviewed the appropriate literature, and provide further readings and inspiring case stories. This book succinctly summarizes the challenges faced by public health leaders (many of their examples resonated with my personal experience). If you want to become a more effective public health leader, or if you want to learn what public health leaders do (or should be doing), I highly recommend this book!

Saturday, April 23, 2016

Not everything that can be counted counts

William Bruce Cameron's 1963 text, “Informal Sociology: A Casual Introduction to Sociological Thinking,” contained the following passage:
It would be nice if all of the data which sociologists require could be enumerated because then we could run them through IBM machines and draw charts as the economists do. However, not everything that can be counted counts, and not everything that counts can be counted.
This quote, "not everything that can be counted counts, and not everything that counts can be counted," is often attributed to Albert Einstein which is incorrect. Nevertheless, the message is full of wisdom and worthy of our focus.

In today's environment we are pressured to deliver results and show impacts. Consequently, we are tempted to prioritize the selection of activities that have indicators that are reliably available and of good quality. We may unintentionally avoid tackling challenges that are difficult to measure because we want our achievements to be counted and recognized.

I recently participated in a planning process where we started by selecting indicators, then developing goals around the indicators. Some participants inquired about the process expressing that they are accustomed to setting goals (desirable results) then selecting or developing measures of success (indicators).

At the SFDPH Population Health Division we use four strategic questions (4SQ):
  1. What are we trying to accomplish and why? (goals aligned to organizational purpose and strategies)
  2. How do we measure success? (measures; may need development)
  3. What other conditions must exist? (assumptions, risks)
  4. How do we get there? (action planning and implementation)
In general, developing goals should precede selecting and developing indicators. If you start with indicators you run the risk of avoiding challenges that count but cannot be counted

Below is a graphic that we have adapted from the Results Leadership Group for our results-based lean approach that summarize this approach.

Results-based lean: Results-based approach to collective impact planning.

Not all is lost if one starts with indicators. Circle back and review your organizational purpose, mission, and strategy goals. The indicators may already fit within existing goals or strategic directions. Planning is an interactive, iterative process. Just review and adjust (i.e., part of any Plan-Do-Study-Act cycle).

Open source recommendations

Here are my recommendations for software solutions that might increase your productivity, improve your product quality, and save you tons of time and money. My philosophy is to use software that is high quality, reliable, secure, multi-platform, and cost-effective. Your feedback and suggestions are welcome. User-friendly programs have an asterisk (*). Enjoy ...

Life / Time / Task Management

Org-mode ( (for Emacs users)

Org-mode is an Emacs mode for keeping notes, maintaining ToDo lists, and doing project planning with a fast and effective plain-text system (GNU Emacs is a text editor---see below under Text Editors). Org-mode develops organizational tasks around NOTES files that contain information about projects as plain text. Visibility cycling and structure editing help to work with the tree. Tables are easily created with a built-in table editor. Org-mode supports ToDo items, deadlines, time stamps, and scheduling. It dynamically compiles entries into an agenda. Plain text URL-like links connect to websites, emails, and any files related to the projects. For printing and sharing of notes, an Org-mode file can be exported as a structured ASCII file, HTML, and PDF LaTeX.

A text file showing a tree in emacs org-mode
I use Org-mode to implement David Allen’s Getting Things Done (GTD) approach and Stephen Covey’s The 7 Habits of Highly Effective People. Whereas the 7 Habits helps one develop a personal mission statement to align long term goals with one’s values and priorities, the GTD approach provides the operational details for “getting things done.” The irony of the 7 Habits approach is that one becomes overwhelmed trying to accomplish many worthwhile and fulfilling endeavors. Hence, the need for the GTD approach. Price = $0.

Task Coach* (

Task Coach is a simple open source todo manager to manage personal tasks and todo lists. If you don’t use Emacs, try Task Coach. Price = $0.

Computer Operating Systems

Ubuntu Linux (

Ubuntu Linux is an open source operating system based on Debian Linux, and is the clear choice if you want excellent functionality, reliability, and security at an very affordable price. You can convert your old MS Windows computer to Ubuntu Linux, or purchase a computer with it pre-installed (e.g., System76). Linux is an affordable alternative to Mac OS (also Linux-like). For the average workplace and home, Ubuntu Linux will have everything you need (including hundreds of free software solutions). For a limited budget, Ubuntu Linux is the clear choice.

Here is a screenshot of Ubuntu Linux on a System76 computer. On the left upper corner is GNU Emacs running AUCTeX; Gmail on the right upper corner; and Terminal on the lower right corner.

Ubuntu Linux Screenshot on System76 computer.

Mac OS* (

Mac OS X is an alternative choice if you want the functionality, reliability and security of Linux combined with the popularity of Macs. After many years of dissatisfaction with Windows, I had switched to the Mac OS, and I have never looked back. Mac OS X is a derivative from the FreeBSD operating system (originally from UC Berkeley!) with lots of open source (free) tools/software (although not nearly as many as Linux). If you are comfortable with Macs you are one step away from moving up to Linux. (Personally, I find Ubuntu Linux much more user-friendly than Macs. Unfortunately, Apple has become much more “closed” and they lock you into their “ecosystem.” So, I no longer used Macs at all. However, Macs are a still significant improvement over Windows!)

Integrated Office Suite

LibreOffice* (

LibreOffice is a free, open source, Microsoft Office-compatible and cross-platform (Windows, Linux, Solaris, and Mac OS) productivity software suite that includes a word-processor, spreadsheet, presentation program, and relational database, comparable to Microsoft Office’s Word, Excel, PowerPoint, and Access. OpenOffice can read and output these MS Office files (I have not used MS Office products since 1997). It also includes editors for HTML, drawing, and math equations. LibreOffice exports to many formats, including Portable Document Format (PDF) and LaTeX. output is of the highest professional quality and gives you the most flexibility in making your work available to the widest audience worldwide. At home, we only have and use LibreOffice. Price = $0.
LibreOffice Writer Screenshot

Web Browsers

Google Chrome* (

Google Chrome is a web browser designed for speed, simplicity, security and much more: search, chat, email, shop, bank, read the news, watch videos online, etc.Price = $0.

Mozilla Firefox* (

Mozilla Firefox is an open-source web browser designed for standards-compliance, performance and portability. Firefox is an award winning preview of next generation browsing technology from Firefox empowers you to accomplish your online activities faster, more safely and efficiently than any other browser, period. Built with Tab browsing, pop-up blocking and a number of other seamless innovations, Firefox stands out ahead. Price = $0.

Epidemiologic Programming

R* (

R is an open source programming language for statistical computing and graphics – my favorite! Better programming language than S-Plus, Stata, SPSS, SAS. Price = $0. If you are new to R, check out my manual Applied Epidemiology Using R. Also check out epitools, our R package for epidemiology. Price = $0.

Read about R in the New York Times.

Screenshot of R

RStudio* (

RStudio is a free and open source integrated development environment (IDE) for R. You can run it on your desktop (Windows, Mac, or Linux). Install R first, then install RStudio. This is the dream IDE customized to running R. RStudio is for newbies and experts alike. You will not be disappointed. Price = $0.

Screenshot of RStudio

Text Editors

GNU Emacs (

GNU Emacs is an open source, extensible, and powerful text editor. Absolutely the best! My clear favorite for R programming, editing (text, HTML), and preparing technical documents using LaTeX. For Mac OS, I recommend the modified Emacs for Mac OS X with AUCTeX, Emacs Speaks Statistics (ESS), and much more. Also consider Aquamacs Emacs --- an easy-to-use, Mac-style Emacs for Mac OS X. For Windows OS, I recommend the Emacs/AUCTeX bundle; however, you will need to add ESS. For Ubuntu Linux, I prefer the Emacs meta package which is available from the package manager. Price = $0.

Here is a desktop screenshot of GNU Emacs running Emacs Speaks Statistics (ESS) and R (left), and an R plot (right).

GNU Emacs running on Ubuntu Linux

Portable Document Format (PDF) manipulation

pdftk --- The PDF Toolkit (

pdftk is a command line program to merge, delete, burst, rotate pages from PDF documents — and much more! Please do not purchase expensive PDF manipulation software! Price = $0.

Photo & Image Editors


GIMP is the GNU Image Manipulation Program. It is an open source program for such tasks as photo retouching, image composition, and image authoring similar to Adobe Photoshop. I use the GIMP primarily for cropping and rescaling images, converting images (e.g., TIFF to EPS, etc.), and creating images for the Web (e.g., PNG). This is the only image (including photos) editing software you will ever need. Price = $0.

Inkscape* (

Inkscape is an open source vector graphics editor, with capabilities similar to Adobe Illustrator, CorelDraw, or Xara X, using the W3C standard Scalable Vector Graphics (SVG) file format. Inkscape supports many advanced SVG features (markers, clones, alpha blending, etc.) and great care is taken in designing a streamlined interface. It is very easy to edit nodes, perform complex path operations, trace bitmaps and much more. Price = $0.

ImageMagick (

ImageMagick is an open source software suite to create, edit, and compose bitmap images. It can read, convert and write images in a variety of formats (over 100) including DPX, EXR, GIF, JPEG, JPEG-2000, PDF, PhotoCD, PNG, Postscript, SVG, and TIFF. Use ImageMagick to translate, flip, mirror, rotate, scale, shear and transform images, adjust image colors, apply various special effects, or draw text, lines, polygons, ellipses and Bézier curves. The functionality of ImageMagick is typically utilized from the command line. Price = $0.

Dia* (

Dia is an open source softward inspired by Windows ‘Visio,’ though more geared towards informal diagrams for casual use. It can be used to draw many different kinds of diagrams. It currently has special objects to help draw entity relationship diagrams, UML diagrams, flowcharts, network diagrams, and many other diagrams. It is also possible to add support for new shapes by writing simple XML files, using a subset of SVG to draw the shape. It can load and save diagrams to a custom XML format, can export diagrams to a number of formats, including EPS, SVG, XFIG, WMF and PNG, and can print diagrams. Dia and VUE are very similar — try both and see what works for you. Price = $0.
Screenshot of Dia Graphics on Ubuntu Linux


Freeplane* (

Freeplane is a multi-platform (Linux, Mac, Windows), free and open source software to support thinking, sharing information and getting things done at work, in school and at home. The core of the software consists of functions for mind mapping, also called concept mapping or information mapping, and tools for using mapped information. Freeplane runs on any operating system on which a current version of Java is installed and from USB. Freeplane can be used to prepared papers in LaTeX, and is the core of an academic literature suite call Docear ( Price = $0.

Screenshot of Freeplane

Professional Typesetting

LaTeX (

LaTeX is a high-quality typesetting system, with features designed for the production of technical and scientific documentation, especially that involving mathematical notation. LaTeX is the de facto standard for the communication and publication of scientific documents. For Ubuntu Linux, just install Texlive using the package manager. For Mac OS, I recommend the MacTeX Texlive distribution. For Windows OS, I recommend the MiKTeX distribution. Price = $0.

If you are new to LaTeX, see my tutorial LaTeX for Public Health and Medicine.


AUCTeX is an open source, extensible package for writing and formatting TeX files in GNU Emacs. It supports many different TeX macro packages. AUCTeX includes preview-latex which makes LaTeX a tightly integrated component of your editing workflow by visualizing selected source chunks (such as single formulas or graphics) directly as images in the source buffer. AUCTeX makes creating LaTeX documents easier, fun, and error-free. Price = $0.

Bibliography Management

JabRef (

JabRef is an open source bibliography reference manager. The native file format used by JabRef is BibTeX, the standard LaTeX bibliography format. JabRef runs on the Java VM, and should work equally well on Windows, Linux and Mac OS X. I use JabRef to search PubMed, and import and manage references. As a bibliography manager, JabRef is clearly superior to EndNote. If you don’t use LaTeX and/or BibTeX, you don’t need JabRef. Price = $0.

Screenshot of JabRef Bibliographic Reference Manager

Slide Presentations

LibreOffice Impress* (

Impress is a truly outstanding tool for creating effective multimedia presentations. Your presentations can be enhanced with 2D and 3D clip art, special effects and transition styles, animations, and high-impact drawing tools. Master pages simplify the task of preparing your materials. And you can save even more time by downloading templates from the LibreOffice template repository. You can also open Microsoft PowerPoint files, and save your work in PowerPoint format for people still locked into Microsoft products. Alternatively, you can use the built-in exporter to create Flash (.swf) versions of your presentations.

Beamer (

Beamer is a LaTeX class for creating presentations that are held using a projector, but it can also be used to create transparency slides. Preparing presentations with Beamer is different from preparing them with WYSWYG programs like LibreOffice’s Impress, Apple’s Keynote, or KOffice’s KPresenter. A Beamer presentation is created like any other LaTeX document: It has a preamble and a body, the body contains sections and subsections, the different slides (called frames in Beamer) are put in environments, they are structured using itemize and enumerate environments, and so on. The obvious disadvantage of this approach is that you have to know LaTeX in order to use Beamer. The advantage is that if you know LaTeX, you can use your knowledge of LaTeX also when creating a presentation, not only when writing papers. Here is a gallery of Beamer themes. Price = $0.

Thursday, April 14, 2016

Leading population health

This document contains my personal notes summarizing the concepts, frameworks, and tools that I rely on and promote for population health work. This is my strategic roadmap for self, team, and organization development. It is dynamic and evolving. I share this document so my staff and colleagues understand my thinking and acting; so they can teach me and support my professional development; and so they can hold me accountable to my values and principles. I hope others find this useful in their own development. I welcome critical feedback and questions.

The challenge of leading population health requires significant amounts of knowledge, skills, and abilities. It can be overwhelming! No one can master everything! Therefore, we must cultivate and practice relentless humility, curiosity, and courage. Humility is the most important! "Humility is the noble choice to forgo your status and use your influence for the good of others before yourself" (John Dickson). The more power or privilege we have, the more we must cultivate humility. Humility generates trust. Humility generates learning and continuous improvement. Humility generates servant leadership.

The Leading Population Health framework has four interdependent components:
  1. Transforming self and interpersonal relationships
  2. Transforming teams and collaboratives
  3. Transforming organizations and communities
  4. Improving performance with results-based lean
My underlying premise is that if we cannot optimally transform ourselves, our teams, and our organizations, then we will not be able to partner successfully to optimally transform communities. An "optimal" transformation is one that results in a team, organization, or community that is healthy, thriving, learning, healing, and resilient. Healthy includes the "Eight Dimensions of Wellness," thriving means high performing, learning means continuous improvement, healing means trauma-informed, and resilient means resistant to and rapid recovery from serious threats.

These high-level summary notes are mostly in outline form. The full updated version is posted here.

Figure 1 has graphical overview of material covered in document.

Figure 1: Leading Population Health Framework

Thursday, April 7, 2016

Welcome to Population Health Data Science! is now

I am moving from ( to or (note this second URL has .science extension instead of .com extension).

More than the health of a population, population health is a systems framework for studying and improving the health of populations through collective action and learning. By systems we mean complex, adaptive, socioecological systems. Data science is the art and science of transforming data into actionable knowledge.

I will be focusing on actionable knowledge from a leader-practitioner perspective.

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With gratitude,

Tomás Aragón