As described by the panelists, identification of stakeholders proceeds in one of two ways, depending on whether the stakeholders are involved in defining or responding to the problem. When stakeholders are involved in problem identification, it is best to cast a wide net, leading particular groups to self-identify as stakeholders and become active collaborators. The stakeholder group may evolve as the process moves from problem identification to intervention to evaluation. It was noted that in the public sector different agencies or different personnel within agencies may become involved depending on the stage of the program.
When a problem is already defined and an intervention is suggested by existing data (as in TAPII), the participation of key stakeholders able to produce the desired results can be actively sought. In Arizona, the process was facilitated by participation of the governor, who convened a meeting of identified stakeholders. Groups with divergent interests may be able to cooperate in implementing solutions to defined problems when data and interventions are available to focus their joint efforts.
Participation by "consumers," that is, members of the general public, was mentioned as an important stakeholder issue. Ideally, participants should reflect the various population groups in the community, based on factors such as age, race or ethnicity, and neighborhood. All members of coalitions are consumers in a sense, but most participants are invested in particular interests. Engaging those participants who are not affiliated with particular stakeholder groups can be difficult. Barriers include the difficulty in identifying interested individuals and the commitment in time and energy that is required. Other barriers to participation can include meetings scheduled for normal working hours or added costs such as transportation and child care. TAPII found that because consumers participated for only a short period of time focus groups and community surveys were helpful for bringing their perspectives into the process.
Epidemiologic data are often used to guide the selection of performance indicators, but community interest may argue for focusing attention on specific issues or indicators, even in the absence of supporting epidemiologic data. It was noted that in some cases, a "triggering event" may focus attention on a particular health issue. The trigger might be a severe adverse event such as a measles epidemic or a more positive stimulus such as the availability of funds and other resources earmarked for specific topics.
Social determinants of health (e.g., income, family structure) and epidemiology are sometimes viewed as separate issues because epidemiology traditionally is associated with the biomedical model. However, the scope of