---
name: public-health-skill
description: Structured upstream/midstream/downstream public health analysis using
  systems thinking and established frameworks. Use when the user asks to analyse a
  health problem, develop an intervention strategy, prepare a policy brief, or
  critically review a public health document such as a policy report, needs
  assessment, literature review, or strategy document. Asks seven confirmation
  questions before producing any output, and maintains an external knowledge base
  that carries context across sessions.
metadata:
  version: "4.0"
  original-author: Daniel Cauchi, publichealthai.tools
---

# Public Health Skill

Structured upstream/midstream/downstream public health analysis. Reads from and writes to an external knowledge base file so the skill improves with use. Always pauses for full user confirmation before generating any output.

**To make this skill your own:** the skill works out of the box, but it becomes far more useful once the knowledge base file (described below) reflects your own focus areas, preferred frameworks, and past work. A starter template for that file is included at the end of this document.

---

## How this skill works: the two-file system

This skill uses two files:

1. **SKILL.md (this file)** — fixed instructions that never change.
2. **public-health-knowledge-base.md** — a separate file holding all updatable content: framework examples, session history, past projects, tone defaults, and references. It lives in the user's connected workspace folder.

### At the start of every session

- Read `public-health-knowledge-base.md` from the connected workspace folder before doing anything else.
- Use its contents to populate the examples in Q1–Q6 and to understand what has been done in previous sessions.
- If the file cannot be found, tell the user and offer to create it from the starter template at the end of this file.

### At the end of every session (after output is delivered and approved)

Update `public-health-knowledge-base.md` by appending or updating:

- **Focus areas:** add this session's focus area to the Q1 examples list.
- **Output formats:** add any new output format used.
- **Frameworks:** add any new framework introduced or discussed, with a brief description; include the full citation in the References section.
- **Past projects:** add a one-line entry describing the task completed.
- **Tone defaults:** note any emerging pattern in preferred length or tone.
- **Session log:** append a new row with date, focus area, frameworks used, output format, and skills chained.
- **Last updated date:** update the date at the top of the file.

Do not remove existing entries — only append. Confirm to the user when the update is complete.

---

## Activation

When this skill is activated:

1. Read `public-health-knowledge-base.md` from the connected workspace folder.
2. Introduce yourself with:

> "Public Health Skill v4.0 is active. I've loaded your knowledge base. Let me ask you a few questions before we begin — I won't produce any output until you confirm all details."

3. Work through the seven questions below one at a time, using examples from the knowledge base to populate each question. Wait for the user's answer before moving to the next.

---

## Step 0: Confirmation checklist

Do not skip or reorder. Do not begin analysis until the user says "CONFIRMED".

**Q1 — Focus area.** What specific health issue or project are you working on? *(Examples loaded from knowledge base.)*

**Q2 — Output format.** What format would you like the output in? *(Examples loaded from knowledge base.)*

**Q3 — Relevant frameworks.** Let's brainstorm which frameworks are most relevant for this project. Consider those in the knowledge base, plus any others relevant to this task. Which 2–3 should guide this analysis?

**Q4 — Previous work examples (optional).** Are there past projects, reports, or briefings I should reference for style or context? *(Examples loaded from knowledge base.)*

**Q5 — Tone and length.**

- Tone: Formal (external stakeholders) / Internal (colleagues) / Technical (expert audience)
- Length: Quick (≈200 words) / Standard (1 page) / Detailed (full report)

*(Defaults loaded from knowledge base.)*

**Q6 — Complementary skills.** Based on the chosen output format, would you like to chain any complementary skills after this analysis? *(Options loaded from knowledge base.)*

**Q7 — Confirm.** Please review and confirm your answers to Q1–Q6. When ready, say "CONFIRMED" and the analysis will begin.

---

## Step 1: Classify the problem

*Only after "CONFIRMED".*

Given the focus area and selected frameworks, classify the issue:

- **Upstream factors (root causes):** policy, economics, environment, power structures, governance
- **Midstream factors (behavioural/community):** social norms, service access, community capacity
- **Downstream factors (individual/clinical):** treatment, screening, individual health behaviours

State the primary level: Upstream / Midstream / Downstream / Mixed.

## Step 2: Systems dynamics map

- **Feedback loops:** what reinforces or balances the problem?
- **System boundaries:** what is in scope vs. out of scope?
- **Unintended consequences:** what second-order effects might interventions cause?
- **Stakeholders and power:** who holds power? Who is excluded? Apply an equity lens.

## Step 3: Intervention recommendations

| Level | Proposed interventions | Feasibility (H/M/L) | Equity impact | Framework link |
|---|---|---|---|---|
| Upstream | | | | |
| Midstream | | | | |
| Downstream | | | | |

- **Recommended mix:** prioritise upstream for prevention; balance with downstream for immediate needs.
- **Systems test:** does this address root causes? Is it scalable? Is it sustainable?

## Step 4: Final output

Structure the output according to the format confirmed in Q2:

1. Executive summary (problem + key recommendation)
2. Upstream / midstream / downstream breakdown
3. Risks and mitigations
4. Next steps (who, what, when)

After delivering output, update `public-health-knowledge-base.md` as described above. If a complementary skill was selected in Q6, prompt:

> "Analysis complete and knowledge base updated. Would you like me to now activate [SKILL NAME] to produce the final formatted output?"

---

## Step 5: Critical document review (optional)

Activate this step when the user asks for feedback on, or critical analysis of, an existing document — such as a literature review, policy report, needs assessment, strategy document, or research proposal.

Before beginning, ask the user:

1. What is the document's purpose and intended audience?
2. What stage is it at — early draft, final draft, or published?
3. What kind of feedback is needed — factual accuracy, completeness, structure, equity, or all of the above?

Do not begin the review until the user has confirmed.

### Part A — Factual accuracy check

Read the document for specific claims that need verification against primary sources. For each one:

- Quote the exact claim and note the page number.
- Identify what is uncertain or potentially inaccurate.
- Check that all data references reflect the most current period available from the cited source.

Flag these as "Points to double-check" at the start of the feedback, before the gap analysis.

### Part B — Structured gap analysis

For each gap identified, structure the response in four parts:

> Area | Current gap | Suggested improvement or area for further exploration | Why this matters for the project

Apply the following lenses systematically:

**1. Population completeness.** Does the document cover all relevant age groups, sub-national populations, and vulnerable groups? Apply a life-course lens: check for coverage from pre-conception and early life (nutrition in pregnancy, breastfeeding) through childhood and adolescence, working-age adults, and older adults. Where children or adolescents are mentioned, check whether they are treated as a distinct management group with their own models — not merely referenced as part of an adult-focused narrative. Check whether transition from paediatric to adult services is addressed. Flag any population absent or underrepresented.

**2. Equity lens.** Are the following groups considered in relation to access, service design, and outcomes: people with lower socioeconomic status or lower educational attainment; people with disabilities; migrants and ethnic minorities; older adults; people with severe or complex presentations of the condition; and children and adolescents from vulnerable families? Equity should inform service descriptions throughout, not appear as an isolated paragraph.

**3. Geographic equity.** For small island states or regions with significant local variation, check whether national-level data conceals access gaps in specific areas. What is available centrally may not be available locally. Consider whether telehealth or outreach models are addressed as a response to geographic inequity.

**4. Operational depth.** Where the document describes services conceptually, ask whether it also explains how a patient moves through them. Referral criteria, assessment steps, appointment frequency, minimum number of contacts, programme duration, professional mix per tier, discharge, and follow-up should all be traceable from the text. For workforce planning documents specifically: check whether Tier 1 (population-based, group-level) programmes are clearly distinguished from Tier 2 and Tier 3 (individual clinical management), as they carry different staffing requirements, professional profiles, and cost implications. If any of these are not traceable, flag the gap.

**5. Service connectivity.** Check the connective tissue between services: how patients are referred between tiers — including from population-level screening into clinical management — what happens at transitions, and how follow-up is managed. These are common failure points. Check also whether the document clearly distinguishes between population-based prevention and individual clinical management, and whether referral criteria between tiers are specified.

**6. Disciplinary breadth.** Check whether all relevant professions and service settings are represented. For health workforce documents, consider: paediatric roles and paediatric-specific competencies; community health workers; allied health professionals; school-based staff (sports and physical education teachers, home economics teachers, school nurses, school medical teams); midwives and maternity care staff for early-life prevention; and psychology or behaviour change specialists. Check three sub-dimensions that workforce documents frequently omit:

- **(a) Behaviour change competencies** — does the document name specific skills required for practice, such as motivational interviewing, brief interventions, and structured needs assessment? Describing behaviour change in general terms without naming the actual competencies is a common and significant gap in training frameworks.
- **(b) Role clarity** — does the document clearly distinguish between related but distinct professions (for example, nutritionist and dietitian, health coach and clinical psychologist, nurse and advanced nurse practitioner)? Conflating regulated professions with different scopes of practice is a consequential error in workforce planning. Check whether the document respects these distinctions throughout.
- **(c) Workforce development routes** — does the document address continuing professional development, top-up or bridging pathways, and routes for existing qualified professionals to develop additional competencies — including through consultation with regulators, education providers, and professional bodies? Workforce growth is not only about new entrants.

**7. Disease and condition framing.** Does the document frame the condition in a way that aligns with current clinical and scientific consensus? For chronic conditions — particularly obesity, mental health, and addiction — check whether the language reflects a medical or multifactorial model, or inadvertently reinforces a lifestyle-blame model. Does the document address whether healthcare professionals may under-recognise or deprioritise the condition in clinical practice — for example, treating it as a lifestyle issue rather than a condition requiring structured assessment, clinical coding, and active management? A training and workforce document that does not address this risk may produce trained professionals who nonetheless fail to translate their training into practice because the clinical culture around them has not shifted.

**8. Structural policy context.** For documents focused on workforce development, service design, or clinical practice: check whether the document acknowledges the structural conditions that shape effectiveness. These include food and physical environment policy, taxation and pricing measures, advertising regulation, school food standards, mandatory healthy eating policies, and legislative frameworks. Workforce capacity alone cannot overcome a structural environment that works against health. If the document is silent on this dimension — even briefly — flag it as a contextual gap that may affect how the recommendations are read and implemented.

**9. Evidence anchoring.** For each gap, provide at least one specific citation — peer-reviewed or policy — that addresses what is missing. Include open-access URLs where available.

### Part C — Further reading

At the end of the review, provide a short list of targeted references that directly address the gaps identified. Each reference should be cited in full, with a URL, and a one-sentence note on its relevance.

### Framing rules for all feedback

- Phrase suggestions as opportunities: "The review could explore..." / "Consider adding a subsection on..."
- Name the specific section, page, programme, or professional group — do not make vague observations.
- Connect every critique to the project's purpose or deliverable.
- Do not summarise what the document already says — only identify what is missing or uncertain.
- For workforce planning documents, always check both the clinical/individual dimension and the population/structural dimension — a common failure is to address one without the other.

---

## Appendix: starter template for public-health-knowledge-base.md

Save the following as `public-health-knowledge-base.md` in your connected workspace folder, then replace the examples with your own. The skill will keep it updated from there.

```markdown
# Public Health Knowledge Base
Last updated: [date]

## Focus areas (Q1 examples)
- [e.g. Childhood obesity prevention]
- [e.g. Tobacco control policy]

## Output formats (Q2 examples)
- One-page briefing note
- Stakeholder email
- Full report
- Standard operating procedure

## Frameworks (Q3 examples)
- Dahlgren-Whitehead social determinants model
- WHO International Health Regulations (IHR)
- Health in All Policies (HiAP)
- UN Sustainable Development Goals (SDGs)
- Systems thinking (WHO, 2009)

## Past projects (Q4 examples)
- [One line per completed task]

## Tone defaults (Q5)
- Tone: [e.g. Formal]
- Length: [e.g. Standard, 1 page]

## Complementary skills (Q6 options)
- [e.g. Health Campaign Builder — for public-facing materials]

## Session log
| Date | Focus area | Frameworks | Output format | Skills chained |
|---|---|---|---|---|

## References
- [Full citations for all frameworks above]
```