ASSESSING COMMUNITY HEALTH NEEDS

THE COMMUNITY DIAGNOSIS

Caring for the community as client starts with determining its health status. We collect data about the community in order to identify the different factors that may directly or indirectly influence the health of the population. Then, we proceed to analyze the seek explanations for the occurrence of health needs and problems of the community. The community diagnoses are then derived and will become the bases for developing and implementing community health interventions and strategies. This process is called community diagnosis. Other call it community assessment or situational analysis.

The health stats of the community is a product of the various interacting elements such as ‘population, “the physical and topographical characteristics,” socio-economic and cultural factors”, health and basic social services and the power structure within the community. The interrelationship of these elements will explain the health and illness patterns in the community.

TYPES OF COMMUNITY DIAGNOSISA comprehensive community diagnosis aims to obtain a general information about the

community. The following are elements of a comprehensive community diagnosis:

A. Demographic VariablesThe analysis of the community’s demographic characteristics should show the

size, composition and geographical distribution of the population as indicated by the following:1. Total population and geographical distribution including urba-rural index and

population density2. Age and sex composition3. Selected vital indicators such as growth rate, crude birth rate, crude death rate and

life expectancy at birth4. Patterns of migration5. Population projections

It is also important to know whether there are population groups that need special attention such as indigenous people, internal refugees and other socially dislocated groups as a result of disasters, calamities and development programs

B. Socio-Economic and Cultural VariablesThere are no limits as to the list of socio-economic and cultural factors that may

directly or indirectly affect the health status of the community. However, we should consider the following as essential information. 1. Social indicators

a. Communication network (whether formal or information channels) necessary for disseminating health information or facilitating referral of clients to the health care system

b. Transportation system including road networks necessary for accessibility of the people to health care delivery system

c. Educational level which may be indicative of poverty and may reflect on health perception and utilization pattern of the community

d. Housing conditions which may suggest health hazards (congestion, fire, exposure to elements)

2. Economic indicatorsa. Poverty level incomeb. Unemployment and underemployment ratesc. Proportion of salaries and wage earners to total economically active

population d. Types of industry present in the communitye. Occupation common in the community

3. Environmental indicatorsa. Physical/geographical/topographical characteristics of the community

land areas that contribute to vector problems terrain characteristics that contribute to vector problems or pose as

geohazard zones climate/session

b. Water supply % population with access to safe, adequate water supply Source of water supply

c. Waste disposal % population served by daily garbage collection system % population with safe excreta disposal system types of waste disposal and garbage disposal system

d. Air, water and land pollution industries within the community having health hazards associated with it air and water pollution index

4. Cultural factorsa. Variables that may break up the people into groups within the community

such as: ethnicity social class language religion race political orientation

b. Cultural beliefs and practices that affect healthc. Concepts about health and illness

C. Health and Illness PatternsIn analyzing the health and illness patterns, we may collect primary data about

the leading causes of illness and deaths and their respective rates of occurrence. If we access to recent and reliable secondary data, then she can also make use of these.

1. Leading causes of mortality2. Leading causes of morbidity3. Leading causes of infant mortality4. Leading causes of maternal mortality5. Leading causes of hospital admission

D. Health ResourcesThe health resources that are available in the community is an important

element of the community diagnosis mainly because they are the essential ingredients in the delivery of basic health services. We needs to determine manpower, institutional and material resources provided not only by the state but those which are contributed by the private sector and other non-government organizations.

1. Manpower resources categories of health manpower available geographical distribution manpower population ratio distribution of health manpower according to health facilities (hospitals, rural

health units, etc) distribution of health manpower according to type of organization (government,

non-government, health units, private) quality of health manpower existing manpower development/policies

2. Material resources health budget and expenditures sources of health funding categories of health institutions available in the community hospital bed-population ratio categories of health services available

E. Political/Leadership Patterns

The political and leadership pattern is a vital element in achieving the goal of high level wellness among the people. It reflects the action potential of the state and its people to address the health needs and problems of the community. It also mirrors the sensitivity of the government to the people’s struggle for better lives.

In assessing the community, we describe the following:1. Power structures in the community (formal or informal)2. Attitudes of the people toward authority3. Conditions/events/issues that cause social conflict/ upheavals or that lead to social

bonding or unification4. Practices/approaches that are effective in setting issues and concerns within the

community.

Problem-Oriented Community Diagnosis Spradley (1990) describes the problem-oriented community diagnosis as the type of

assessment that responds to a particular need. For example, a doctor is confronted with health and medical problems resulting from mine tailings being disposed into the river systems by a mining company. Since a community diagnosis investigates the community-meaning, the people and its environment, the doctor proceeds with the identification of the population who were affected by the hazards posed by mine tailings. Then she goes on to characterize the environmental factors along with the other elements which are relevant to the specific problem being investigated.

Community Diagnosis: The Process

The process of community diagnosis consists of collecting, organizing, synthesizing, analyzing and interpreting health data. Before she collect the data, the objective must be determined by as we will dictate the depth or the scope of the community diagnosis. We needs to resolved whether a comprehensive or a problem-oriented community diagnosis will accomplish the objectives.

Steps in Conducting Community Diagnosis

In order to generate a broad range of useful data, the community diagnosis must be carried out in an organized and systematic manner keeping in mind that the community should take an active part in indentifying community needs and problems.

1. Determining the Objective

In determining the objectives of the community diagnosis, we decide on the depth and scope of the data we need to gather. But whether we undertake a comprehensive or a problem-oriented community diagnosis, Dever (1980) explains that we must determine the occurrence and distribution of selected environmental, socio-economic and behavior conditions important to disease control and wellness promotion.

2. Defining the Study PopulationBased on the objectives of the community diagnosis, we identify the population

group to be included in the study. It may include the entire population in the community or focused on a specific population group such as women in the reproductive age-group or the infants and young children. There are situations, however, when a complete enumeration of the desired population is not possible. We then, may collect data from a subset of the population.

3. Determining the Data to be Collected

Whether the community diagnosis is going to be comprehensive or focused on a specific problem, the objectives we will guide in identifying the specific data we will collect. We decide on the sources of these data. Are these data available from records of agencies? Or from people themselves?

4. Collecting the Data

In according community diagnosis, different methods may be utilized to generate health data. We decide on the specific methods depending on the type of data to be generated. For example, through an ocular survey we are able to determine, the physical and topographical characteristics of the community. We may also interview people about their health beliefs or she can review existing health records in the Rural Health Unit. In general, we use the following methods to collect data:

a. Records review – data may be obtained by reviewing those that have been complied by health or non-health agencies from the government or other sources.

b. Surveys and observations – can be used to obtain both qualitative and quantitative data

c. Interviews – can yield first hand informationd. Participant observation – is used to obtain qualitative data by allowing us to

actively participate in the life of the community.

5. Developing the Instrument Instruments or tools facilitate us in data-gathering activities. The following are

the most common instruments that we use in the data collection.a. Survey questionnaireb. Interview guidec. Observation checklist

6. Actual Data Gathering Before the actual data gather, it is suggested that we meet the people who will be

involved in the data collection. The instruments are discussed and analyzed. If necessary, the instruments may be modified or simplified in order not to overburden

the people who may have limitations in terms of educational preparation or available time to finish data collection. Pre-testing of the instruments is highly recommended.

During the actual data gathering, we supervises the data collectors by checking the filled-up instruments in terms of completeness, accuracy and reliability of the information collected.

7. Data CollectionAfter data collection, we are now ready to put together all the information.

There are two types of data that may be generated. They are either numerical data which can be counted or descriptive data which an be described.

To facilitate data collation, we must develop categories for classification of responses making sure that the categories are mutually exclusive and exhaustive.

Mutually exclusive choices do not overlap, For example.

Exhaustive categories mean that we anticipate all possible answers that a respondent may give. For example:

To classify sex:MALEFEMALE

To classify monthly income:Below Ps 500Ps 501 – Ps 1000Ps 1000 – Ps 1500Ps 1501 – Ps 2000

Family planning methods:Lactational Amenorrhea MethodNatural

Basal body temperatureCervical Mucus MethodSymptothermal Method

Standard Days MethodOthers (specify):

Artificial IUD PillsInjectables CondomOthers (specify):

PermanentTubal ligation Vasectomy

In collating fixed response questions, choices must be provided which will serve as categories for the respondent’s answer.

For example:

Exhaustive categories mean that they anticipate all possible answers that a respondent may give. For example:

The next step after categorizing the responses will be to summarize the data. One can do it manually by tallying the data or by using the computer. Tallying involves entering the responses into prepared tally sheets showing all possible responses. For example:

Question: Bakit hindi kayo nagpapasuso ng iyong sanggol?

Response 10: Bawal sa akin, sabi ng doctorResponse 27: nagtatrabaho akoResponse 30: Ayaw ni MisterResponse 45: MasakitResponse 59: Masisira ang figure koResponse 60: Medical reasonsResponse 62: May sakit akoResponse 67: Modern at convenient ang bottle feeding Response 75: Pagod na ako pagkagaling sa trabahoResponse 77: Mas gusto ko ang magpasusu sa bote

For these responses, possible categories are:Convenience – Responses 67, 77Medical reasons – Responses 10, 60, 62Personal reasons – Responses 30, 45, 59Economic/work reasons – Responses 27, 75

Diseases Tally Mark Frequency

Parasitism /////-/////-/////-/////- 20Diarrhea /////-/////-/////-// 17Cough /////-/////-/////-/////- /////-/////-/// 33

When computers are going to be used in summarizing results, the responses are given numbers or codes. For example:

Sex MaleFemale

12

Religion CatholicINKMethodistAglipayano

1233

8. Data PresentationData presentation will depend largely on the type of data obtained. Descriptive data

are presented in narrative reports. Examples of data appropriate for descriptive presentation are geographic data, history of a place or beliefs regarding illness and death.

Numerical data may be presented into table or graphs. Tables or graphs are useful in showing key information making it easier to show comparisons including patterns and trends. The choice of graphs will depend on the type of data being presented.

TYPE OF GRAPH DATA FUNCTION Line graph

Bar graph/pictograph

Histogram/frequency polygon

Proportional or component bar graph/ pie chart

Scattered diagram

Shows trend data or charges with time or age with respect to some other variables

For comparisons of absolute or relative counts and rates between categories

Graphic presentation of frequency distribution or measurement

Shows breakdown of a group or total where the number of categories is not too many

Correlation data for two variables

9. Data AnalysisData analysis in community diagnosis aims to establish trends and patterns in terms of

health needs and problems of the community. It also allows for comparison of obtained data with standard values. Determining the interrelationship of factors will help us view the significance of the problems and their implications on the health status of the community.

10. Identifying the Community Health Nursing Problems

Community health problems are categorized as:

a. Health status problems – They may be described in terms of increase or decrease morbidity, mortality, fertility or reduced capability for wellness.

b. Health resources problems – They may be described in terms of lack of or absence of manpower, money, materials or institutions necessary to solve health problems.

c. Health-related problems – They may be described in terms of existence of social, economic, environmental and political factors that aggravate the illness-including situations in the community.

11. Priority-setting After the problems have been identified, the next task for us and the community is to

prioritize which health problems can be attended to considering the resources available at the moment.

In priority-setting, we makes use of the following criteria:

a. Nature of the condition/problem presented – The problems are classified by the health worker as health status, health resources or health-related problems:

b. Magnitude of the problem – This refers to the severity of the problem which can be measured in terms of the proportion of the population affected by the problem;

c. Modifiability of the problem – This refers to the probability of reducing, controlling or eradicating the problem;

d. Preventive potential – This refers to the probability of controlling or reducing the effects posed by the problem;

e. Social Concern – This refers to the perception of the population or the community as they are affected by the problem and their readiness to act on the problem.

Below is the scoring system utilized as we are deciding which of the problems need to be prioritized:

Criteria Weight Nature of the problem Health status Health resources Health-related

321

1

Magnitude of the problem 75% - 100% affected 50% - 74% affected 25% - 49% affected <25% - affected

4321

3

Criteria Weight Modifiability of the problem High Moderate Low Not modifiable

3210

4

Preventive potential High Moderate Low

321

1

Social Concern urgent community concern; expressed readiness recognized as a problem but not needing urgent attention not a community concern

2

20

1

Each problem will be scored according to each criterion and divided by the highest possible score multiplied by the weight. Then the final score for each criterion will be added to give the total score for the problem. The problem with the highest total score is given high priority by us.

APPLICATION OF PUBLIC HEALTH TOOLS IN THE COMMUNITY HEALTH

Aside from the biophysical and social sciences, community health also synthesis in its practice the concepts, knowledge and skills derived from public health. Tools in measuring and analyzing community health problems such as epidemiology and biostatistics were borrowed to form part of our assessment tools in the diagnosis of community health problems.

The health disciplines of demography, vital statistics and epidemiology are three important tools that help us in identifying the community’s health needs.

Demography

More than just being aware of how large a population is in a community, we need to comprehend the characteristics of the population that makes the people vulnerable to certain health conditions. We can determine the nature and magnitude of existing and potential community health problems if she possesses knowledge about the population’s size, composition and distribution in space. Demography, the science of population helps to find reasons or rationale why or how a particular population or group is influenced by a variety of factors resulting in vulnerability to diseases.

Demography is the science which deals with the study of the human population’s size, composition and distribution in space. Population size simply refers to the number of people in

a given place of area at a given time. When the population is characterized in relation to certain variables such as age, sex, occupation or educational level, then the population composition is being described. We also describe how people are distributed in a specific geographic location.

The three events described above are affected depending on how fast or how slow people are added to the population as a result of births, deaths and migration occurring in the community.

Sources of Demographic Data

Demographic information can be obtained from a variety of sources but the most common come from censuses, sample surveys and registration systems.

Census is defined as an official and periodic enumeration of population. During census, demographic, economic and social data are collected from a specific population group. These data are later collated, synthesized and made known to the public for the purpose of determining and explaining trends in terms of population changes and planning programs and services.

There are two ways of assigning people when the census is being taken. The de jure method is done when people are assigned to the place wherein they usually live regardless of where they are at the time of the census. On the other hand, when the de facto method is used, the people are assigned to the place where they are physically present at the time of the census regardless of their usual place of residence.

Registration systems such as collected by the civil registrar’s office deal with recording of vital events in the community. Vital events refer to births, deaths, marriages, divorces and the like. Other registration systems can also be used to describe specific characteristics of the population.

Population Size

We determining the population size not because we simply want to know how large or small the population is. Knowing the population size of a place allows us to make comparisons about population changes over time. It also helps us rationalize the types of health programs or interventions which are going to be provided for the community.

One method of measuring the population size is by determining the increase in the population resulting from excess of births compared to deaths. This can be done in two ways:

1. Natural increase is simply the different between the number of births and the number of deaths occurring in a population in a specified period of time.

2. Rate of Natural Increase is the difference between the Crude Birth Rate and the Crude Death Rate occurring in a population in a specified period of time.

The second method of measuring population size is to determine the increase in the population using data obtained during two census periods. This implies that the increase in the size of the population is not merely attributed to excess in births but also the effect of migration. These are:

1. Absolute Increase per year measures the number of people that are added to the population per year. This is computed using the following formula:

2. Relative Increase is the actual difference between the two census counts expressed in percent relative to the population size made during and earlier census.

Natural increase = Number of births – Number of deaths (specified year) (specified year) (specified year)

Rate of Natural Increase = Crude Birth Rate – Crude Death Rate (specified year) (specified year) (specified year)

Absolute increase per year = P1−Pot

Where:P1 = population size at a later timeP0 = population size at an earlier timet = number of years between time 0 and time t

Relative Increase = P1−P0P0

Where:P1 = population size at a later timeP0 = population size at an earlier time

Population Composition

The composition of the population is commonly described in terms of its age and sex. We utilizes data on age and sex composition to decide who among the population groups merits attention in terms of health services and programs.

1. Sex Composition

To describe the sex composition or the population, we computers for the sex ratio. The sex ration compares the number of males to the number of females in the population using the formula below.

The sex ratio represents the number of males for every 100 females in the population.

2. Age compositionThere are two ways to describe the age composition of the population

a. Median age divides the population into two equal parts. So, if the median age is said to be 19 years old, it means half of the population belongs to 19 years and above, while the other half belongs to ages below 19 years old.

b. Dependency Ratio compares the number of economically dependent with the economically productive group in the population. The economically dependent are those who belong to the 0 – 14 and 65 and above age groups. Considered to be economically productive to be economically productive are those w within the 15 to 64 are group. The dependency ration represents the number of economically dependent for every 100 economically productive.

3. Age and Sex Composition

The age and sex composition of the population can be described at the same time using a population pyramid. It is a graphical presentation of the age and sex composition of the population.

Population Distribution

The distribution of the population in space can be described in terms of urban-rural distribution, population density and crowding index. The measures help the nurse decide how

Sex Ration = numberof malesnumberof females

x 100

meager resources can be justifiable allocated based on concentration of population in a certain place.

1. Urban-rural distribution simply illustrates the proportion of the people living in rural compared to the rural areas.

2. Crowding index will describe the ease by which a communicable disease will be transmitted from one host to another susceptible host. This is described by dividing the number of persons in a household with the number of rooms used by the family for sleeping

3. Population density will determine how congested a place is and has implications in term of the adequacy of basic health services present in the community. It can be computed by dividing the number of people living in a given land area.

VITAL STATISTICS

Vital statistics is much appreciated as a tool in estimating the extend or magnitude of health needs and problems in the community. Through vital statistical indicators, we are able to describe the health status of the people which serves as the basis for developing, implementing and evaluating programs and intervention strategies.

The table below summarizes the various vital statistical indicators the we will find useful as she assesses the health status of the community.

Common Vital Statistical Indicators

FERTILITY RATES

Crude Birth Rate = numberof live birthsmidyear population

x 100

General Fertility Rate = number of livebirthsmidyear population of

women,15−44 years of age x 100

MORTALITY RATES

Crude Death Rate = number of deathsmidyear population

x 100

Specific Mortality Rate =

number of deaths∈aspecified group

midyear population of thesamespecified group

x 100

Cause of Death Rate = number of deaths

¿a¿ specified cause ¿ ¿

midyear population x 100

Infant Mortality Rate = deathunder one year of agenumberof livebirths

x 100

Maternal Mortality Rate = number of deaths due

¿pregnancy ¿delivery∧puerpuerium¿ ¿

number of live births x 100

Proportionate Mortality Rate = number of deaths

¿a¿ particular cause ¿ ¿

total deaths x 100

Swaroop’s Indez = numberof deaths amongthose

50 years∧¿total deaths

x 100

Case Fatality Rate =

number of deaths¿ specified causenumber of casesof the samedisease

x 100

MORBIDITY RATES

Incidence Rate = number of newcases of disease

developing¿

a period of time ¿p opulationrisk of developing teh disease

x F

Prevalence Rate = numberof old∧new cases of adisease

populationexamined x F

Source: Mendoza, OM and others. (1997) Foundations of Statistical Analysis for the Health Sciences (Volume I). Manila: Department of Epidemiology and Biostatitics, College of Public Health, UP Manila

Epidemiology

Epidemiology is defined as the study of the occurrence and distribution of health conditions such as disease, death, deformities or disabilities on human populations. It is also concerned with the study of probable factors that the development of these health conditions.

We measure the frequency and distribution of health conditions using vital statistical indices. Epidemiology, however is used to analyze the different factors that contribute to disease development. We identify the factors related to time, place and person characteristics in order to explain how the disease developed in the community. Understanding disease causation helps us plan and develop strategies to prevent and control spread of disease especially for high risk groups.

Epidemiology rests on two important concepts: the Multiple Causation Theory and the Levels of Prevention of Health Problems.

The Multiple Causation Theory

Disease development does not rest on a single cause. Health conditions result from a multitude of factors.

There are three models that explain the multiple causation theory – the wheel, the web and the ecologic triad. Of the three, the ecologic triad is most helpful because it highlights not only the host’s and agents roles in disease development but also regards the role of the environment as important in disease causation.

An agent of a disease is any element, substance or force, either animate or inanimate, the presence or absence of which may serve as stimulus to initiate or perpetuate a disease process. This happens only when the agent comes in contact with a susceptible host and under proper environmental conditions.

Agent Example BiologicalChemicalPhysicalMechanicalNutritive

Virus, bacteria, fungus, parasitelead, mercury, insecticidehumidity, atmospheric pressure, radiationstab, traumairon or iodine deficiency, cholesterol

A host is any organism that harbors and provides nourishment for another organism. The characteristics of the host will affect his or its risk of exposure to sources of infection and his or its susceptibility or resistance. The resistance of the host may be specific or non-specific. Specific resistance results from an immunologic experience such as undergoing immunization or vaccination. Nonspecific resistance results from an intack skin, mucous membrane, reflexes

as lacrimatin, coughing, diarrhea, or vomiting. They can be maintained though personal hygienic practices, environmental sanitation, proper nutrition and a healthy lifestyle.

The environment is the sum total of all external conditions and influences that affect the life and development of an organism. The environment both affects the agent and the host. There are three components of the environment:

1. Physical environment is composed of the inanimate surroundings such as the geophysical conditions or the climate;

2. Biological environment makes up the living things around us such as plant and animal life;

3. Socio-economic environment which may be in the form of level of economic development of the community, presence of social disruptions and the like.

The three elements of the ecologic triad interact with one another in an attempt to maintain an equilibrium. Any major change in any one of the factors may bring about a disturbance in the equilibrium provoking the appearance of a health problem.

Levels of Prevention of Health Problems

Primary PreventionPrimary prevention is directed to the healthy population, focusing on prevention of

emergence of risk factors (primordial prevention) and removal of the risk factors or reduction of their levels (specific protection).

Specific measures include provision of immunization and prohylaxis to vulnerable or at-risk groups (e.g. chemoprophylaxis for travelers to malaria endemic areas).

Secondary PreventionSecondary prevention aims to identify and treat existing health problems at the earliest

possible time.

Tertiary PreventionTertiary prevention limits disability progression.