MODULE: COMMUNITY HEALTH III

UNIT: COMMUNITY ANALYSIS AND DIAGNOSIS

By
Carey Francis Okinda
September 2016

OUTLINE
S/NO Topic Duration (Hours)
1. Introduction to Community Diagnosis 2
2. Steps in Community Diagnosis – Exploration 2
3. Steps in Community Diagnosis – Cont... 2
TOTAL 6

Lesson 1: INTRODUCTION TO COMMUNITY DIAGNOSIS

Learning Outcomes

At the end of the lesson the learner will be able to: -

1) Define basic terms
2) Identify community health indicators
3) Determine key study variables
4) Determine key steps in community diagnosis

1.0 INTRODUCTION

 Community is a cluster of people with at least one common characteristic

(geographic location, occupation, ethnicity, housing condition) or a group of
people with a common characteristic or interest living together within a larger
society. Community diagnosis is one method of making medical education more

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 community oriented and making the students learn and appreciate intellectual
discovery and critical thinking.

 A community is a whole entity that functions because of the interdependence of

its parts or subsystems. Eight subsystems plus the community core are identified.
Community core includes history, socio-demographic characteristics, vital statistics,
and values/beliefs/religions. The eight subsystems include the physical
environment, education, safety and transportation, politics and government, health
and social services, communication, economics and recreation.

 Community Diagnosis (community or needs assessment) is the foundation for

improving and promoting the health of community members. The role of
community assessment is to identify factors that affect the health of a population
and determine the availability of resources within the community to adequately
address these factors

 Community assessment is the foundation for improving and promoting the health
of community members. The role of community assessment is to identify factors
that affect the health of a population and determine the availability of resources
within the community to adequately address these factors. Through collaborative
efforts forged among community leaders, public health agencies, businesses,
hospitals, private practitioners, and academic centres, the community can begin to
answer key questions such as (a) “What are our problems?” (b) “What factors
contribute to these problems?” and (c) “What resources are available in the
community to address these problems?”

 Medical education should become more community oriented if today’s medical

students are to become effective medical practitioners. Students should be
encouraged to learn by intellectual discovery and critical thinking. Learning to work
effectively with communities is an essential part of health education and training.

 Community diagnosis aims to understand many facets of community including: -

i) Culture
ii) Values and norms
iii) Leadership and power structure
iv) Means of communication
v) Helping patterns within community
vi) Important community institutions and
vii) History of the community

2.0 DEFINITIONS

1) Process of determining the pattern of health problems in a community including

factors that influence them

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2) “A means of examining aggregate and social statistics in addition to the knowledge
of the local situation, in order to determine the health needs of the community”

3) Process of evaluation the health and nutritional status of a community, determining

their health and nutritional needs and finding out the needs that are not being met.
This is a process of identifying community needs by assessment to establish their
current situation, the problems facing them and what needs to be done.

4) Process seeks to identify community health care problems by analyzing health

statistical data and community surveys

5) Identification and quantification of health problems in a community as a whole in

terms of mortality and morbidity rates and ratios, and identification of their
correlates for the purpose of defining those at risk or those in need of health care.

6) Comprehensive assessment of health status of the community in relation to its

social, physical and biological environment. The purpose of community diagnosis
is to define existing problems, determine available resources and set priorities for
planning, implementing and evaluating health action, by and for the community.

7) Identification and quantification of health problems in a community as a whole in

terms of mortality and morbidity rates and ratios, and identification of their
correlates for the purpose of defining those at risk or those in need of health care.

8) “A means of examining aggregate and social statistics in addition to the knowledge

of the local situation, in order to determine the health needs of the community”

9) Process of appraising the health status of a community, including assembly of vital

statistics and other health related statistics and of information pertaining to
determinants of health, and the examinations of the relationships of these
determinants to health in specified community (Last, 1995).

10) “A means of examining aggregate and social statistics in addition to the knowledge
of the local situation, in order to determine the health needs of the community”

3.0 HEALTH INDICATORS

 Community Diagnosis is done using a tool called "Health Indicators" which are the
variables used for the assessment of community health. Indicators must be valid,
reliable, sensitive, specific, feasible and relevant.
 Health indicators can be classified as:

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Table 1.1: Health Indicators
Indicators Examples
1. Mortality
2. Morbidity
3. Disability
4. Fertility
5. Nutritional
6. Health care delivery
7. Utilization
8. Social and mental health
9. Environmental
10. Socio-economic
11. Quality of Life

4.0 COMMUNITY ANALYSIS

 Community analysis is the process of examining data to define needs strengths,

barriers, opportunities, readiness, and resources.
 The product of analysis is the “community profile”.
 Analysis of assessment data is key to categorize the data and this may be done as
following: – demographic, environmental, socioeconomic, health resources and
services, health policies analysis and study of target groups

5.0 IMPORTANT VARIABLES IN COMMUNITY DIAGNOSIS

Table 1.2: Important Variables

Variable Examples
1. Ecological variables – Type of water source by distance, Practice of boiling
the environment water, Type of excreta disposal, Type of garbage
disposal, Type of drainage system
2. Social Population of the community – number, age, sex,
geographical distribution; Family details – size,
relationships, interval between children; Types of
family; Household size and household head
characteristics; Years of residence in community;
Place of origin; Place of last residence; Religion;
Educational attainment; Dwelling units –type of
housing material, house ownership lot ownership,
electricity, cooking facility; Community organization
structures; Cultural factors
3. Economic factors Number of Source of Income/occupation; Type of
Main occupation by gender; Type of other source of
income by gender; Family incomes -total monthly
income by main and other source, wages, industries,
cash crops; Income bracket; Food prices
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 Variable Examples
4. Political factors The political environment determines the policy
environment and the general levels of a country; It
influences government policies on resource
distribution, education (institutions, policies and
levels), population changes e.g. refugee influx; Political
factors also affect policies on agricultural sector and
hence food production; Macro-economic factors
(inflation rates, money-supplying and employment
levels) are dictated by the prevailing political
environment hence governance
5. Food security Availability, accessibility, stability and utilization

6.0 IMPORTANCE OF COMMUNITY DIAGNOSIS

1) It helps to find the common problems or diseases, which are troublesome to the
people and are easily preventable in the community
2) Community diagnosis can be a pioneer step for betterment of rural community
health.
3) It is a tool to disclose the hidden problems that are not visible to the community
people but are being affected by them.
4) It helps to access the group of underprivileged people who are unable to use the
available facilities due to poverty, prevailing discriminations or other reasons.
5) It helps to find the real problems of the community people which might not have
perceived by them as problems.
6) It helps to impart knowledge and attitudes to turnover people’s problems towards
the light of solution
7) Direct participation of residents in initiating change in the health services and
delivery system

7.0 STAGES IN COMMUNITY DIAGNOSIS

 There are four stages with eight steps

1) Initiation
a. Exploration
b. Planning the survey - Setting Objectives, development of tools, training of
interviewers
c. Pretesting Instruments
d. Sampling
2) Data Collection and Analysis
3) Diagnosis – Data Interpretation
4) Dissemination
a. Feedback/Communication
b. Action plan/intervention
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Lesson 2: INITIATION OF COMMUNITY DIAGNOSIS

Learning outcome

At the end of the lesson the learner will be able to discuss the main activities and
processes in the initiation stage of community diagnosis

1.0 INTRODUCTION

 The initiation stage involves exploration, planning the survey , pretesting

Instruments and sampling

2.0 EXPLORATION

Introduction
 Identify the community by gathering information through formal and informal
means including reading from available literature; talking to knowledgeable
people:
 Informal sources include market places, drinking bars, funerals, festive occasions
 Identify the leadership
 Request for a survey emanates either from the community or health providers.
 Involves interaction with community leaders and other key stakeholders such as
government representatives, NGOs, CBOs and other institutions within the
community with an interest in improving the health of the community.
 Protocol should be followed and the medical team send out
 Reactions of members of the community should be assessed
 The community’s opinions of the problem and what could be done about the
problems should be considered.
 Involves preliminary visits to the community and review meetings with all leaders
and at the same time collection of data on the community which could give an
insight on the current problems being faced.

Preparations Made Before Entry

 Form a reconnaissance team which is a team which spy.
 Read about the community (read annual report from the DHMT, District Assembly
or from our serious *or special report, disease durance report, newspapers health
journals)
 Collect informal information about the community (this is done through interview
with individuals, through focus groups discussion, through mapping, contact
opinion leaders, through house to house census)
 Transect walk and observation

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Community Entry
 Refers to the process of initiating, nurturing and sustaining a desirable relationship
with the purpose of securing and sustaining the community’s interest in all aspects
of a programme.
 Refers to the process, principles and techniques of community mobilisation and
participation. This involves recognizing the community its leadership and people
and adopting the most appropriate process in meeting, interacting and working
with them
 Various interest groups and personalities in the community who can serve as
contact persons are:
i) Prominent head of families.
ii) Heads of schools/teachers.
iii) Religious leaders/catechists
iv) District assembly members.
v) Unity committee members
vi) Youth leaders
vii) Women group leaders
viii) The water and sanitation committee
ix) Disease surveillance volunteers.
x) Traditional birth attendants. (TBA’s)
xi) Other health workers.

Community Gate Keepers

 A Gatekeeper is any community member who provides a service or has a trust

relationship with the community. Give examples of gate keepers.

Advantages of contact Persons

 Good organisers people respect their authority.
 Their presence helps people see the issues as important.
 Trust by their people.
 They are credible

Disadvantages
 Sometimes not respected-so people may not come to the meeting.
 Presence at meetings may discourage people from talking.

Challenges
 Some may have lost credibility.
 Some may embezzle funds.
 Some dominate meetings.
 Some may have conflict with chiefs.
 Some may be too bossy to help

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Steps
 Identify and contact key people and target significant constituencies for
involvement (e.g., youth, ethnic minorities, elderly, etc.).
 A loosely formed group begins to develop
 Group members
• begin preliminary definition of community
• identify and contact existing groups
• create/increase awareness and involve community

Skills and Attitude Needed

 Skills include - maintain good eye contact, active listening, paraphrasing, be

empathetic and communication skills
 Attitude required include patience, tolerance, respect for other people, good
listening attitude and humility

Entry Strategies

1) Responding to trigger events

2) Supporting the emergence of natural or charismatic leaders.
3) Involving political/powerful/formal leaders
4) Using media—public service announcements, specials on local news
5) Seeking the support and leadership of key organization or agencies
6) Using powerful language when appropriate as a marketing tool (“drug-free”)
7) Initiating other awareness activities (beginning the appeal to entire community)

Outcomes
 A core group of people commits to continue the process of comprehensive,
community-wide prevention (safety, access, opportunity).
 This group begins to:
o Identify its leaders
o Seek representation that reflects the entire community
o Seek community acknowledgement of the need for health promotion
o Identify issues of common concern

Support Required

 What support might help the group?

1) Technical Assistance:
 How to get started
 How to identify and engage critical individuals and groups
 How to identify and develop leaders

2) Materials:
 General information on prevention
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  General information on social change and community

3) Training:
 Activation
 Awareness-building
 Team-building
Identify important
Advantages community leadership
structures and leaders
 Objectives will be achieved
 Gain support
 It ensures the establishment of good working relationship
 It helps one to plan his / her work
 It helps to observe protocols

3.0 PLANNING THE SURVEY

 The process of setting goals, developing strategies, and outlining tasks and
schedules to accomplish the goals
 A critical face in the success of the survey the following should be addressed
i) Define aims and scope of study
a. Why a survey is needed
b. What are the needs and health problems to be investigated?
c. How will the information obtained be used?
d. Can the information be obtained in any other way?
e. What are the objectives – SMART/CLEAR
ii) Decide upon the information requirements
a. What information is required to deal with the community’s needs and
problems?
b. What information is needed for proposing a solution of for allocating
resources to health and community needs?
c. What do the local field officers/community health workers feel should be
included in the survey?
d. What does the community feel should be included in the survey?
e. Determine the keys variables (dependent, independent, intervening )
iii) Find out if the information needed is readily available
a. Have other surveys been carried out
b. Are there any books or publications dealing with similar issues in other
communities, at a regional or national level?
iv) Establish if the survey can succeed
a. Will the survey provide the information needed?
b. Are there sufficient resources?
v) Make decisions on sampling, data collection and implementation
vi) Estimate the cost and prepare a budget

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 Table 1.3: Variables
Data Category Variables
General Geography; Climate/temperature; Road condition/ How reached;
Description Households –number; Houses spatial arrangement; Source of
Livelihood; Means of transportation
Health Resources/ Facilities; Infrastructure/ Educational/ Sports
Facilities
Population Age; Sex; Civil status; Dependence ratio; Natural growth rate; Vital
indices
Social Number and Type of Family; Household size; Household Head
Characteristics; Years of residence in community; Place of Origin; Place
of Last Residence; Religion; Educational Attainment; Membership in
community organization x type x name; Dwelling Unit –type of housing
material, house ownership, lot ownership, electricity, cooking facility
Economic Number of Source of Income; Type of Main Occupation by gender;
Type of other source of income by gender; Total monthly income by
main and other source; Income bracket
Mean, median, mode
Environment Type of water source by distance; Practice of boiling water; excreta
disposal; garbage disposal; drainage system
Health status 1 year Mortality –Rates; Cause by Age by Sex; Households with Deaths;
6 months Morbidity –Prevalence Rates; Cause by Age by Sex;
Households with Sick; Nutritional Status 0 -71 months; Weight by Age
by Sex; Height by Age by Sex
 Instruments and tools – questionnaires, interview schedules, check lists and
observer sheets
o Prepare the tools

 Principles of constructing questionnaires

 Construct the instruments of data collection – questionnaire and/or interview
schedule
 Advantages and disadvantages of questionnaires and interview schedules

 How the process will be conducted – logistics such as transport, lunches, finances,
stationary

4.0 PRETESTING OF INSTRUMENTS

 Pre-testing of the measurement instruments and physical examination is necessary

 This helps to refine questions for accurate data collection and avoid
misinterpretation or omitting questions too sensitive
 A community similar to that studied should be selected

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 Pre-testing determines whether the questions are acceptable, “askable”,
“answerable’, analysable and applicable

 Recall the probability and non-probability sampling methods

 Pre-test the tool and make the necessary changes

5.0 SAMPLING FOR THE SURVEY

 Unless for specific surveys a general survey for all the residents should be
conducted
 A representative sample should be selected
 All bias should be minimized
 Too small a sample should be avoided as it may not be representative

1) How will you sample the respondents?

2) Outline the various sampling methods
3) What are the characteristics of an appropriate sample?

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Lesson 3: DATA ANALYSIS, DIAGNOSIS AND DISSEMINATION

At the end of the lesson the learner will be able to: -

1) Discuss data collection and analysis procedures in community diagnosis
2) Interpret data and make a community diagnosis
3) Disseminate the outcome of a community diagnosis

1.0 EXECUTION/FIELD WORK/DATA COLLECTION

 This is the data collection stage

 Depending on the survey it could be either individual or household based
 All questionnaires filled should be checked daily and laboratory specimens
analysed on time unless storage arrangements have been made
 Data will include qualitative data e.g. opinions from interviews with key informants
and quantitative data e.g. vital statistics
 Methods of data collection
 Sources of data in community diagnosis
1) Published sources
2) Records
3) Interviews
4) FDGs
5) Observations

 Recall the pre-field, field and post-field logistics in

Research methodology

2.0 DATA COLLECTION AND ANALYSIS

Type of Data
 Primary or secondary data
 For qualitative data simple descriptive statistics and inferential statistics can be
made upon analysis
 Quantitative data should be analysed and usually provides reasons why certain
phenomenon is evident
 Hypothesis can be tested and inferences made
 General community characteristics can be described in prevalence

Data Collection Tools

 Questionnaire
 Interviews schedule
 Checklist
 Video recording
 Tape recording
 Photography

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 Data Collection
 Explain the procedure for collecting data

Data Analysis
 Involves editing and coding of data
 Methods of data analysis
1) Descriptive statistics
o Measures of central tendency – mean, mode, median, fractiles (deciles,
percentiles, quartiles)
o Measures of dispersion – range, variance, standard deviation, interquartile
range, mean deviation
2) Inferential statistics – probability, correlation, hypothesis testing

Methods of data presentation

3.0 DIAGNOSIS – DATA INTERPRETATION
 Text, tables, graphs, diagrams, pictures and frequency distributions (tables, ogives,
histograms)
 Community diagnosis entails accurate interpretation of analysed data to make
sense of meaning of the indicators and statistics accrued

Table 2.1: Interpretation

Finding Interpretation
1. High PTB prevalence
2. Many cases of malaria
3. High maternal mortality rates
4. Poor Housing Conditions
5. Low BMI
6. Low MUAC
7. High birth rates
8. Low utilization of maternal health services
9. High prevalence of drug and substance abuse
10. High school dropout
11. High teenage pregnancies
(This is a group discussion task)

4.0 DISSEMINATION

4.1. Feedback/Presentation/Documentation

 Report writing
 A report should be given back to the community on the findings and their
implications to the community health status
 This should be done in an open forum where the community can be allowed to
give their opinions and the suggestions on what needs to be done

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 Confidential aspects of the individuals must be respected and feedback given in
population rates other than individual rates

What channels of communication will be appropriate?

How will you establish the channels in a certain
community?

4.2. Action Plan/Implementation of Interventions

 A plan of action which details the interventions selected to alleviate the problems
identified is outlined
 Priorities should be outlined then the health outcome that is of most importance
selected
 Health outcome refers to the effect of an intervention on the health and wellbeing
of an individual or population e.g. drop in blood pressure, increase in fibre intake
etc.
 Among the health needs of a community a decision should be made on the
intervention that is likely to produce the best health outcome
 The role of all stakeholders is spelt out as well as their contribution during the
implementation phase
 A monitoring and evaluation process must be incorporated during the
implementation to enable the community measure the outcomes or effectiveness
of their initiatives verses the health outcomes
 Re-evaluation, planning and assessment should be on-going
 Constant consultation with the community leaders is crucial for overall success of
the intervention

Table 2.2: Intervention (Action Plan)

Finding Intervention Responsibility
1. High PTB prevalence
2. Many cases of malaria
3. High maternal mortality rate
4. Poor Housing Conditions
5. Low BMI
6. Low MUAC
7. High birth rates
8. Low utilization of maternal health services
9. High prevalence of drug and substance abuse
10. High school dropout
11. High teenage pregnancies
(This is a group discussion task)

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