The preparatory phase
Community (and institutional) preparation If the diagnosis is to have a truly community orient-ation, health professionals must involve both the community and professionals of other disciplines concerned from the preparatory phase onwards. It is essential to avoid facing the community and its repre-sentatives with afait accompli, and asking them to 'parti-cipate' in a project which has already been planned without them.
Cooperation can be ensured from the start through a working group3 or a coordinating body to bring together health professionals and members of the community. It will be for the working group to decide on the successive steps; define the objectives of the community diagnosis; determine how it is to be carried out and the methods to be used; mobilize the necessary resources; evaluate the results, and make the pre-liminary contacts required. In practice, however, it will often be necessary for a more limited group to start the process and extend it as and when the first contacts are made, at the same time ensuring that a satisfactory balance is maintained between professionals and repre-sentatives of the different groups in the community.
Technical preparation This consists of:
• Briefing, and if necessary trammg, the people directly involved in the diagnosis, particularly the members of the working group (professionals and non-professionals). This training must of course deal with methodology, but it must also prepare those who take part in it for communication with the community, and for analysis and interpretation of the data collected.
• Planning and working out the various stages of community diagnosis.
Community diagnosis
per seOnce the preparatory phase is completed and the working group set up, the following steps will need to be taken in succession:
• Definition of the objectives of the proposed com-munity diagnosis.
106 Community diagnosis
CLASSICAL APPROACH
Regional or intermediate level
Health activities are planned at central level and applied at peripheral level to the population, whose role is usually passive
APPROACH BASED ON PRIMARY HEALTH CARE
Primary health care
COMMUNITIES
Fig. 1.5.2 Hierarchy of health services and activities.
• Compilation of the list of information or data to be collected.
• Identification of sources of data, choice of the most appropriate methods of data collection, and, if necessary, drawing up of instruments for data collection, taking available resources into account.
• Collection of data.
• Analysis and interpretation of the data collected.
• Identification of the problems, needs, resources, and groups at risk.
• Establishment of prioritie"s.
• Documenting priority problems.
Health activities are decided upon, planned and carried out jointly by professionals and members of the community on the basis of local
identification of problems, needs and resources (community diagnosis)
The intermediate level is responsible for coordination and supervision of local activities
The central level decides on the main trends of health policy and provides the additional support needed (in human, material and financial resources) to the intermediate and peripheral levels
These steps are considered in some detail below.
Definition of objectives
Agreement must be reached from the start on what it is hoped to achieve and with what aim in view, and which community(ies) are to be included.
It may be decided that a health team should identify the priority problems and needs of children in a partic-ular community, in order to orient or reorient the activ-ities for which it is responsible. In other cases, a problem that has already been identified may be taken
as the basis for ascertaining its true importance, or for gathering further background information to enable a suitable community programme to be established.
It may also be desirable to find out whether the estab-lishment of a new health service in the community is justified, or to evaluate the impact of activities that have been undertaken, or simply to gain a better under-standing of the community in which the health team is working.
Finally, the objective may be primarily an educa-tional one, using community diagnosis as a practical field exercise within the basic or refresher training of health personnel.
Information or data to be collected
The information needed depends primarily on the objectives of each particular community diagnosis, but the following list may be put forward.
The characteristics oj the community General environment:
• history of the community;
• geographical characteristics of the area, and its climate;
• urban or rural nature of the area;
• distribution of population in the area; type(s) of housing;
• the main communications network;
• transportation and travel facilities.
Demography:
• population size and age structure;
• birth, death and fertility rates; age of marriage;
• migration.
Socio-economic situation:
• occupations of the community and local resources;
• employment situation; unemployment;
• socio-professional categories;
• income;
• cost of living;
• social and family organization;
• system of social protection.
Administrative and political organization:
• degree of administrative centralization;
• government policy on health;
• health and social legislation.
Cultural and religious life:
• traditions, customs, habits with regard to food, health, and reproduction;
The methodology oj community diagnosis 107
• different ethnic groups and religions;
• leisure pursuits;
• schooling and literacy level;
• existence of cultural, political, military, religious or other associations or groups;
• modes of relationship and communication among the members of the community and between them and the outside world (mass media).
The health system:
• existing health facilities (public and private);
• current health activities (e.g. curative and preventive care, health education);
• accessibility and use of the health services by the population;
• health personnel: number, categories, training, skills;
• traditional medicine.
The classification adopted is arbitrary, and some of the items could equally well be placed under other headings. Furthermore, this list is purely indicative, and makes no claim to be exhaustive.
Data for assessing the health status of the population with special reference to children: these data cover primarily mortality and morbidity.
Relationships between the characteristics of the community and its health status This can be done by trying to identify the factors which play a determining role (whether positive or negative) in the health status of a community and its members (particularly children). (See Fig. 1.5.3.) The negative factors are the risk factors which will need to be controlled through preventive
Environmental factors
Demographic
factors~
Cultural factors
Health factors
Socio-economic factors
Administrative and political factors
Fig. 1.5.3 Factors that may influence the health status of a community.
108 Community diagnosis
measures. The positive factors are the eXIstmg or potential resources which can be used, or which will need to be developed, in the programmes of activities.
The risk factors may include for example:
• difficulties of access to health services (environ-mental factor and health factor);
• too early or too closely spaced pregnancies (demo-graphic factor);
• unemployment, or lack of social protection (socio-economic factor);
• certain habits such as abrupt stopping of breast-feeding as soon as another pregnancy starts (cultural factor);
• poor immunization coverage (health factor).
On the other hand the positive factors and resources which could be used for the development of community health programmes include:
• the existence of a good communications network (environmental factor);
• later age for marriage ( demographic factor);
• abundant local food crop resources (socio-economic factor);
• a high literacy rate among mothers, or the existence of a dynamic women's association (cultural factor);
• health personnel skilled in primary health care (health factor).
Depending on the community some factors will play a more important role than others, and emphasis will need to be given to these when community diagnosis is undertaken.
By this method a preliminary list of information can be drawn up. Before going on to the subsequent stages, however, a number of questions should be asked, as is suggested by Brownlee:4
If the workers are attempting to develop a study that is truly relevant in the cultural area where they work they must also ask themselves at least four basic questions concerning each piece of information that may be sought before choosing what information they will actually gather:
1. Will this piece of information be of real use in the program we are planning? If so, just how will it be used?
2. Is the category of information meaningful in the local context?
3. If so, will the methods we are planning to use give us information that is accurate?
4. Are there any other categories of information (possibly irrelevant in our own culture) that would be important in the local culture?
Where the term 'our own culture' is used, it must be clear that this refers not only to foreign personnel taking part in community diagnosis in a country other than their own, but also to personnel who are natives of the
country but are working in an area, ethnic group, socio-economic environment or socio-professional environ-ment other than their own. For this reason, the subjects to be covered in the diagnosis must be worked out by a multidisciplinary team (part of the working group mentioned earlier for instance) which includes local personnel and members of the community.
Ways of expressing the data Some data can be expressed quantitatively. This is the case with epidemiological data, which express the health status of the community in terms of mortality or morbidity rates or demographic data. These quantitative data will prove very useful, perhaps essential, in setting definite objectives and later on evaluating the impact of the programmes estab-lished.
The following are some examples of quantitative data:
• death rates by age; morbidity rates (e.g. incidence of measles or diarrhoeal diseases);
• birth rate;
• fertility rate;
• statistics on utilization of the health services;
• average age of marriage and average interval between births.
In addition, these indicators may be analysed by age, socio-professional category, ethnic origin, and the religion of the parents.
Other data are of a qualitative nature. They relate particularly to cultural factors and to the opinions of different population groups on health problems - their importance, their meaning, their causes, or the most effective solutions.
Every effort should be made to provide numerical data whenever possible, and to be meticulous in collection and expression of data. Health professionals must, however, beware of the magic of statistics, which can give a false impression of objectivity. The same applies to the number of subjects surveyed or inter-viewed. It is sometimes better to obtain more data on a small number of families than brief data on a large number.
Identification of sources of data, choice of methods, and drawing up of instruments for data collection
Once it has been decided what information should be collected, the possible sources of information will need to be identified and the most suitable methods of collection chosen.
It is necessary to determine what information is already available and what information needs to be
built up. The smaller the community, the more difficult it is to obtain data which can be used or transposed directly, and the more need there will be to build up data.5
Information already available The working group will have to make an index of all existing information about the community or about the area in which the community is located. This may require a great deal of work and tedious searching, but it is often surprising to find how many studies, reports and documents already exist. This search also provides an opportunity to make contact with administrations and services with which it may be useful to cooperate later on.
The documents to be consulted include:
• the plan for national socio-economic development and the national health plan;
• records of births, marriages and deaths;
• health and population statistics (particularly concer-ning the area in which the community is located);
• reports on activities of the health services (especially those of paediatric services or MCH and family planning/birth spacing clinics);
• reports on studies or surveys already made in the area (or if none is available, in a similar area) and covering the data to be collected;
• theses and papers on the area prepared by students in medical schools or institutions for the training of health personnel or other professionals;
• the local or regional press.
Information to be built up Several complementary techniques may be used to collect specific information about the community directly.
Qualitative data. In the first place, relevant information about the life of the community should be collected. This covers primarily qualitative data, i.e.
what we have termed the psycho-social approach to needs and problems.
For this purpose, it will be necessary to observe the community. Observation is one of the best ways of analysing a community's problems and needs, but it requires much more careful and meticulous work than would appear at first sight. It is also important to collect the views expressed by key persons and groups in the community, especially:
• the various professionals concerned - in the health serVIces, the social services, education, rural development, etc;
• official community leaders - civil, religious and (if relevant) military authorities;
• traditional leaders and practitioners - tribal chiefs, medicine-men, traditional midwives;
The methodology of community diagnosis 109
• the various established associations and groups - women's, men's, or joint associations for sports, cultural activities, politics;
• other members of the community - school-age children, adolescents, families representing different socio-economic strata, and representatives of the various socio-professional categories.
This may be done through structured interviews. A semidirective style, or even informal conversations, often provide extremely useful information which is usually missed in systematic surveys. As Brownlee says:4
Every culture has ways people traditionally relax, times when they let down their defences and talk sometimes of nothing in particular, other times about what is most important to them.
[This is] one of the best and most painless ways to learn about many aspects of local life.
It may also be useful to hold meetings with large or small groups, such as the community forum which is open to all members of the community. This technique can be used to complete data obtained from key persons, or to ascertain how valid and representative these data are.
Visits can also be paid to various services and public places (health services, social centres, schools, profes-sional training centres, cultural centres, places of worship, markets, shops) and to the workshops and factories in the area.
Quantitative data Precise and quantifiable data need to be collected with the community itself, to confirm and complete the items of information shown up or .surmised as a result of the non-systematic methods mentioned above, or identified through a study of existing documentation. Systematic epidemiological or sociological surveys will be required.
The choice of methodology and techniques will depend on the means (and particularly the skills) available. Some surveys can only be carried out by highly specialized personnel such as epidemiologists or sociologists. The methods chosen must therefore be those that can be planned and carried out with local personnel, even if this means some loss of precision in the information. Otherwise, community diagnosis is condemned to be a luxury activity carried out in pilot areas by a few privileged teams. An increasing number of epidemiologists now agree to take part in field activ-ities, and this change is all to the good.
One of the roles of national and international staff responsible for establishing or developing primary health care is to work out, with the help of epidemio-logists, simplified methods of data collection suitable for use in community diagnosis at local level by local staff.
110 Community diagnosis
This has already been done for assessment of immuni-zation coverage under the Expanded Programme on Immunization, as well as in the Diarrhoeal Diseases Control Programme, on the initiative of WHO.6,7 Studies are underway to adapt such methods to other fields of primary health care.
It will usually be necessary to give additional training, in the form of refresher sessions, to those who will be responsible for helping to prepare methods for data collection, draw up instruments for collection, and actually collect the data.
No single method can provide all the data needed to identify the health problems and needs of a given community and to solve them with a community health approach - that is, with the participation of the community. Only with a combination of several of the different methods that have been described, and perhaps others as well, will it be possible to achieve the objectives and at the same time remain consistent with the approach.
Data collection
The time required for data collection will depend on the objectives, the urgency of the problems to be solved, the needs to be satisfied and the resources available. It will also depend on the availability of the members of the working group. Community diagnosis should be part of the priority activities for health professionals. However, a certain amount of time will need to be set aside to prepare and put into operation some of the methods of data collection, especially surveys. The availability of members of the community may vary from one period of the year to another (according to seasonal agri-cultural work, for instance), and the working group should take this into account in their planning.
Collection of data for community diagnosis is a more or less continuous activity, with peak periods.
Community diagnosis may be undertaken as part of a training programme. In this case, the actual collection of data will often have to be concentrated into a few days. The resulting diagnosis can only be partial and provisional and will have to be completed by the local health team. However, it is surprising how much high-quality information can be collected, within a week or even within a few days,8,9 by a group of students who are strangers to a community.
Analysis and interpretation of data
On the basis of the data collected (whether quantitative or qualitative, statistical or non-statistical) the working group responsible for community diagnosis will try to bring out the main points. These might include:
• rates considered to be abnormal (death rates, birth rates, etc.);
• statistics that are too high or too low (e. g. data on average intervals between births, health serVIces attendance) ;
• factors which have a decisive effect on the health of the community;
• the opinions of members of the community on problems or needs considered to be of priority, their perception of certain events related to health, their expectations, their willingness to change, etc.
This analysis will enable the working group to draw up a list of the chief problems and needs. In the literature as well as in professional practice, the terms 'health problem' and 'health need' are often used synonymously but a distinction should be made between them: 'A problem may be considered as objective, identifiable by an outside observer; a need is more subjective, and is connected with the individual's or the community's own characteristics'. 5
At this point health professionals and members of the community may diverge in their perception of problems and needs, the professionals tending to give more importance to the problems highlighted by the quantitative data, and the members of the community having more feeling for the subjective and qualitative expression of the needs.
In addition, confusion frequently arises between health needs and needs for services or resources.10 It may however be useful to distinguish clearly among these different catagories of needs, with a view to establishing priorities as well as choosing a strategy for action once the community diagnosis is completed.
Community diagnosis also consists of identifying resources. These include existing health, social or educational facilities, and the personnel available and their qualifications. The resources of the community are:
• the skills of one or another of the members or groups in the community which might be used to solve problems;
• existing community networks, both formal and informal (e. g. different associations, and also welfare networks);
• formal and informal channels of communication and meeting-places used by the community.
A great deal of imagination must be used to identify everything that can contribute to solving problems and promoting community participation.
Analysis of the data will often reveal that certain groups or individuals in the community are especially vulnerable to particular health problems, for example