The critical problem of the medical encounter is the interpretation of patients’ conditions within sociocultural systems of experience and meaning. Anthropological and community public health approaches contribute to these perspectives, providing the tools to determine the community-based realities of maladies and their detection and treatment. The develop- ment of effective health programs requires resources—physical and intellectual—to engage community involvement, beginning with planning stages and continuing through health program implementation and evaluation activities. Community involvement is necessary because effectiveness must be measured in goals specifi c to the particular community and its circumstances. Because improving the community’s perception of its health is part of public health goals, determining community views of desirable improvements in its health is part of an evaluation. The health of a community is a function not only of biological dis- ease rates but also of quality-of-life concerns based on cultural values and expectations.
Community approaches are central to health because they refl ect social expectations regarding quality of life.
A variety of models exist for community involvement in the implementation of health improvement programs (e.g., Healthy People, 2010 [National Center for Health Statistics, 2000]; Healthy Communities, 2000: Model Standards [American Public Health Association, 1991]; Assessment Protocol for Excellence [in Public Health;
APEX]; Planned Approach to Community Health); Community Oriented Primary Care;
and Healthy People and Cities programs [see Lasker et al., 1997; Durch et al., 1997]).
These provide health departments with guidelines for community-based approaches to identifying local health problems and creating programs to address them. The Institute of Medicine (IOM) developed national health goals and model standards for local com- munities to use in formulating appropriate public health policy and culturally responsive services. These provide guidelines for evaluating organizational self-assessment capaci- ties; establishing community relations; determining community health status, needs, and priorities; and monitoring success in achieving goals. The APEX model focuses on the following steps:
Community Process Steps
Assess organizational capacities for community relations and organization Collect and analyze health data
Form community health committee to identify, prioritize, and analyze community health needs
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Inventory community health resources
Develop and implement community health plan Monitor achievement of health goals
Implementing Model Standards
The following steps are critical for implementing model standards:
Assess agency capacity for community engagement Develop agency capacity-building plan
Assess community organization and structures Organize community members in health coalitions Assess community health needs
Determine community priorities and health resources Select outcome objectives
Develop intervention strategies Implement intervention strategies
Conduct continuous monitoring and evaluation
Approaches for achieving collaborative community engagement in health assess- ments are illustrated in the IOM’s Community Health Improvement Process (CHIP), which utilizes interacting cycles of analysis, action, and measurement. CHIP forms com- munity health coalitions, involving community members in the analysis of community health problems, identifying the critical health issues to be addressed, and developing socially and culturally appropriate responses to those problems. Contemporary national and community health agendas all emphasize community assessment and collaboration, which require cultural perspectives and competence in addressing health issues. Cultural perspectives are vital for addressing all three of the core functions of public health:
assessing communities and their needs, developing appropriate policies, and ensuring culturally sensitive services. IOM principles for community health improvement all involve cultural dimensions: the WHO defi nition of health and its broad conceptual model; the community’s desired health outcomes; and community coalitions that incor- porate the diverse community sectors and stakeholders , people and groups with interests and involvements in specifi c health outcomes.
Measurements of institutional, coalition, and community preparedness for collabora- tion are key to addressing community health. Key issues are mediating among the vary- ing priorities, goals, and objectives of the numerous stakeholders. The IOM recommends using frameworks like the cultural systems models to develop indicators that incorporate the broad range of factors that impact health. Assessment of health systems depends largely on anthropology’s ethnographic approaches: participant observation, unstructured and informal interviewing, use of experts and key informants, archival research, and the
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development of formal questionnaires where appropriate. These methods may be supple- mented by approaches for hard-to-reach groups (Schensul and LeCompte, 1999).
A variety of methods are used to assess and adapt to community and cultural factors in assessing health care issues (Brownlee, 1978):
Practicing direct personal involvement in doing the research Building personal relations and involving community members Finding a confi dant who can help bridge the culture gap
Understanding the other culture, particularly its differences, as normal Utilizing community resources and networks
Observing and listening before asking and acting
Finding out if any special rules of protocol need to be followed Getting to know local leaders: residents who are widely respected Talking to ordinary workers and community people
Getting to know the patients, the recipients of care
Learning through participating, observing, and informal conversations
Determining cultural attitudes toward questioning and adapting questions to the culture
Learning how to interview within the local area
Learning when to ask questions and what questions not to ask
Assessing Community Health Involvement Because engagement with the community is a necessary component of effective public health interventions, measuring the stage of development of community coalitions and their input into health intervention projects is fundamental to evaluating the effectiveness of health programs (Goodman, Wandersman, Chinman, Imm, and Morrisey, 1996). Organizational measures assess the extent to which relationships between public health institutions and their communities have been developed (Smithies and Webster, 1998). Dimensions and levels of community partici- pation include the quality and length of participation and effects and outcome from participation processes. The capacity of the community coalition to respond to health needs is a basic aspect of involvement; other measures focus on the implementation of initiatives and their impacts on the community (Goodman et al., 1996). Effective com- munity participation requires sustained coalition function with community participation and leadership and support from health care institutions. Community involvement can be assisted with rapid ethnographic assessment protocols (see “ Rapid Assessment, Response, and Evaluation [ RARE ]” below). These approaches facilitate community participation by accommodating to local cultural dynamics and taking direction from the community. Community health coalitions and advisory boards allow community perspectives to be incorporated into the assessment of health problems, development
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and implementation of health programs, assessment of their effectiveness, and their con- tinued modifi cation to meet community health needs.
Evaluating Community Health
The evaluation and assessment of community health generally include three phases:
Formative evaluations (needs assessments)
Process assessments of the implementation of interventions Outcome measures evaluating intervention effects on communities
Because interventions can affect many social levels and groups, multiple sources of data are required for effective program evaluation. Triangulation (Goodman et al., 1996;
Trotter and Needle, 2000a, 2000b; Beebe, 2001) is a method of relying on several sources of information for ascertaining a condition; it is also known as mixed or multiple strate- gies or combined operationalism. Combining several sources of information improves the validity of assessments by reducing biases inherent in any single approach. For instance, deciding which areas of the community are in most need of teen pregnancy pre- vention programs might be best determined by consulting school counselors, adoption agencies, social services, and health care providers.
Formative Evaluation
Formative evaluations emphasize needs assessments (or discrepancy analysis) to discover gaps in services and make programs more responsive. A primary focus is the community health profi le: determining existing conditions and local programs that may facilitate interventions. Community-based evaluations of health concerns and needed services are performed before intervention programs are implemented to provide a baseline from which to assess program impacts.
Evaluations generally take place at several levels (e.g., targeted populations, the wider community, and political and administrative organizations). Formative assessments clarify project goals and concerns of sponsors and communities regarding needed information, preferred research designs, and the nature of the results needed. They determine the context for proposed interventions; the antecedents and consequences of the problem of concern;
resources available to address the problem; and the programs, policies, and attitudes affect- ing the proposed interventions. Formative evaluations include an understanding of the administrative and organizational structures of health agencies, their delivery systems, and their interactions with other institutions, agencies, and communities.
The starting point for community health assessments is the production of community health profi les. Minimum IOM indicators for community health profi les include sociode- mographic characteristics, the health status of the population and its subgroups, principal risk factors in the environment, and the resources and health status of the population.
These profi les address the broader economic, social, and political dynamics of the com- munity, particularly those aspects that most directly affect health status and risk factors.
Assessing health needs of communities requires consideration of existing conditions, the community’s perspectives on what constitutes threats to health, and the perceived needs
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with respect to those conditions. Formative assessments use general cultural systems models as well as more specifi c subsystems directly relevant to the health problem and capacities of institutions, communities, health providers, and other stakeholders (see RARE models below for detailed community assessment protocols).
The extent of the formative assessment depends on resources; the nature of the prob- lem; the scope of the project; and the interests of sponsors, institutions, and communities involved. Analysis of health issues, community health resources, and existing health pro- grams provides a basis for the creation of performance and evaluation indicators and the development of new health improvement strategies. This includes knowledge of a commu- nity’s infrastructural capacity to respond to health needs: government agencies; community leadership; and programs for surveillance, data monitoring, health promotion, service provi- sion, and other activities that maintain health (e.g., sanitation, food quality).
Process Evaluations
Community health improvement requires monitoring of the implementation of programs.
Process evaluations (or implementation evaluations) ascertain whether interventions were delivered as planned. Programs are generally assessed as to the effectiveness of program implementation and the effects of programs on intended audiences. Process evaluations use many forms of information:
A chronological narrative of program activities Records of project workers
Objective-based evaluations of progress toward goals Evaluation of cost-effectiveness or cost-benefi t analysis
Expert or professional judgments based on various forms of assessment Evaluation of program recipients’ use of and views of the program
Evaluations use participant observation and derive information from many sources, including community discussions, interviews, examination of critical incidents, and case studies. They also may include more formal evaluations based on structured interviews, surveys, and organizational records. Process evaluation feedback may be incorporated midcourse to modify processes to ensure achievement of desired goals.
Outcome Evaluations
Outcome evaluations are concerned with the effects of programs. The activist role of med- ical anthropology makes the outcome-focused evaluation, which attempts to ascertain the attainment of desired outcomes, particularly important. Multiple stakeholders mean a vari- ety of assessments are necessary to determine the impact of intervention programs on different segments of the community (e.g., at-risk groups; different ethnicities, providers, administrators, politicians, educators; and so on). These assessments may ascertain
Community awareness concerning health issues Community knowledge of contributory and risk factors
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Changes in the community members’ lifestyles, attitudes, and health-related behaviors Modifi cations in the physical and social environments
The nature and extent of enhancement of interaction between health organizations and their constituencies
The level at which institutionalization of needed programs should be targeted Assessments are also made of coverage—that is, the extent to which the target pop- ulation was aware of having received the message, understood its intentions, accepted it,
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Noel J. Chrisman
Noel J. Chrisman, Ph.D., M.P.H., is professor in the Department of Psychosocial and Commu- nity Health, School of Nursing, University of Washington, Seattle, with adjunct appointments in anthropology, health services (School of Public Health), and family medicine. Since 1977 he has been teaching in family medicine. He teaches a course cross-listed between anthropology and nursing, “Clinically Applied Anthropology,” that explores data and concepts from medi- cal anthropology and then determines ways to use the information to improve clinician prac- tice. A course cross-listed between nursing and health services is “Dynamics of Community Health Practice,” which examines the interface between medicine and public health, explic- itly to teach primary care practitioners and managers how to work with communities. Also cross-listed between nursing and health services is “Health, Culture, and Community,” a course that explores how to construct health promotion and disease prevention projects in multicultural communities. Within nursing, he teaches “Transcultural Nursing Practice,” an examination of thirty to forty years of health practice literature to show how to take care of patients in culturally appropriate ways. For undergraduates in nursing, he teaches “Culture, Diversity, and Nursing Practice,” a required cultural competence course. In addition, he teaches senior undergraduate nursing students how to do community organizing for health promotion and disease prevention. As part of this effort, he has been working in a small Lat- ino neighborhood with students since 1995, building community through enhancing the capabilities of a neighborhood coalition.
A large proportion of Chrisman’s work has been on cultural competence. He discusses, for example, professional attitudes, practice skills, and system savvy for cross-cultural situa- tions using an easy-to-remember set of guidelines called “culture-sensitive care” (knowledge, mutual respect, and negotiation). In addition to these invented concepts, he uses major ideas from medical anthropology such as ethnocentrism and cultural relativism, the illness-disease distinction, variations in health and illness beliefs cross-culturally, the role of value complexes such as time orientation or human-nature relations, and how to work with interpreters.
PRACTITIONER PROFILE
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and changed its behavior. Assessment of the effectiveness of the intervention in the target population generally requires controlling for confounding effects: for example, changes in the broader social environment in the direction of program intervention changes. These include public occurrences that infl uence people’s behavior in the direction of interven- tion (e.g., a prominent person’s AIDS-related death motivates people to adopt protective behaviors). Assessments of the effects of intervention also focus on political leaders and policymakers who have the potential to produce long-term changes. Long-term success is achieved by securing the necessary resources through infl uence on public leaders and bureaucrats. Leaders and organizations can produce long-term changes in the behaviors of communities through institutionalization of interventions into permanent programs.