Skip to main content

Full text of "Assessing the public's health : community diagnosis in North Carolina"

See other formats


f/2: 63 








P.O. BOX 29538, RALEIGH, N.C. 27626-0538 

No. 63 

April 1992 



Kathryn B. Surles and Kathryn P. Blue 


The Community Diagnosis process in North Carolina has evolved over a period of years, beginning in 
1974 but greatly gaining impetus during and after 1983. It serves to address the "true" health problems of 
the state's citizenry through the identification and communication of these problems from the local level 
to the state. In this "bottom-up" planning process, which is conducted biennially, the state prepares 100 
county-specific Health Data Books and an accompanying guide which advises local health department 
personnel on the concepts, methods, and materials of community diagnosis. 

This information is presented at a series of workshops attended by local personnel who subsequently 
analyze the data and their local situations and report back to the state their county's priority health 
problems and solution strategies. These results are then used by the State Health Director to determine 
funding requests to the legislature. In the end, it is hoped that the products of this process serve the 
ultimate goal of allocating resources on a priority basis to meet the documented health needs of North 

For a local health authority, The Future of Public Health (Institute of Medicine, 1988) defines a health 
planning and leadership role that is fundamental to the protection of the community's health. 
Community Diagnosis provides for the kind of needs assessment that is crucial to that role. 


The discipline of epidemiology has long espoused 
the cause of health agency studies of community 
health problems. As noted by Schuman in 1963, "... 
health agencies on the firing-line should be natural 
initiators of studies in the very domain of their 
responsibilities and activities" (1). 

In 1968, Dr. B. G. Greenberg of the University of 
North Carolina School of Public Health stated that 
public health officers had the responsibility to 
"purposefully measure the needs in a community." 
This measurement process he termed "Community 
Diagnosis." (2) 

Twenty years later, the Institute of Medicine 
(lOM) reported on its two-year study of the future 
of public health in America (3). This study was 
undertaken to address a growing perception that 
"this nation has lost sight of its public health goals 
and has allowed the system of public health activities 
to fall into disarray." 

The IOM report asserts that "effective public 
health action must be based on accurate knowledge 
of the causes and distribution of health problems ..." 
and recommends that "every public health agency 
regularly and systematically collect, assemble, analyze, 
and make available information on the health of the 
community, including statistics on health status, 
community health needs, and epidemiologic and 
other studies of health problems." 

But how does the local health agency get started 
when they have little or nothing in terms of technical 

Cochran has said there is no way to start but to 
start ( 1 ); however, it is clear that not every agency is 
independently capable of doing the required research. 
But all should be capable of cooperation. Thus, in 
North Carolina, the state's public health agency has 
taken the lead in developing a cooperative venture 
with health departments throughout the state. The 
result is the community diagnosis process, now 
conducted biennially as later described. 


Following a number of years of alternative strategies 
to health planning (4-6), the Community Diagnosis 
process in North Carolina began to evolve in 1974 
with implementation of the Planning and Budgeting 

System (PBS) (7). This planning approach began at 
the service delivery level, where local health 
departments identified and prioritized their needs, 
and continued at the region, division and department 
levels. After this process was completed, a priority 
list of health needs was developed and presented to 
the legislature for funding. 

Coincidental with the implementation of PBS, the 
state's health statistics agency prepared for the first 
time 100 county-specific data books. Titled "Baseline 
Statistics for Needs Assessment" (8), these reports 
included county-level census data, population 
projections, and information about the sources of 
vital statistics data deemed to be most useful in 
determining the health needs of each county's 
residents. These data were intended to aid local 
health directors in formulating program objectives 
and providing population measures that would serve 
the state's attempt to allocate resources on a priority 
basis to meet the documented needs of North 
Carolina citizens. 

In 1976, the state again produced 100 county- 
specific publications, these called "Population and 
Program Statistics for Public Health Needs 
Assessment" (9). In addition to the statistical 
information described above, these reports included 
state and county-specific statistics for thirty public 
health programs in order that local health departments 
might better develop a "profile" for a particular 
human service need. 

About this time, "standards" — which govern 
services rendered by local health departments — 
assumed a prime focus, and PBS became less 
important. Meanwhile, based on recommendations 
from the North Carolina Health Directors Associa- 
tion, the "Consolidated Planning Process" was 
adopted in 1981. This planning process required 
local health departments to submit to the state health 
agency a county profile of health needs (Part I) and 
outcome objectives relative to funding expectations 
(Part II). The process to develop Part I was later 
coined "Community Diagnosis" after Greenberg. 

Aware that the results of earlier efforts fell short of 
the goal of community health assessment, the state's 
health statistics agency dramatically expanded its 
efforts in 1983 with the production of 100 county- 
specific Health Data Books and an accompanying 
report, "Guide for a Community Health Diagnosis: 
A Special Report for Local Health Departments" 

The county-specific data book brought together, 
under one cover, all of the known health-related 
state and county data available from standard reports 
and computer printouts. The Guide attempted to 
advise the user on the concepts, materials, and 
methods of community diagnosis. For the first time, 
the term "community diagnosis" was defined: a 
means of examining aggregate health and social 
statistics, liberally spiced with the investigator's 
subjective knowledge of the local situation, to 
determine the health needs of the community. 

These materials and underlying concepts were 
presented at a series of six strategically located 
workshops attended by local health department 
personnel from across the state. Since that time, 
selected data in the Health Data Book have been 
updated annually and the series of workshops 
conducted biennially. Thus began a biennial process 
whereby local health departments were asked to 
"analyze" the county-specific data provided by the 
state as well as their own local situations and to 
report back to the state each county's priority health 

At the 1987 community diagnosis workshops, 
statisticians from the state health agency attempted 
to go a step further in assisting local health depart- 
ments by presenting the methods and materials of 
community diagnosis in the form of a "model" 
diagnosis developed for one county. The results 
were encouraging; at least some counties were able to 
examine their data and local situations and to 
produce fairly comprehensive reports of health- 
related needs in their counties. Other counties, 
however, still did not have a toe-hold on how to 
examine and assess their data. 

In early 1989, the state health agency conducted a 
sample survey of participants in the 1987 workshops 
to determine how best to meet their future needs in 
the matter of community diagnosis. The result was a 
cry for help in the organization and structure of the 
data analysis. Thus, in 1989, the state prepared a new 
Health Data Book for each county and wrote an 
all-new "Guide for a Community Diagnosis" (2). 
The Guide included worksheets for use in the 
analysis of data, questions to answer about com- 
munity perceptions and behavior, and pointers on 
program evaluation. 


Based on participants' comments and responses to 
a sample survey conducted in 1990, the "cookbook" 
approach used in the 1989 workshops was deemed 

highly successful, so the same approach was planned 
for 1991. However, past results and several new 
national and state initiatives suggested the need 
to review and define the counties' reporting 

In previous cycles of Community Diagnosis, the 
state health agency had requested the reporting of 
"health needs" but without defining the term. The 
result had been a mishmash of problem and need 
statements which were sometimes difficult to 
categorize, so some sort of standardization was 
deemed essential. Meanwhile, these initiatives and 
their protocols also needed to be considered: 

• Healthy People 2000 (national objectives 
focusing on the health problems of people) 

• Health} Communities 2000: Model Standards 
(community objectives to address the national 

• Assessment Protocol for Excellence in Public Health 
(APEX), Part II (guide to identifying priority 
community health problems and 
programmatic objectives, in a manner consistent 
with Healthy People and Healthy Communities) 

• House Bill 183, Section 1, Subsections (a)(2) 
and (a)(4) which address the state health agency's 
role in assessing health status and health needs in 
every county and in monitoring and evaluating 
local achievement of health outcome objectives. 

In order to standardize reporting and to be 
responsive to the above, the Community Diagnosis 
protocol now requests local reporting of two types 
of community health problems, defined as follows: 

I. Health Status Problem: A situation or 
condition of people which is considered 
undesirable, is likely to exist in the future, and is 
measured as death, disease or disability (APEX). 

A health problem reported in this category must 
be measurable at the county level. It may be a 
leading cause of death or of premature mortality, 
a leading cause of hospitalization, a leading 
communicable disease, or another unhealthy 
condition of people for which there are quantified 
data. Examples are infant mortality, cancer, 
heart disease, injuries, AIDS, gonorrhea, measles, 
substantiated child abuse/neglect, etc. These 
problems may identify particular subpopulations 
at risk, e.g., homicide among nonwhite males. 

This definition asks counties to look at their 
measurable people problems that are known to 
have public health significance. It is exactly the 
same as the APEX definition of a health problem. 
It is also responsive to the mandates of House 
Bill 183 relative to health status and health 
outcome objectives. This focus on health 
outcomes is essential to protect the public's 

II. Other Health Problem: A situation or 
condition of people, the environment, or the 
health delivery system that contributes directly 
to a health status problem. 

A problem reported in this category may or may 
not be measurable at the county level. It may be a 
known environmental threat, an unhealthy 
behavior of people, or a deficit in the provision 
of preventive or primary health care. These 
problems may identify particular subpopulations 
at risk, e.g., pregnancy among teenagers. 

Some of these problems will relate to the health 
status problems identified above and would be 
consistent with APEX's impact and process 
objectives. Others may not correlate with current 
levels of morbidity/mortality. 

Based on these definitions, each county is asked to 
report up to five prioritized health status problems 
and up to five prioritized other health problems. For 
each problem reported, the county is also asked to 
specify one or more interventions it plans to develop 
and implement in the next two years and to identify 
the corresponding new resource requirements. For 
reporting purposes, intervention is defined as "a 
process or action intended to address an existing or 
potential community health problem." This includes 
specific actions needed for environmental control, 
behavioral risk reduction, and the provision of 
preventive and primary health care. 

On an optional basis, counties may also report 
their Health Department Operational Needs. These 
are administrative-type needs perceived by the health 
department as being amenable to assistance by the 
state. They may include assistance in relation to 
policy development, space planning, computer skills 
training, program management, personnel and fiscal 
management, community relations, networking with 
sister agencies, and other areas where central or 
regional staff might provide a focus and/or actual 
technical assistance. The state health agency will 
assess these results and attempt to address as many 
needs as possible during the second year of the 
biennium (1992-93). 


In June of 1991, current (1990) data for the 100 
county-specific Health Data Books began to become 
available. These books contain pertinent health data 
available on a county level and corresponding data 
for the state. Nine color-coded sections of data 
correspond to the following topics: Population at 
Risk, Pregnancy and Live Births, Fetal and Infant 
Mortality, General Mortality, Morbidity, Health 
Care Resources, Public Health Program Data, 
Environmental Program Data, and Public Health 
Fiscal Resources. 

The companion volume, Guide for a Community 
Diagnosis: A Report for Local Health Departments 
(11), provides definitions and explains how to use 
the county data and other local information to 
perform the local needs assessment. It is the state's 
attempt at a "cookbook" approach, providing 
worksheets to lead users through data analysis and to 
aid them in relating other local information to a 
particular health matter. It also includes discussions 
on the importance of community diagnosis, the 
prioritizing of health problems, and program 
evaluation. Finally, it provides a glossary as well as 
instructions for submitting requisite information to 
the state office for use in preparing the expansion 
budget request to the legislature. 

Each worksheet pertaining to data analysis is tied 
to one or more of the color-coded data series in the 
data book or to data in the "North Carolina Health 
Statistics Pocket Guide," which is prepared biennially 
and includes a large amount of county-level and 
statewide data. For these data items, as well as some 
in the Health Data Book, a county may compare 
itself to the state as well as other counties. 

Shown on the next page is a worksheet from the 
Guide's section on Fetal and Infant Mortality. Note 
that the data are race-specific since North Carolina 
counties vary tremendously in their racial 

On an arbitrary basis, the "average range" for each 
statistic assessed in the worksheets was set at 20 
percent above and below the state value. Although 
one may prefer to compute variances or perform 
cluster analysis to determine the benchmarks against 
which a county should measure itself, this was not 
done because counties may examine many statistics 
not covered by the worksheets and they would be 
unable to perform the required calculations. 

Counties having few nonwhites should complete this worksheet for whites only. 

Worksheet 3.1 
Fetal, Neonatal, Postneonatal, and Infant Death Rates 1986-90 

(See items 11-14 of page II-3 of the Data Book) 


Fetal Death Rate 

















Neonatal Death Rate 



Postneonatal Death Rate 


Infant Death Rate 



Fetal Death Rate 



Neonatal Death Rate 



Postneonatal Death Rate 


Infant Death Rate 


*20% above and below the state 

At the end of each of the Guide's sections on data 
analysis (sections corresponding to topics in the 
Health Data Book), a final worksheet asks for other 
local information related to a health problem in the 
county. These questions are meant simply to aid the 
locals in thinking about situations that may contribute 
to an identified problem. For example, through this 
process, one county was led to reveal that teenagers 
were not using a family planning clinic located 
directly across from a large high school because they 
did not want to be observed going there by their 


Following a "dress rehearsal" by planners and 
statisticians, the Community Diagnosis workshops 
began in mid-October and continued through mid- 
November 1991. The workshops began in mid- 
morning on the first day to allow travel from distant 
counties and closed in mid-afternoon the following 
day. In addition to a video and slide show about 
Community Diagnosis and general instructions about 

analysis, topics covered on the first day were 
population at risk, pregnancy and live birth, and fetal 
and infant mortality. Day two dealt with general 
mortality, morbidity, health care resources, public 
health program data, environmental program data, 
and public health fiscal resources. 

Planners and statisticians presented their segments 
in a style that was as down-to-earth as possible, 
stressing the availability of state and regional staff for 
consultation. Regional health educators, who usually 
bear the brunt of this need for consultation, attended 
a Community Diagnosis session. 

The workshops stressed hands-on participation, 
using a lecture coupled with the worksheets. 
Attendees filled out worksheets using their county's 
data to get some of the statistical data down on paper 
while statisticians were on hand to answer questions. 
Help with the completion of worksheets was also 
offered at night. One of the workshops was held at 
the Microelectronics Center of North Carolina 
where it was video-taped. Several counties who did 
not participate in the workshops and some who did 
have requested copies of this "training tape." 

The last workshop was held November 19-20, 
giving local health departments until February 1 to 
complete the reporting forms and their Community 
Diagnosis documents. The counties were given no 
format to use for the Community Diagnosis 
document; instead it was suggested that they create 
such a document in a form that would be useful to 
them, i.e., a short work plan or public relations 
piece, or a lengthy description of the county, its 
health problems, and proposed intervention 


Attendance at the six workshops exceeded 300, 
with 96 of the state's 100 counties represented. 
Based on evaluation forms completed by these 
attendees, each of the workshops was successful: the 
mean scores over 10 evaluation criteria ranged from 
4.0 to 4.4, based on a scale of 1 (very dissatisfied) to 
5 (very satisfied). For eight of the 10 evaluation 
criteria, the highest satisfaction ratings came from 
participants of the smallest workshop held. At all 
workshops, participants were particularly satisfied 
with the handouts (Health Data Books and the 
Guide) and the instructors' knowledge of their 

On the negative side, some workshop participants 
complained that the training was redundant (they 
had attended before) or not needed (the very 
structured Guide was sufficient). These complaints 
will need to be addressed in future cycles of 
Community Diagnosis. 

As in the past, health problems identified in the 
course of Community Diagnosis and reported by 
local health departments to the state health agency 
will be categorized, weighted according to priority 
status, and summarized for use by the State Health 
Director in determining expansion budget requests 
to the legislature. The reporting of planned 
intervention strategies and new resource requirements 

associated with each reported problem should 
contribute to a much better understanding and 
accounting of local health needs than was possible in 
the past. 

In addition to this use of Community Diagnosis, 
the products of this process should also: 

• Provide to state-level programs and their regional 
office personnel information that fosters better 
planning, promotion, and coordination of 
prevention and intervention strategies at the 
local level; 

• Serve health planning and advocacy needs at the 
local level. Here, the local health authority 
provides the leadership to ensure that 
documented community health problems are 

In the last biennium, largely as a result of 
Community Diagnosis and media attention to the 
problem, the State Legislature appropriated $10 
million to combat the state's infant mortality 
problem. The result has been 16 new initiatives to 
foster the recruitment and retention of prenatal care 
providers, to enhance maternity and child services 
provided through Medicaid, and to enhance basic 
services for family planning patients, pregnant 
women, and children. 


The Community Diagnosis process is "alive and 
well" in North Carolina! It has the enthusiastic 
support of both state and local health officials, and it 
is viewed by health planners and statisticians at the 
state level as one of their more important respons- 
ibilities. Finally, of course, the bottom line is that 
Community Diagnosis serves the state's citizenry 
well as government goes about the business of 
allocating resources on a priority basis to meet the 
documented health needs of North Carolinians. 


In hi in 

REFERENCES 3 3091 00739 3986 

1 . Schuman, Leonard M. (Consulting Editor). "Research Methodology and Potential in Community Health 
and Preventive Medicine," Annals of the New York Academy of Sciences. Volume 107 Art 2 oases 
471-808. May 22, 1963. ' ' PB 

2. North Carolina Department of Environment, Health, and Natural Resources, Division of Planning and 
Assessment and Division of Statistics and Information Services. Guide for a Community Diagnosis: A Report 
for Local Health Departments. Raleigh, September 1989. 

3. Committee for the Study of the Future of Public Health, Institute of Medicine. The Future of Public Health. 
National Academy Press. Washington, 1988. 

4. Campbell, Kent. Evolution and Analysis of Planning Systems Used by the Division of Health Services and Local 
Health Departments Since 1968. April 27, 1984. 

5. North Carolina State Board of Health Planning Office. North Carolina State Board of Health Planning 
Manual. July 14, 1969. 

6. North Carolina Department of Human Resources. A Manual for Applying Management by Objectives to 
Human Services Programs. June 1973. 

7. North Carolina Department of Human Resources. Handbook: Planning and Budgeting System. March 1974. 

8. North Carolina Department of Human Resources, Division of Health Services, Baseline Statistics for Needs 
Assessment. April 1974. 

9. North Carolina Department of Human Resources, Division of Health Services, Population and Program 
Statistics for Public Health Needs Assessment. February 5, 1976. 

10. North Carolina Department of Human Resources, Division of Health Services, State Center for Health 
Statistics, "Guide for a Community Health Diagnosis: A Special Report for Local Health Departments," 
SCHS Statistical Primer, Vol. 1, No. 4. (Undated.) 

11. North Carolina Department of Environment, Health, and Natural Resources, State Center for Health and 
Environmental Statistics, Division of Planning and Assessment and State Center for Health and 
Environmental Statistics. Guide for a Community Diagnosis: A Report for Local Health Departments. Raleigh, 
October 1991. 

Department of Environment, Health, and Natural Resources 
State Center for Health and Environmental Statistics 
P.O. Box 29538 
Raleigh, N.C. 27626-0538 


U.S. Postage 


Raleigh, N.C. 27626-0538 

Permit No. 1862 

600 copies of this public document were printed at a cost of $37.08 or 60 per copy.