Assessing the public's health : community diagnosis in North Carolina

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A SPECIAL REPORT SERIES BY THE N.C. DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES

STATE CENTER FOR HEALTH AND ENVIRONMENTAL STATISTICS

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

No. 63

April 1992

SPECIAL EDITION

ASSESSING THE PUBLIC'S HEALTH:
COMMUNITY DIAGNOSIS IN NORTH CAROLINA

by
Kathryn B. Surles and Kathryn P. Blue

ABSTRACT

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
Carolinians.

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.

INTRODUCTION

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
resources?

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.

BACKGROUND

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.
(4)

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"
(10).

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
needs.

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.

THE 1991-92 APPROACH

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
requirements.

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
objectives)

• 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
health.

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).

DATA BOOKS AND GUIDES

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
composition.

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)

Whites

Fetal Death Rate

U.S. RATE
1988

6.4
5.4

3.2
8.5

11.2

9.7

5.4
15.0

rate.

AVERAGE
RANGE*

5.4-8.2
4.8-7.2
2.5-3.7
7.3-10.9

10.2-15.2
9.4-14.2
4.3-6.5

13.8-20.6

YOUR
COUNTY

Y

LOW
LOW-
LOW-
LOW-
LOW
LOW
LOW
LOW

OUR COUNTY IS

AVFR A OF HTP,H

Neonatal Death Rate

AVERAGE
AVERAGE
^AVERAGE

_HIGH_

Postneonatal Death Rate

_HIGH_

Infant Death Rate

—HIGH—

Nonwhites

Fetal Death Rate

-JWERAGE

_HIGH_

Neonatal Death Rate

AVERAGE
^AVERAGE
^AVERAGE

_HIGH_

Postneonatal Death Rate

_HIGH_

Infant Death Rate

HTHH

*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
teachers.

COMMUNITY DIAGNOSIS WORK-
SHOPS

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
strategies.

RESULTS

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
subjects.

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
addressed.

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.

CONCLUSION

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.

JSTATE LIBRARY OF NORTH CAROLINA

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
919/733-4728

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