c, f/2: 63 . ^SjPg" . \n ES 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. J STATE 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 BULK RATE U.S. Postage PAID 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.