an innovative model for conducting a participatory community health assessment

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An Innovative Model for Conductinga Participatory Community HealthAssessmentAlice Running , Kathlee Martin & Lauren Woodward TollePublished online: 07 Jun 2010.

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An Innovative Model for Conductinga Participatory Community Health Assessment

Alice Running RN, PhD, FNP, Kathlee Martin RN, MS, FNP,Lauren Woodward Tolle, MA

University of Nevada, Reno

Understanding a community’s perceived health care needs is essential to the promotion ofcommunity health. The purpose of this article is to review various methodologies used to as-sess community health care needs, and then provide a case example of a transcultural explo-ration of perceived health care needs of the residents of Utila, Honduras. This study presentsa template for using unique assessment tools to empower communities to identify theirhealth care needs. Implications for future transculutural community nursing studies are dis-cussed.

In 2004, the World Health Organization (WHO) recommitted to the goals of “Health forAll by the Year 2000” by stating that primary health care is

essential health care based on practical, scientifically sound and socially acceptable meth-ods and technology made universally accessible to individuals and families in the commu-nity through their full participation and at a cost that the community and country can affordto maintain at every stage of their development in the spirit of self-reliance and self-determi-nation. (Pan American Health Organization [PAHO], 2004)

This declaration emphasizes that health is the fundamental right of all people world-wide and that, both individually and collectively, people have the right and the duty toparticipate in their own health care (WHO, 2006).

Primary health care (PHC) is a key strategy for achieving the WHO goal and the goalof health for all. PHC is based on the premise that desired changes in health status mustinvolve citizens in the creation of their own future (PAHO, 2005). PHC stresses the provi-sion of basic health care that includes, but is not limited to, the following eight essentialelements: nutrition, sanitation and safe water, maternal-child care and family planning,

JOURNAL OF COMMUNITY HEALTH NURSING, 2007, 24(4), 203–213Copyright © 2007, Lawrence Erlbaum Associates, Inc.

Communications should be addressed to Alice Running, RN, PhD, FNP, Associate Professor, GraduateCoordinator/Coordinator FNP Program, Orvis School of Nursing, University of Nevada, Reno, Reno, NV89557. E-mail: [email protected]

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immunizations, prevention and control of locally endemic diseases, health education,treatment of common diseases and injuries, and provision of essential drugs (PAHO,2005).

PHC does not actually promise to extend past the guarantee of essential services, butdoes commit to access, equality, and affordability, particularly with emphasis on vulnera-ble populations. PHC also focuses on prevention and promotion rather than just curativecare alone. PAHO (2005) views nursing as the primary profession to implement world-wide health changes and describes the role of nurses as leaders and managers of PHCteams.

COMMUNITY INVOLVEMENT IN HEALTH

One of the essential components of the PHC approach is community involvement(Dawson & Joof, 2005). There is increasing recognition of the import of communitiesidentifying their own health needs (Dawson & Joof, 2005; Lindsey, Stajduhar &McGuinness, 2000). Community involvement has been defined as “a process of volun-tary cooperation and self-help/mutual aid among residents of a locale aimed at the im-proved physical, social, and economic conditions which includes citizen action, volun-tary participation, cooperation and collaborative problem solving, empowerment, and afocus on community-wide outcomes” (Chavis & Florin, 1990, as cited in Lindsey,Stajduhar & McGuiness, 2000, pp. 832). A necessary step in achieving community in-volvement is the health care provider’s ability to demonstrate cultural competence (John-son, 2005; Ross, 2006). Multiple transcultural studies describe the health beliefs of othercultures and support nursing research that seeks to provide culturally competent care(Campinha-Bacote, 2003; Johnson, 2005; Torry, 2005). Research that focuses on com-munity-based interventions has demonstrated the necessity of such research on assessingthe needs of a community and implementing health care that is appropriate to that com-munity (Shapiro, 2006; Sensor, 2006; Kelly, 2005).

An example of such research is a 2001 study that examined a community health as-sessment conducted in 26 indigenous communities in rural Ecuador (Puertas &Schlesser, 2001). The study used a participatory approach in that the call for a commu-nity-based health assessment was initiated by the citizens themselves, organized undera nongovernmental agency termed Union de Organizaciones Campesinas del Norte deCotopaxi. The assessment was conducted with cooperation from the School of HealthSciences at the Universidad San Francisco de Quito, the Swiss Red Cross, and anongovernmental Ecuadorian organization called Desarrollo y Autogestion. The as-sessment was conducted with a questionnaire, developed by representatives from the26 rural communities in conjunction with the collaborating agencies, consisting of 67open and closed questions centering around 6 main issues including: access to ser-vices, family composition, most frequent illnesses, family health, reproductive health,

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and health of children under 5 years of age (Puertas & Schlesser, 2001). Trained localinterviewers conducted in-home interviews and, in total, gathered information from1,928 individuals. The results of the surveys informed an integrated plan to improvethe health of individuals in rural Ecuador, and to diminish health disparities (Puertas &Schlesser, 2001).

A similar study using a slightly different method for gaining information concerning acommunity’s health care needs was conducted in rural Japan (Hatashita & Anderson,2004). In this study, a public health nurse individually interviewed the 250 families in thevillage of Hanazono, Japan using the community as partner model (Anderson &McFarlane, 2000). The aim of this model was to incorporate all areas of the community,as well as to bring the community into the assessment, building empowerment in thecommunity, and trust between the health care provider and the community. The homevisits provided the public health nurse with a comprehensive look at how the villagerslived in their environment and provided villagers with an opportunity to communicatetheir needs and feel comfortable building a relationship with the public nurse. In addi-tion, volunteers from the community were identified as community leaders and providedinsight as to how the community perceived the health care system, and served to furtherfoster the relationship between the community and the health care provider (Hatashita &Anderson, 2004). Finally, to create revised guidelines in public health nursing inHanazono, lifestyle surveys were mailed to villagers over the age of 65 and to the publichealth nurse; furthermore, a researcher conducted a second in-home interview with theseindividuals to gain more perspective on the health care needs of the elderly in this com-munity. Upon analyzing data from the in-home interviews, as well as the survey, severalhealth care needs were identified, and solutions to meeting these needs were developedand implemented. These solutions not only served to improve health care in Hanazono,but also improved attendance at health care visits from a previous 30% to 83%, largely inpart due to the trust that was created through the community as partner model (Hatashita& Anderson, 2004).

Another study used a community-partnering approach to reduce health disparities in aLatino community in Los Angeles by appointing and training individuals in the commu-nity to act as lay health advisors (LHAs) for their community (Kim, Flaskerud,Koniak-Griffin, & Dixon, 2005). The LHAs, being part of the community and culture,“are intimately aware of the community’s history, strengths and challenges; have intri-cate social networks in place and are well positioned to provide culturally competent careas they often become a natural link between their community and the dominant healthsystem” (Kim et al., 2005, p. 200). This study was separated into three phases, the firstbeing to conduct a thorough health needs assessment in the community via telephone in-terviews with important figures in the community including health care professionals,teachers, and local leaders. Results of the phone interviews indicated that a local Latinocommunity had the fewest resources and access to health care services, which then be-came the target of the health education intervention.

Community Assessment Model 205

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In Phase 1, agencies in the community were contacted for willingness to participateand act as partners with the investigators in providing health education to members of thecommunity. Phase 2 consisted of selecting and training individuals in the community toact as lay health advisors, and, finally, in Phase 3, community outreach and education ac-tivities by the LHAs were implemented (Kim et al., 2005).

Finally, a very creative study was conducted in Kenya with a nomadic Somali commu-nity using the participatory rural appraisal (PRA) approach to establishing the health careneeds of a community (Maalim, 2006). The PRA approach maintains that the communityhas the knowledge and capabilities to participate fully as a partner in the research processand, in some cases, collect data for the research with little help from the researcher. Par-ticipants in the nomadic Somali community were asked to record daily activities and logtheir seasonal movements throughout the country, so as to assist researchers in establish-ing where optimal locations to set up health care clinics for the community would be, aswell as to help health care providers understand the community’s everyday life. Uponanalysis of the data collected regarding the community’s nomadic lifestyle, several op-portunities were highlighted to improve the community’s access to medical services.These opportunities included improving participatory relationships with members of thecommunity, and having better understanding of the community’s health problems andcultural practices on the part of local health care providers (Maalim, 2006).

These examples provide several unique and creative ways that health care deliverysystems have empowered communities to assist in establishing their own health careneeds, which have not only diminished health disparities in rural communities but havealso improved relationships between health care providers and members of ruralunderserved populations. The purpose of this article is to highlight and applaud variousmethodologies that have been used to assist communities in voicing their own health careneeds and also to provide, in detail, another innovative and creative example that has em-powered the community of Utila, Honduras in establishing their own health care needs.In addition, this study is an example of the fruitfulness of allowing graduate nursing stu-dents the flexibility and ingenuity to develop community needs assessment tools in aunique and thoughtful way that address both the importance of communities being em-powered to voice their own health care needs, as well as provide an exemplar for a veryunique method for achieving this.

CASE STUDY: AN INNOVATIVE MODEL FOR CONDUCTINGA PARTICIPATORY COMMUNITY HEALTH ASSESSMENT

This study used a combination of the central concepts of Leininger’s (1985) nursing the-ory and the basic premises of Hildebrandt’s (1994) community involvement in healthempowerment model. Leininger’s influential work in cultural care diversity nursing hasopened the doors to numerous subsequent transcultural community nursing projects


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(Lundberg, 2000; Lundberg, Backstrom & Widen, 2005; Zoucha & Husted, 2000). Coreto Leininger’s theory is that nursing is transcultural, and that patient’s cultural values, be-liefs, and practices are vital to holistic care. Sociocultural factors including religion, edu-cation, technology, language, and worldview are equally important to health status, andLeininger (1999) posited that culturally congruent care, or care that is meaningful and fitswith cultural beliefs of the population treated, is necessary to best treat patients from di-verse cultural backgrounds. For the purpose of this study, step one of Hidlebrandt’s(1995) eight-step Community Involvement in Health (CIH) approach, identifying theneeds of the community, was applied.

Case Study

Utila, a small island located in the Caribbean Sea of Honduras, supports a colorful seafar-ing community of 2,500 residents with a diverse culture. At the time that the study wasconducted, Utila faced numerous health care challenges including (a) limited access tohealth care services, (b) a lack of health education and prevention programs, and (c) acommunity plan that did not address health care. In an effort to effectively promote com-munity health, this study explored the community health needs of Utila as defined by theresidents of Utila.

Methodology

A qualitative exploratory descriptive design was used to discover and describe the per-ceived community health needs of residents of Utila.

Sample

The study used a convenience sample of 21 Utilan residents. The sample included 7 men,14 women, 5 Latino, 4 Black, and 12 Caucasian-mixed residents ranging in age from 20to 81 years. All participants had lived on Utila at least 5 years; 17 had lived on the islandtheir entire life. The participants represented a variety of cultural experiences and allwere invested in the community’s future.

The researcher, having a 4-year history of service at the community clinic, had estab-lished trust with many community members. The clinic nurse and a well-respected fe-male elder served as the researcher’s primary liaisons and gatekeepers to the community.The former president of the Bay Island Conservancy Association, the town baker, theclinic nurse, and the well-respected female elder served as an advisory committee be-cause they were all native to the island and were also actively engaged in the community.


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Data Collection

The study utilized informal interviews and participant observation for data generation.Open-ended and semi-structured questions guided the interview. Open-ended questionspermitted the collection of large amounts of data and were applicable when answers werean expression of personal responses and feelings. In addition, in order to achieve as muchdepth as possible, questions with varying degrees of structure were combined to elicit re-sponses in areas of interest. Questions used to guide the interview were:

1. Is Utila a healthy place to live and why?2. What is healthy about living in Utila?3. What is not very healthy about living in Utila?4. What does this community need to be healthier? And5. If you had three wishes that you knew could come true, what would you wish for

Utila?

Interviews were audiotape recorded and took place in the setting most preferred by theparticipant; usually in their home or yard between 1 PM and 4 PM.

Data Analysis

Using interview notes, nursing observations, and experiences recorded daily, patternswere extracted based on verbal report from, and observation of, the participants. Thisdata was then grouped into larger themes and, finally, with the assistance of a local artist,a visual tool was created (similar to a board game) to be utilized by participants duringthe verification process. The researcher returned to each participant in his or her homeand presented the tool. Participants were given 25, single dollar bills and asked to allocatethose bills to various themes based on what they believed the community needed to behealthier.

Nineteen themes emerged from the interviews and observation. Figures 1 and 2 rankorder the themes using percentages to describe (a) how many participants mentionedeach theme during the interview process, and (b) how many votes (dollars) were allo-cated to each theme using the verification tool.

Verification Process

All 21 participants completed both the original interview and subsequent verificationprocess. During the original interviews, each participant generated between 2–7 per-ceived community needs or concerns. Later, when the verification tool with its 19 themes


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209

FIGURE 1 Interview themes by percentage.

FIGURE 2 Verification tool: Votes.

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was presented, typical participant responses was, “Oh yes, this is important too.” Thus,when presented with 19 options, many participants chose to allocate their dollars amongseveral themes that they had not originally identified during their interview.

During the verification process, 19 participants placed between $2 and $6 on a varietyof themes. The two youngest participants exceeded this trend by placing $7 and $10 onthe “Less Drugs” theme.

Themes

The 19 themes emerged from the interviews and are included in Table 1. The number ofvotes each theme received from participants during the verification process prioritizesthem.

Also presented are two graphs. Graph 1 represents the percentage of participants thatmentioned a particular theme during the interview process. Graph 2 represents the per-centage of votes (dollars) a theme received during the verification process.

Results Summary

Overall, the wide range of perceived health needs reflected the PHC issues of access, eq-uity, and affordability. The participants expressed needs, the community’s social and eco-nomic environment, as well as a desire for specific health care services. All participantsstrongly expressed a concern for the health of their youth and perceived the influence ofdrugs and its sequelae (increased violence) as rapidly accelerating problems for whichthey were not prepared.

In general, participants were very receptive to being involved in a study about theircommunity. Both the study participants and other community members took interest indiscussing the proposed themes and displayed a great amount of enthusiasm when inter-acting with the verification tool. Although the themes endorsed by the participants were


TABLE 1Community Health Themes

1. Less drugs 11. Recreation center2. Better airport 12. Christianity3. Electricity 24 hr/day 13. Better job opportunities4. Doctor 14. Public health center5. Less trash 15. Child day care center6. Less violence 16. Better drinking water7. Better teachers/schools 17. Stronger leadership/more community involvement8. Less sand flies 18. Trade school9. Less drunkenness 19. Better highway

10. Better sewer

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predictable, based upon Utilas resources, the order in which the participants prioritizedtheir perceived health needs was surprising, thereby reinforcing the importance of gain-ing community involvement to guide health care services. These results also remindnurses of the need to remain flexible. Their greatest contribution to the health of a com-munity may be in a nontraditional role, such as initiating a program to decrease illiteracyor campaigning for funds to build a new airport.

DISCUSSION

The concept of PHC strives to ensure a continuum of preventive and caring service thatreflects active involvement and ownership of the communities in which it is practiced(PAHO, 2005). The 2004 renewal of the WHO’s commitments to the goals establishedoriginally in “Health for All by the Year 2000” (WHO, 1988, 2004), challenges nursesmore then ever to continue to implement the PHC strategy of community involvement inhealth and to make the transition from health care provider to community partner.

As is reflected by extant literature and this study, the importance of PHC principles areevident and should continue to guide nursing research in areas such as community partic-ipation and empowerment, in particular where vulnerable populations are concerned.Community members’ participation in decisions about their health reflect the process ofempowerment. Empowerment is one of the least researched concepts in community de-velopment (Dawson & Joof, 2005). A further examination of the concept of empower-ment is needed to better understand how poor communities with few resources are able totransform themselves and mobilize around health issues, as has been demonstrated in theliterature (Hatashita & Anderson, 2004; Puertas & Schlesser, 2001).

CONCLUSION

Global health disparities have existed and will continue to exist, despite rapid advance-ments in medical technology and improved access to health care throughout the world.Innovative assessment tools like those presented in this article provide ways in which pri-mary health care nurses might assist in closing the gap and improve rural communities’health care through heightening awareness around the community’s perceived healthcare needs. Speaking to members of the community not only builds trust and improvesrelationships between the people of the community and health care providers, but it alsoimproves the health care providers’ understanding of and respect for the lives and uniqueculture of the members of the community. This improved relationship has been found toencourage better attendance at health care visits, as well as improve patient educationthrough exposure to medical services and education programs. Finally, feeling that theyare heard empowers community members to push for more economic and social changes


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in their community (Hatashita & Anderson, 2004; Maalim, 2006; Puertas & Schlesser,2001). The case study presented provides an example of a unique method for communityneeds assessment delivery that empowered the Utilan community to voice their ownhealth care needs. Future research is needed to provide further evidence of the effective-ness of this creative assessment tool in rural communities.

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