THE COMMUNITY DIAGNOSIS Caring for the community as client starts with determining its health status.

The nurse collects data about the community in order to identify the different factors that may directly or indirectly influence the health of the population. Then, she proceeds to analyze and seek explanations for the occurrence of health needs and problems of the community. The community health nursing diagnosis is then derived and will become the basis for developing and implementing community health nursing interventions and strategies. This process is called community diagnosis. Others call it community assessment or situational analysis. The health status of the community is a product of the various interacting elements such as population, the physical and topographical characteristics, socio-economic and cultural factors, health and basic social services and the power structure within the community. The interrelationship of these elements will explain the health and illness patterns in the community. TYPES OF COMMUNITY DIAGNOSIS In the assessment of the communitys health status, the nurse considers the degree of detail or depth she should go into. There are times when situations call for a comprehensive assessment. Oftentimes, the nurse is confronted with a specific problem area like a disaster situation or an outbreak of disease. In these instances, a problem-oriented assessment will have to be conducted. A nurse may decide to assess a specific population group in the community, in which case, she may opt to conduct a comprehensive assessment of that group and at the same time, focus on the specific problems of that same group. It is important, therefore, to decide on the objectives of the community diagnosis, the resources and time available to implement it. COMPREHENSIVE COMMUNITY DIAGNOSIS A comprehensive community diagnosis aims to obtain general information about the community. The following are elements of a comprehensive community diagnosis: A. DEMOGRAPHIC VARIABLES The analysis of the communitys demographic characteristics should show the size, composition and geographical distribution of the population as indicated by the following: 1. Total population and geographical distribution including urban-rural index and population density. 2. Age and sex composition. 3. Selected vital indicators such as growth rate, crude birth rate, crude death rate and life expectancy at birth. 4. Patterns of migration. 5. Population projections.

It is also important to know whether there are population groups that need special attention such as indigenous people, internal refugees and other socially dislocated groups as a result of disasters, calamities and development programs. B. SOCIO-ECONOMIC AND CULTURAL VARIABLES There are no limits as to the list of socio-economic and cultural factors that may directly or indirectly affect the health status of the community. However, the nurse should consider the following as essential information: 1. SOCIAL INDICATORS a) Communication network (whether formal or informal channels) necessary for disseminating health information or facilitating referral of clients to the health care system. b) Transportation system including road networks necessary for accessibility of the people to health care delivery system. c) Educational level which may be indicative of poverty and may reflect on health perception and utilization pattern of the community. d) Housing conditions which may suggest health hazards (congestion, fire, exposure to elements) 2. ECONOMIC INDICATORS a) Poverty level income b) Unemployment and underemployment rates c) Proportion of salaried and wage earners to total economically active population. d) Types of industry present in the community. e) Occupation common in the community. 3. ENVIRONMENTAL INDICATORS a) PHYSICAL/GEOGRAPHICAL/TOPOGRAPHICAL CHARACTERISTICS OF THE COMMUNITY Land areas that contribute to vector problems. Terrain characteristics that contribute to accidents or pose as geohazard zones. Land usage in industry. Climate/season b) WATER SUPPLY % population with access to safe, adequate water supply. Source of water supply
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c) WASTE DISPOSAL % population served by daily garbage collection system. % population with safe excreta disposal system Types of waste disposal and garbage disposal system. d) AIR, WATER AND LAND POPULATION Industries within the community having health hazards associated with it Air and water pollution index 4. CULTURAL FACTORS a) Variables that may break up the people into groups within the community such as: Ethnicity Social class Language Religion Race Political orientation b) Cultural beliefs and practices that affect health c) Concepts about health and illness C. HEALTH AND ILLNESS PATTERNS In analyzing the health and illness patterns, the nurse may collect primary data about the leading causes of illness and deaths and their respective rates of occurrence. If she has access to recent and reliable secondary data, then she can also make use of these. 1) 2) 3) 4) 5) Leading causes of mortality Leading causes of morbidity Leading causes of infant mortality Leading causes of maternal mortality Leading causes of hospital admission

D. HEALTH RESOURCES The health resources that are available in the community are an important element of the community diagnosis mainly because they are the essential ingredients in the delivery of basic health services. The nurse needs to determine manpower, institutional and material resources provided not only by the state but those which are contributed by the private sector and other non-government organizations.

1) MANPOWER RESOURCES Categories of health manpower available Geographical distribution of health manpower Manpower-population ratio Distribution of health manpower according to health facilities (hospitals, rural health units, etc) Distribution of health manpower according to type of organization (government, non-government, health units, private) Quality of health manpower Existing manpower development/policies 2) MATERIAL RESOURCES Health budget and expenditures Sources of health funding Categories of health institutions available in the community Hospital bed-population ratio Categories of health services available

E. POLITICAL/LEADRESHIP PATTERNS The political and leadership pattern is a vital element in achieving the goal of high level wellness among the people. It reflects the action potential of the state and its people to address the health needs and problems of the community. It also mirrors the sensitivity of the government to the peoples struggle for better lives. In assessing the community, the nurse describes the following: 1) Power structures in the community (formal or informal) 2) Attitudes of the people toward authority 3) Conditions/events/issues that cause social conflict/upheavals or that lead to social bonding or unification. 4) Practices/approaches that is effective in setting issues and concerns within the community. PROBLEM ORIENTED COMMUNITY DIAGNOSIS Spradley (1990) describes the problem-oriented community diagnosis as the type of assessment that responds to a particular need. For example, a nurse is confronted with health and medical problems resulting from mine tailings being disposed into the river systems by a mining company. Since a community diagnosis investigates the community-meaning, the people and its environment < the nurse proceeds with the identification of the population who were affected by the hazards posed by mine tailings. Then she goes on to characterize the environmental factors along with the other elements which are relevant to the specific problem being investigated.

COMMUNITY DIAGNOSIS: THE PROCESS The process of community diagnosis consists of collecting, organizing, synthesizing, analyzing and interpreting health data. Before she collects the data, the objectives must be determined by the nurse as these will dictate the depth or the scope of the community diagnosis. She needs to resolve whether a comprehensive or a problem-oriented community diagnosis will accomplish her objectives.

STEPS IN CONDUCTING COMMUNITY DIAGNOSIS In order to generate a broad range of useful data, the community diagnosis must be carried out in an organized and systematic manner keeping in mind that the community should take an active part in identifying community needs and problems. 1) DETERMINING THE OBJECTIVES In determining the objectives of the community diagnosis, the nurse decides on the depth and scope of the data she needs to gather. But whether she undertakes a comprehensive or a problem-oriented community diagnosis, Dever (1980) explains that the nurse must determine the occurrence and distribution of selected environmental, socio-economic and behavioural conditions important to disease control and wellness promotion. 2) DEFINING THE STUDY POPULATION Based on the objectives of the community diagnosis, the nurse identifies the population group to be included in the study. It may include the entire population in the community or focused on a specific population group such as women in the reproductive age-group or the infants and young children. There are situations, however, when a complete enumeration of the desired population is not possible. The nurse, then, may collect data from a subset of the population. 3) DETERMINING THE DATA TO BE COLLECTED Whether the community diagnosis is going to be comprehensive or focused on a specific problem, the objectives will guide the nurse in identifying the specific data she will collect. She also decides on the sources of these data. Are these data available from records of agencies? Or from people themselves? 4) COLLECTION OF DATA In conducting community diagnosis, different methods may be utilized to generate health data. The nurse decides on the specific methods depending on the type of data to be generated. For example, through an ocular survey the nurse is able to determine the physical and topographical characteristics of the community. She may also interview people about

their health beliefs or she can review existing health records in the Rural health Unit. In general, we use the following methods to collect data. a) Records Review Data may be obtained by reviewing those that have been compiled by health or non-health agencies from the government or other sources. b) Surveys and Observations Can be used to obtain both qualitative and quantitative data c) Interviews Can yield first hand information d) Participants Observation Is used to obtain qualitative data by allowing the nurse to actively participate in the life of the community 5) DEVELOPING THE INSTRUMENT Instruments or tools facilitate the nurses data-gathering activities. The following are the most common instruments that the nurse uses in her data collection: a) Survey questionnaire b) Interview guide c) Observation checklist 6) ACTUAL DATA GATHERING Before the actual gathering, it is suggested that the nurse meet the people who will be involved in the data collection. The instruments are discussed and analyzed. If necessary, the instruments may be modified or simplified in order not to overburden the people who may have limitations in terms of educational preparation or available time to finish data collection. Pre-testing of the instruments is highly recommended. The data collectors must be given an orientation and training on how they are going to use the instruments in data gathering. The nurse can ask the data collectors to role-play an interview scene so that they can place themselves in an actual interview situation. During the actual data gathering, the nurse supervises the data collectors by checking the filled-up instruments in terms of completeness, accuracy and reliability of the information collected.

7) DATA COLLATION After data collection, the nurse is now ready to put together all the information. There are two types of data that may be generated. They are either numerical data which can be counted or descriptive data which can be described. To facilitate data collection, the nurse must develop categories for classification of responses making sure that the categories are mutually exclusive and exhaustive. Mutually exclusive choices do not overlap. For example: To classify sex: MALE FEMALE To classify monthly income: Below P500 P501-P1000 P1001-P1500 P1501- P2000 Exhaustive categories mean that they anticipate all possible answers that a respondent may give. For example: Family planning methods: Lactational Amenorrhea Method Natural Basal Body Temperature Cervical Mucus Method Symptothermal Method Standard Days Method Others (specify): Artificial IUD Pills Injectables Condom Others (specify): Permanent Tubal Ligation Vasectomy

In collating fixed response questions, choices must be provided which will serve as categories for the respondents answer. In some community diagnosis designs, data collectors use flashcards to help the respondents choose his answer. Open-ended question do not provide choices or categories. But the nurse can still facilitate data collection by constructing categories from answer in randomly selected questionnaires. For example: Questions: Bakit hindi kayo nagpapasuso ng inyong sanggol? Response 10: Bawal sa akin sabi ng doctor Response 27: Nagtratrabaho ako Response 30: ayaw ni mister Response 45: Masakit Response 59: Masisira ang figure ko Response 60: Medical Reason Response 62: may sakit ako Response 67: Modern at convenient ang bottle feeding Response 75: pagod na ako pagkagaling sa trabaho Response 77: Mas gusto ko magpasuso sa bote For these responses, possible categories are: Convenience responses 67,77 Medical reason responses 10, 60, 62 Personal reason responses 30, 45, 59 Economic/work reason responses 27, 75 The next step categorizing the responses will be to summarize the data. There are two ways to summarize data. One can do it manually by tallying the data or by using the computer. Tallying involves entering the responses into prepared tally sheet showing all possible responses. For example: Diseases Parasitism Diarrhea Cough Tally Mark /////-/////-/////-///// /////-/////-/////-// /////-/////-/////-/////-/////-/////-/// Frequency 20 17 33

When computers are going to be used in summarizing result, the responses are given numbers or codes.

For example: Sex Male Female Catholic INK Methodist Aglipayan 1 2 1 2 3 3

Religion

8) DATA PRESENTATION Data presentation will depend largely on the type of data obtained. Descriptive data are presented in narrative reports. Examples of data appropriate for descriptive presentation are geographical data, history of a place or beliefs regarding illness and death. Numerical data may be presented into table or graphs. Tables or graphs are useful in showing key information marking it easier to show comparisons including patterns and trends. The choices of graphs will depend on the type of data being presented. TYPES OF GRAPH Line graph Bar graph/pictograph Histogram/frequency polygon Proportional or component bar graph Scattered diagram 9) DATA ANALYSIS Data analysis in community diagnosis aims to establish trends and patterns in terms of health needs and problems of the community. It also allows for comparison of obtained data with standard values. Determining the interrelationship of factors will help the nurse view the significance of the problems and their implications on the health status of the community. DATA FUNCTION Shows trend data or charges with time or age with respect to some other variable. For comparisons of absolute or relative counts and rates between categories Graphic presentation of frequency distribution or measurement Shows breakdown of a group or total where the number of categories is not too many Correlation data for two variables

10) IDENTIFYING THE COMMUNITY HEALTH NURSING PROBLEMS Community health nursing problems are categorized as: a) Health Status Problems They may be described in terms of increased or decreased morbidity, mortality, fertility or reduced capability for wellness; b) Health Resources Problems They may be described in terms of existence of social, economic, environmental and political factors that aggravate the illness-inducing situations in the community. 11) PRIORITY-SETTING After the problems have been identified, the next task for the nurse and the community is to prioritize which health problems can be attended to considering the resources available at the moment. In priority-setting, the nurse makes use of the following criteria: a) Nature of the condition/problem presented The problems are classified by the nurse as health status, health resources or health related problems; b) Magnitude of the problem This refers to the severity of the problem which can be measured in terms of the proportion of the population affected by the problem; c) Modifiability of the problem This refers to the probability of reducing, controlling or eradicating the problem; d) Preventive potential This refers to the probability of controlling or reducing the effects posed by the problem. e) Social Concern This refers to the perception of the population or the community as they are affected by the problem and their readiness to act on the problem.

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Below is the scoring system utilized by the nurse in deciding which of the problems need to be prioritized: CRITERIA Nature of the problem Health Status Health Resources Health related Magnitude of the problem 75% - 100% affected 50% - 74% affected 25% - 49% affected <25% affected Modifiability of the problem High Moderate Low Not modifiable Preventive potential High Moderate Low Social Concern Urgent community concern; Expressed readiness 2 Recognized as a problem but Not needing urgent attention 1 Not a community concern 0 Source: UP College of Nursing, Community Health Specialty Group, 1989. Each problem will be scored according to each criterion and divided by the highest possible score multiplied by the weight. Then the final score for each criterion will be added to give the total score for the problem. The problem with the highest total score is given high priority by the nurse. WEIGHT 1 3 2 1 3 4 3 2 1 4 3 2 1 0 1 3 2 1 1

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