Familiarization Approach: Nurse have information of community.
Chapter 15 Community Assessment
Sergio Osegueda Acuna, MSN-FNP-BC
MRC
Community assessment: application to community/public health nursing practice
Assessment, the first step of the nursing process, forms the foundation for determining the client’s health, regardless of whether the client is an individual, a family, or a community.
Nurses gather information by using their senses, as well as their cognition, past experiences, and specific tools.
These data are analyzed to make diagnoses about the community’s health status and allow the nurse to answer the question, “How healthy is this community, or what are its strengths, problems, and concerns?”
Components of Healthy Communities
Low crime rates
Good schools
Strong family life
Robust economy, good jobs
High environmental quality (clean air, water)
Accessible and quality health services
Adequate housing
Civic involvement
Nice weather
Good transportation (roads, public transportation)
Wide variety of leisure activities
Exposure to the arts
Reasonable taxes
Community defined
Community is defined as an open social system that is characterized by people in a place who have common goals over time.
Aggregate is any number of individuals with at least one common characteristic (Williams, 1977). The terms population group and aggregate are synonyms for population (Williams, 1977)
Population is a collection of individuals who share one or more personal or environmental characteristics, the most common of which is geographical location (Schultz, 1987).
Critical Components of a Community
People, Population is the most obvious of the necessary community components.
Place, traditionally, communities were described in relation to geographical area.
Social interaction or common characteristics, interests, or goals.
Geopolitical
The geopolitical community is a spatial designation—a geographical or geopolitical area or place.
Geopolitical communities are formed by either natural or human-made boundaries. A river, a mountain range, or a valley may create a natural boundary
Human-made boundaries may be structural, political, or legal.
Political boundaries may be exemplified by congressional districts or school districts.
Phenomenological
Another way of thinking about community is in terms of the members’ feeling of belonging or sense of membership, rather than geographical or political boundaries
People in a phenomenological community have a group perspective that differentiates them from other groups.
A group consists of two or more people engaged in an interdependent relationship that includes repeated face-to-face communication.
A group’s identity may be based on culture, beliefs, values, history, common interests, characteristics, or goals.
Social Interaction or Common Interests, Goals, and Characteristics
Communities, similar to families, have their own patterned interaction among individuals, families, groups, and organizations; this interaction varies from community to community depending on needs and values.
In a geopolitical community, this interaction may go beyond talking to one’s neighbor and may include interactions with agencies and institutions within the community.
A phenomenological community exists because of a common interest or feeling of belonging (Dreher & Skemp, 2011).
Nursing Theories Applicable to Community Assessment
Most nursing theories were developed for individual clients, not communities (Alligood & Marriner-Tomey, 2010; Hanchett, 1988).
Many nursing theories view the community as the environmental system influencing individuals and families.
Only a few nursing theories view the community as client (Hamilton & Bush, 1988). Goeppinger and colleagues (1982) proposed the development of a community assessment tool using Cottrell’s characteristics (1976) of a competent community as a framework.
Community competence is based on eight variables:
Commitment
self and other awareness and clarity of situation definitions
Articulateness
Communication
Conflict containment and accommodation
Participation
Management of relations with the larger society
Machinery for facilitating participant interaction and decision making
Basic Frameworks Used to Assess Communities
Developmental Framework Information about the community is collected from several points in time because communities change
Epidemiological Framework An epidemiological perspective focuses on the health of the population. In this approach to community assessment, the nurse identifies persons who are at greater risk of illness, injury, disability, and premature death so that targeted interventions aim at reducing the risk or preventing the problem
Health Disparities and At-Risk/Vulnerable Populations
Structural–Functional Framework
Overview of Systems Theory
Dorothy Johnson:
Successful community functioning and adjustment to environmental factors
Sister Callista Roy:
Effectiveness of the community in accomplishing its functions and adapting to external stimuli
Imogene King:
Quality interactions between individuals, groups, and the entire community that contribute to community functioning and development
Betty Newman
Competence of the community to function and maintain balance and harmony in the presence of stressors
Jean Watson:
A healthy community is a holistic community, one which is able to integrate social and personal resources and capacities to attain or maintain health for its members
Boundaries
A community is defined in terms of the three critical components: people, place, and social interaction or common interests.
Defining the boundary also identifies the suprasystem, the environment outside the community.
Data collected from the suprasystem are considered external influences, or inputs, and may impact or influence the community.
Boundaries, similar to the skin of an individual, maintain the integrity of the system and regulate the exchange between a community and its external environment, the suprasystem.
Permeability of Boundaries
The boundaries of any system may be relatively permeable (open) or impermeable (closed).
A geographical community that has a gated entrance and homes that cost $350,000 or more is impermeable to people with an annual income of $25,000 to $30,000. Communities with greater variety of housing prices and rental units would be open to more people; thus the boundaries would be permeable.
For example, entrance or membership into a religious community may be contingent on accepting certain beliefs and rituals, making the boundary impermeable to someone who does not hold these beliefs.
Suprasystem
Once you have determined the boundary of the community, anything outside the boundary becomes the suprasystem.
No system (individual, family, or community) can exist in isolation.
Therefore, every client system operates within a larger system.
The larger system, the suprasystem, is defined as the environment external to, or outside of, the community that affects the community system.
In a phenomenological community, the suprasystem becomes anything outside of the community that affects or is affected by the community. Identifying a single suprasystem for a phenomenological community is sometimes difficult; many suprasystems may be found.(Older population)
Goals
Goals of communities vary with the type of community, but in general, they are focused on maximizing the well-being of members, promoting survival, and meeting the needs of the community members.
What are the goals of the community in which you live?
Are they to provide safe housing for residents?
The community health nurse can assess the goals of the community by asking questions such as, “What is the purpose of the community?”.
Characteristics
Characteristics are the physical, biological, and psychosocial factors of the community.
These characteristics are often referred to as demographics.
Characteristics are usually not easily changed, or they change slowly.
Physical characteristics include (1) the length of time the community has been in existence, (2) pertinent demographic data about the community’s members (e.g., age, race, gender, ethnicity, education, income, housing, density of population), and (3) physical features of the community that influence behavior.
Psychosocial Characteristics
Religion: Beliefs may involve the use or nonuse of contraceptives, abortion, living will, circumcision, and organ donation.
Socioeconomic level: Poverty reduces access to health care services and increases health risks.
Educational level: Higher education levels are associated with higher rates of preventive health behaviors.
Occupation: A person’s livelihood may influence the risk of disease or injury. For example, coal miners are prone to silicosis and lung cancer, computer users to carpal tunnel syndrome, or sedentary white-collar professionals to coronary artery disease.
External Influences
Money. Outside sources would include taxes, state or federal funds, contributions, grants, or endowments.
Facilities. Look for the following potential outside facilities: health care facilities such as hospitals, health maintenance organizations (HMOs), nursing homes, home care agencies, and facilities and clinics that promote safety and transportation.
Human services.
Health information.
Legislation.
Values of the suprasystem.
Internal Functions of the Community
Internal functioning of the community occurs through its internal structures and processes.
For the purpose of data collection and analysis, the tool examines four functional areas: economy, polity, communication, and values (University of Maryland School of Nursing, 1975)
Asset models of community assessment stress the positive abilities and capacities of communities to identify their own health problems and plan solutions.
Community resiliency is the ability of a community to use its assets and resources to adapt to adversity and improve its capacity (Kulig, 2000; Moorhead et al., 2008; Racher & Annis, 2008).
Economy
Human services. Services available within the community may be either formal (e.g., nurses and physicians) or informal (e.g., volunteers).
Money. What is the budget? How does the community get its money? How is revenue generated from within the community? What are the fund-raising activities? For what is the money spent?
Facilities, equipment, and goods.
Education. Education assists people in learning how to function productively in society so it is included in this subsystem. How are the members educated?
Polity
Polity is the politics of a community. The goal of polity is coordination, control, and direction of activities to maintain the community and attain the system goals. Formal government, as well as informal leadership, serves these functions.
The polity subsystem of a community provides:
Organizational structure.
Leadership. Both formal and informal leadership are present in any group; identifying both types is important.
Decision making or problem solving.
Social control. This refers to the rules and norms of a community that affect behavior.
Communication
The goal of the communication subsystem is to provide identity and support to its members—that is, to provide a sense of belonging.
People in the community offer group participation in exchange for support and identity from the community.
The communication subsystem includes the many affective relationships that exist among community members.
These relationships provide the emotional tone of the community.
Emotional tone is communicated through nonverbal as well as verbal communication.
Values
The goal of the values subsystem is to provide guidelines for behavior.
This component addresses the general orienting principles that guide the socialization and behavior of members of the community.
Community members accept and conform to the standards of the community in return for approval.
The patterns of behavior that are examined include:
Traditions. Traditions often reflect the ethnic background of a community’s members and can also vary with the age of the community.
Subgroups.
Aesthetics and environment.
Health.
Homogeneity.
Outcomes (Health Behavior, Health Status, Community Competence)
Outcomes include measurable, health-related behaviors and health status of the populations in the community. Outcomes also include community competence. Outcomes influence the community and its suprasystem(s). The health status of the community includes two interrelated factors: people and environment.
Identifying trends in health behavior and health status over time, rather than simply looking at health behaviors at one point in time, gives a clearer picture of health outcomes.
People Factors
Growth trends. The stability and growth of the community have implications for health and health planning. Therefore, the nurse must examine the current size of the community and compare it with its original size or size at a particular point in time.
Trends in mortality and morbidity.
Vulnerable aggregates and risky behavior.
Prevalence of presymptomatic illness.
Level of social functioning. What is the level of social functioning in a community? The level of social functioning refers to the quality of life and the relationship of dependency to independency in a community.
Disabilities and impairments.
Environmental Factors
Environmental factors include the physical and the social environment.
Indicators of the health status of the physical environment include the air, food, and water quality; the adequacy of housing; and the quality of home, school, and work sites.
Solid waste disposal and hazardous waste disposal are also relevant.
Feedback
Feedback may be internal or external:
Internal feedback is information from within the community that helps the community monitor its functioning. For example, if the city council or township receives information that tax revenues are lower than projected, the community may need to modify its budget and reduce spending.
External feedback is information from the suprasystem and larger environment about a community’s functioning. For example, community health nurses within a local health department may receive information about new state guidelines that require directly observed medication therapy for persons with newly diagnosed tuberculosis.
Tools for data collection
Personal Observation
Use your eyes, ears, nose, hands, and body to inspect, auscultate, palpate, and percuss the community:
Eyes. What do you see? Describe the people, what they are doing, and the environment.
Nose. Smell the environment. Is it pleasant, polluted, fresh, or stale?
Ears. Is the community noisy or quiet? Are the people talking to one another?
Palpate and percuss. What is the feeling of the community? Is it warm, open, and friendly, or is it cold, hostile, and suspicious?
Existing Data Sources: Secondary Data
National Sources:
The National Center for Health Statistics, a federal agency established to collect and disseminate data about the health of U.S. residents, conducts the National Health Interview Survey.
The United States Government Manual is a good reference for information about federal programs and agencies that have health data.
The U.S. Census Bureau collects information on the demographic characteristics (age, gender, race, ethnicity, socioeconomic level, marital status, educational level, and housing) of the U.S. population every 10 years
Many special interest groups collect and publish data about their particular group. For example, the American Heart Association, the American Lung Association, and MADD have publications that provide useful information about their respective topics and the aggregate characteristics
Existing Data Sources: Secondary Data
State and Local Sources:
Local and state health departments collect and disseminate information about the vital statistics in their localities.
County and city planning and zoning boards often have current demographic data and a list of many resources.
Health department websites, agency records, libraries, business people, the clergy, telephone books, and service directories are additional sources of information.
Surveys:
If you cannot locate sources of data for the community under study, you may need to develop a survey to obtain needed information.
The purpose of a survey might be to collect demographic data, obtain information on assets and problems, conduct a needs assessment, identify utilization patterns of services and facilities, or determine health interests of community members.
Existing Data Sources: Secondary Data
Interviews with Key Informants:
Interviews with key informants—people in the community and leaders of the community—are valuable sources of data.
Interviews may be open ended in which the interviewer starts by asking a few broad questions.
Interviews also may be highly structured, using formal surveys.
Meetings with Community Groups:
Community forums are regular or special public meetings that provide an opportunity to obtain input from members of the community regarding their opinions about needs, services, or specific health-related topics.
Focus groups are conversations held in a group with a small number of people (usually 5 to 10) to identify different perceptions and experiences about a subject (Polit & Beck, 2010).
Geographical Information Systems
Geographical information systems (GIS) are computer-based programs used to store and statistically manipulate geographical and location-based data to provide visual maps.
Traditionally, public health professionals plotted communicable disease outbreaks on wall maps; these could be overlaid with transparent sheets to show changes in cases over time.
Data can include demographics, morbidity and mortality, cases of communicable diseases, reported health behaviors, housing types, distribution of health facilities and services, and sources of environmental exposures, among others.
This assists public health practitioners to analyze health disparities, disease outbreaks, availability and use of resources, and the relationship of environmental exposures with health problems
Approaches to community assessment
Comprehensive Needs Assessment Approach:
Comprehensive needs assessment is the most thorough assessment of the community; it is also the most traditional and the most time consuming.
In the comprehensive approach, the nurse begins with the total community (geopolitical or phenomenological) and uses a systematic process to assess all aspects of the community to identify or validate actual and potential health problems.
Problem-Oriented Approach.
Single Population Approach:
In the single population approach, the community/public health nurse assesses one population in a community (e.g., women of reproductive age, teenagers, homeless persons, migrants).
The nurse begins the process with defining the population and then assesses the population in a specific community.
Familiarization Approach: Nurse have information of community.
Analysis
When applying a systems analysis to the data, three parameters are used to make inferences about the level of health:
Congruency must exist among the physical, psychological, and social data and imperatives.
The community requires a minimum amount of energy to function (efficiency).
The health status behaviors must be satisfying to the population and the community
Through analysis of the relationships between the component parts of a community system and its external environment (suprasystem), the health status of the community may be determined; its strengths, assets, and health needs identified; priorities established; and programs planned and implemented.
