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7.4 Community assessment of behaviour

7.4 Community assessment of behaviour
Oxford Textbook of Public Health

Community assessment of behaviour

Donald E. Morisky

What makes a community?
Psychosocial and behavioural determinants of health
Conceptualizing the needs of the target population

Identifying needs

Survey techniques

Validation of response

Resources inventory

Social indicator analysis
Health service utilization

Structured group assessment
Healthy People: objectives for the nation
Surveillance and data sources
Theoretical models used in community-based research
Role of theory in behavioural assessment

The health belief model

Social cognitive theory

Theory of reasoned action

Stages of change model

Diffusion of innovation model
Community assessment of HIV/AIDS in the Philippines
Chapter References

In 1988, the Institute of Medicine of the National Academy of Science published The Future of Public Health, a report that continues to stimulate interest and discussion on the core functions of public health. In this landmark report, the Institute of Medicine recommended a shift from the traditional clinical service functions of health agencies (Walker 1989; Scutchfield et al. 1997). The report sought to define new boundaries of public health by identifying three core functions of public health—assessment, policy development, and assurance—functions that are comparable with those generally ascribed to the medical care system: diagnosis and treatment. Assessment is the analogue of diagnosis, except that the diagnosis or problem assessment is made for a community or a population. Also, assurance is analogous to treatment in that it implies that the required remedies or intervention strategies are put into place. Finally, policy development is an intermediate role of collectively deciding which remedies or intervention techniques are most appropriate and tailored for the problems identified. These core functions broadly describe what public health does as opposed to its definition. The first of these core functions, assessment, will be addressed in detail in this chapter.
This chapter focuses on the process of community health assessment and improvement, including the conceptualization of community factors that influence health and health behaviour. In addition, the variety of approaches and techniques employed in conducting a needs analysis are described. Healthy People 2010 is used as an example of a comprehensive data assessment technique, in which goals and objectives are identified and quantified. The dependence of national and state data-gathering systems provides a solid basis for the establishment of national objectives (US Department of Health and Human Services 2000).
In order to develop and implement community-based programmes that address the social and psychological determinants of health-related behaviours, a solid theoretical and conceptual framework is required. This chapter identifies several psychosocial and sociostructural/environmental theories which have guided programme implementation and evaluation. A set of examples is presented as to how investigators and communities have employed needs analysis techniques in the development of their intervention strategies. Also, examples of how communities have benefited from scientifically validated behavioural, environmental, and psychosocial assessment of determinants of major health concerns are presented. Finally, a detailed overview of the needs assessment processes in a large-scale community HIV/sexually transmitted disease prevention programme in the Philippines is presented.
Community health assessment is a dynamic process undertaken by an investigative team of health professionals to identify the health needs of the community, resulting in prioritizing health concerns and collaborative action planning. Both quantitative and qualitative assessment procedures are employed in gathering the necessary information specific to the target population. The quantitative assessment provides the numerical indicators, along with its statistical parameters; qualitative assessment involves descriptive information that supplements and complements these statistical data. Quantitative assessment provides answers to who and how much; qualitative assessment provides answers to the why and how.
What makes a community?
Traditionally, a community has been thought of as a geographical area with specific boundaries, such as census tracts, ‘zip’ or postal code areas, a neighbourhood, city, county, or state. However, in the context of community health, ‘community’ is defined as a group of individuals sharing a common characteristic. Communities can be defined by location, race, ethnicity, age, work site, interest in particular problems or situation in life, health concern, or common bonds (Glasgow et al. 1997; VanEenwyk 1997; Han et al. 1999). Examples of communities include the individuals residing in the city of Los Angeles (location), the Asian community (race), the Hispanic community (ethnicity), senior citizens (age), the hotel industry (occupation), the homeless (specific population), individuals on public assistance (particular outcome), patients with hypertension (health concern), or church members (common bond). A community may be as small as a group of students in a particular class or as large as all the individuals who make up an entire nation.
Community health, which is a component of the field of public health, includes both private and public (government) efforts of individuals, groups, and organizations to promote, protect, and preserve the health of those in the community. Community health is the sum of all governmental and non-governmental efforts. Community health includes personal health, which is made up of individual actions and decision-making activities that affect the health of an individual or his or her immediate family members. These activities may be preventive or curative in nature but seldom do not primarily affect the behaviours of others. Choosing not to smoke, to engage in physical exercise, to wear a seat belt regularly, and to visit the doctor are all examples of personal health decisions (Pinder 1994).
Community health activities are those that are aimed at protecting or improving the health of a population or a community. Maintenance of accurate vital health statistics (birth and death records), sanitation services to protect the food and water supply, and participating in fund-raising activities for a voluntary health organization are all examples of community health activities (McKenzie et al. 1999).
Psychosocial and behavioural determinants of health
There are a number of factors that affect the health of a community, and for this reason, the health status of each community is quite different. These factors may be physical, social, and/or cultural. They also include the ability of the community to organize and work together as well as the individual behaviour of individuals in the community. Physical factors include the influences of geography, such as the climate and altitude. In tropical countries where warm humid temperatures and rain prevail throughout the year, parasitic and infectious diseases are a leading community health concern. Other physical factors include the quality of our environment, community size and population density, and industrial development. Industrial development, like size, can have either positive or negative effects on the health status of a community. Industrial development provides a community with increased resources for community health programmes but may also bring with it environmental pollution and occupational illnesses. Communities that experience rapid industrial development need to regulate the manner in which industries obtain raw materials, discharge byproducts, dispose of wastes, treat and protect their employees, and clean up environmental accidents. Unfortunately, many policy regulations are often passed only after these communities have suffered significant reductions in the quality of their life and health (American Thoracic Society 1996).
Social and cultural factors are also important in the health of a community. Social factors include those interactions that arise from individuals or groups within a community. For example, individuals who live in urban communities, where life is fast-paced, experience higher rates of stress-related illnesses than those who live in rural communities, where life is more leisurely. Conversely, the health-related resources in rural areas may not be equivalent to the urban areas. Cultural factors arise from guidelines (both explicit and implicit) that individuals ‘inherit’ from being a part of a particular society. These guidelines tell them how to view the world and how to behave in relation to other people, to supernatural forces, and to the natural environment.
The beliefs, traditions, and prejudices of community members can also affect the health of a community. The beliefs of those in a community about such specific health behaviours as exercise and smoking can influence policy makers on whether or not they will spend money on hiking trails or no smoking legislation (Moskowitz et al. 1999). The traditions of specific ethnic groups can influence the types of foods, restaurants, and services available in a community. Prejudice in one specific ethnic or racial group against another can result in acts of violence and crime. Racial and ethnic disparities will continue to put certain groups at greater risks.
National as well as local economies can affect the health of a community through reductions in health and social services. An economic downturn means that lower tax revenues will be available for programmes including public assistance and community health care. This occurs because revenue shortfalls cause agencies to experience budget cuts. With less money, communities often must alter their eligibility requirements, thereby restricting aid to only the most needy individuals.
Individuals in political office, either nationally or locally, can also improve or jeopardize the health of their community by the decisions they make (Lemen 1999). Generally, the argument is over greater or lesser governmental participation in health issues. For example, in the United States, there has been a long-standing discussion on the extent to which the government should involve itself in health care. Historically, Democrats have been in favour of such action while Republicans have been against it. However, as the cost of health care has continued to grow. Both sides now see the need for some type of increased regulation (Levin-Epstein 1999).
Religion also plays a major role in the health of a community (Ellison and Levin 1998). A number of religious organizations have taken a position on health care, such as limiting the type of medical treatment their members can receive. Some do not permit immunizations; others do not permit their members to be treated by a doctor. Still others prohibit certain foods. Some religious communities actively address moral and ethical issues such as abortion, premarital intercourse, and homosexuality (Sheard 2000).
The influence of social norms can be positive or negative and can change over time. Cigarette smoking is an excellent example. During the 1940s, 1950s, and 1960s, it was quite socially acceptable to smoke in most settings. In fact, in 1960, 53 per cent of American men and 32 per cent of American women smoked. Thus, in 1960 it was socially acceptable to be a smoker, especially if you were male. In 1994 those percentages had dropped to 28 per cent for males and 23 per cent for females, in most public places it has become socially unacceptable to smoke (Montazeri and McEwen 1997). The current lawsuit in the United States against tobacco companies by both the state attorneys general and private citizens provide further evidence that smoking is no longer socially acceptable (Novotny and Siegel 1996; Balbach and Glantz 1998).
Unlike smoking, alcohol consumption represents a continuing negative social norm in America, especially on college campuses. The normal expectation seems to be that drinking is fun, and certainly everyone wants to have fun. Despite the fact that most college students are below the legal age limit to drink alcohol, still 80 to 90 per cent of college students drink (Clements 1999). In 1997, the Harvard School of Public Health College Alcohol Study resurveyed colleges that participated in a 1993 study. The findings revealed little change in binge drinking: a slight decrease in percentage of binge drinkers and slight increases in percentages of abstainers and frequent binge drinkers (Wechsler et al. 1998).
Finally, socio-economic status has perhaps the most significant effect on health. In the United States and Western Europe, the gap in health status and mortality between those with and without economic power and social resources continues to widen. Those in the community with the lowest socio-economic status also have the poorest health and the most difficulty in gaining access to health care, primarily due to lack of health insurance in the United States. The point of entry into the health-care system for most Americans is the family doctor or the family health maintenance organization. The economically disadvantaged seldom have a family doctor. For these individuals, the point of entry is the local hospital emergency room. It is therefore not surprising that individuals with incomes below the federal poverty level have death rates twice as high as those with incomes above the poverty level (Amler and Dull 1987).
Conceptualizing the needs of the target population
In order to establish a useful and effective programme for a specific target population, programme planners must determine the needs and wants of these individuals. This procedural assessment technique is referred to as a needs assessment or analysis. Similar terms, such as social diagnosis, epidemiological diagnosis, behavioural diagnosis, educational and administrative diagnosis (Green and Kreuter 1999), and community analysis/community diagnosis are also found in the literature (Dignam and Carr 1992). The purpose of the needs assessment is to determine whether the needs of the target population are being met. This information is part of the six steps in the development and conceptualization of a health promotion/disease prevention programme. These steps consist of the following:

needs assessment

problem(s) identification

setting goals and objectives

intervention development

programme implementation

programme evaluation.
Identifying needs
Needs assessment is the process of evaluating the problems and solutions identified for a specific target population. The population can be as small as a clinical study involving patients with hypertension (Morisky et al. 1983; Ward et al. 2000), a community of individuals sharing a similar cardiovascular disease, breast cancer, or sexually transmitted disease concerns (Ward et al. 1982; Morisky et al. 1989; Tiglao et al. 1996), or a national sample of mothers with children under 2 years of age to assess breast-feeding practices (Morisky et al. 1992). Assessing needs moves beyond the information gathering of need identification, requiring evaluative judgments about problems and their solutions. McKillip (1987) identifies three models of needs assessment: the discrepancy model, the marketing model, and the decision-making model. The most popular assessment procedure is the discrepancy or gap model, in which one identifies desirable performance standards. These performance expectations are indicators of what ought to be. For example, health counsellors may be asked about performance standards on risk behaviour knowledge among programme participants, health maintenance organizations may be asked about member participation in smoking cessation programmes, or a county health department may be asked about the completion of care of patients with active tuberculosis. Once the performance standard has been defined, the next step in the analysis is performance measurement. Actual outcomes are determined for the target population on each of the performance dimensions. This is most often done by surveys, although additional needs assessment techniques are conducted, including resource inventory, social indicator analyses, utilization of services, and structured group assessment techniques.
Survey techniques
Surveys are a popular method of gathering information on needs. They provide a flexible means of assessing the expectations both of subgroups of the target population and of other audiences to the need analysis. Surveys can generate a great deal of information; they can probe knowledge, attitudes, beliefs, and opinions as well as measure behaviours and population characteristics. Surveys, however, have the potential to be expensive and complex. Three survey methods are usually considered for needs assessment: face-to-face interviews, telephone interviews, and mailed surveys.
Face-to-face interviews
The face-to-face interview allows for in-depth, person-to-person exchanges. It is the most appropriate of all survey techniques for the developmentally disabled but it is also the most expensive. Blinson et al. (1996) have estimated the cost per completed interview varied over time, ranging from a low of $US48 during the height of survey activity to $US243. The average cost per completed interview overall was $US113. Several factors contributed to the overall costs of interviews, including the economy of the community, the number of call-backs made, and local environmental conditions. Additional issues to consider in personal interviews include the question format, consisting of the use or rankings versus ratings, controlling for social desirability of responses, and readability. Use of coding of open-ended responses is also an important consideration. Pilot testing of the instrument can identify potential responses to open-ended questions, thereby eliminating their need. In cases where open-ended questions are required, the interviewer should be trained to record responses verbatim. These responses are then subjected to content analysis, in which independent investigators categorize responses into specific dimensions. For example, in a community household survey, adults ever diagnosed with high blood pressure, were previously on medication and had stopped their medication were asked ‘Why did you stop taking your medication?’ The questionnaire identified seven categorical answers and one ‘other’ response. These ‘other’ responses were categorized into doctor-related responses or patient-centred responses (Levine et al. 1982). It should be remembered that the ‘other category’ should contain the fewest proportion of responses.
Telephone interviews
This technique has become a very popular method for conducting a survey, particularly in areas having a high ratio of telephones to households. It is estimated that in the United States, approximately 98 per cent of households have a telephone (Anderson et al. 1998). With the advent of random-digit dialling and computer-assisted telephone dialling (Slade et al. 1995), easy techniques have been identified for drawing representative samples. However, telephone surveys also have certain drawbacks, including multiple call-backs for individuals not home, difficulties associated with the impersonal nature of phone contact, and distractions of the respondent. Visual aids cannot be used, so the interviewer must be able to convey verbally all information regarding response choices and skip patterns. Despite these cautions, telephone surveys tend to be the method of choice for relatively short surveys. Response rates are generally higher in telephone surveys compared with face-to-face interview—as high as 90 per cent for telephone surveys compared with as low as 54 per cent for personal interviews (Templeton et al. 1997).
Mailed surveys
A mailed survey is perhaps the most difficult assessment procedure with respect to getting participants to complete all items in the survey. Also, response rates are generally poorest among mailed surveys. Furthermore, it is impossible to follow-up on certain questions and there is no opportunity to probe on answers to highly salient issues. In all survey techniques, it is important for the researcher to assess the potential causes of non-response and the differences between the observed values in the sample compared with what may have been gained if the sample was complete, particularly when the response rate is low (Asch et al. 1997).
Validation of response
Valid assessment of personal health risk behaviours has always been a challenge to investigators. Gerbert et al. (1999) describe a study to determine if primary care patients’ disclosures of potentially stigmatizing behaviours would be affected by (a) their expectation about whether or not their doctor would see their disclosures, and (b) the assessment method. A questionnaire assessing HIV, alcohol, drug, domestic violence, tobacco, oral health, and seatbelt risks was completed by 1952 primary care patients; half were told their responses would be seen by the researcher and their doctor and half were told that their responses would be seen by the researcher only. Patients were randomly assigned to one of five assessment methods: written, face-to-face, audio-based, computer-based, or video-based. The results of the study indicated that, across all risk areas, patients did not disclose differently whether or not they believed their doctor would see their disclosures. Technologically advanced assessment methods (audio, computer, and video) produced greater risk disclosure (4 to 8 per cent greater) than traditional methods in three of seven risk areas. These findings suggest patients are not less willing to disclose health risks to a research assistant knowing that this information would be shared with their doctor and that a number of assessment methods can effectively elicit patient disclosure. Potentially small increases in risk disclosure must be weighed against other factors, such as cost and convenience, in determining which method(s) to use in different health-care settings.
Different assessment techniques may also result in less socially desirable or biased responses. It is well known that many individuals are quite embarrassed when questioned about their sexual behaviour. Liu et al. (1998) used an innovative technique to assess drug use and sexual behaviours among rural populations in China. Sensitive questions related to these behaviours were administered using a tape recorder, earphones, and an answer sheet that did not include the text. It is not known exactly how much this technique improved the validity of the assessment, but researchers identified high response rates and high completion rates of sensitive questions.
Resources inventory
Resource inventories describe the services available to a target population and reveal gaps and limitations in the service. A resource inventory may indicate underutilized services and may assist agencies and funding organizations to avoid launching services and programmes where there is already a great deal of competition. However, by itself, a resource inventory cannot indicate need. The collection of service information by type of provider and service will make the resource inventory most useful. Ward et al. (1982) described the community assessment technique utilized to identify community resources related to the control of high blood pressure in East Baltimore. Hypertension-related resources were direct (hospitals, clinics, doctor’s offices, pharmacies, dental offices) as well as indirect (churches, recreation centres, social service offices, schools, and work sites). A ‘windshield’ survey was conducted to enumerate all hypertension-related resources within a 21-census tract area comprising a health-planning district. While most of the direct services were included in the programme implementation, several indirect services, particularly churches, recreation centres, and barber (beauty) shops, proved to be important players in the programme. Without the complete identification and enumeration of hypertension-related resources in the community, the programme would not have been as effective (Levine et al. 1982, 1983; Bone et al. 1984).
Social indicator analysis
Social indicators are aggregate statistical measures that depict important aspects of a social situation and of underlying historical trends and developments. Through synthetic estimation procedures, characteristics of subgroups can be estimated from data concerning a larger group. Risk factors are social indicators that predict undesirable outcomes such as infections, injuries, or hospital admissions. Census and other national indicators, such as the Health Examination Survey or the Health and Nutrition Examination Survey in the United States are some examples. These social indicators are generally available only for large groups of individuals and are often tied to a specific geographical area.
Social indicators describe population distributions, for example, ethnicity, age, or place of residence. They describe government expenditures and other inputs, such as the number of doctors per 100 000 population. They measure social concerns such as quality of life, crime rates, and unemployment. Social indicators are often considered ‘objective’ or ‘hard data’. Finally, they reveal problems rather than solutions in a needs assessment.
Health service utilization
Examining solutions to problems involves estimating how much use will be made of the solutions. Development of a service or programme that will be used is important to all need analysis models. Few agencies or governmental units can afford to fund services that are not utilized. Use analysis is based on comparative expectations; patterns of utilization for one group may indicate patterns for another. Use can be redirected from the experience of current programmes or programmes offered to a similar population. Use can also be compared among subgroups or the target population. Statistical indicators used to define utilization include rates, ratios, and other indices such as incidence and prevalence.
Rates of infection, admissions, or services provided are basic to use analysis. A rate is a fraction, with a numerator and a denominator. The numerator comes from agency records and the denominator from the service or target population. The numerator is the number of individuals served or number of services provided; the denominator is the number eligible in the population. Because numerators are based on agency records, they are usually easier to compute than denominators. Rates apply in many areas. The incidence of a disease is the rate of new cases (numerator) occurring in a defined time period (usually 1 year) divided by the population at risk (denominator) and multiplied by some base. An infection rate is the number of individuals diagnosed with the disease divided by the number of individuals exposed and multiplied by some base. A use ratio compares two services (for example, abortions to births), characteristics of the populations (for example, number of infected men to number of infected women), or some measure of services to number of individuals served (for example, faculty to student ratios). A third assessment of use compares the fit between use and expectations. If the index is positive, use exceeds expectations; if it is negative, use falls short of expectations. Researchers often refer to this as a percentage of unmet need.
Structured group assessment
Perhaps the simplest method of needs assessment is to assemble a group of experts and concerned individuals and charge them with identifying the needs of the population served by the organization or agency. Using their knowledge and experience with the population and the services available, a need analysis committee can identify problems and their solutions. Structured groups provide a supplement and alternative approach to the need assessment techniques previously reviewed. One of the most popular structured processes is the focus group, which has been widely used in marketing to assess consumers’ reactions to products or packaging (Moore 1987). They can be used in need assessment to explore the acceptability and accessibility of proposed solutions, or to test hypotheses generated from other social indicator or use analysis. Most often, the focus group is used to explore issues in which little information is known or to identify content areas of a proposed questionnaire. Baldwin et al. (1999) describe a multisite study to determine the HIV/AIDS prevention needs of Native American out-of-treatment drug users. The investigators conducted a series of focus groups at each of their four study sites to assess various community needs. Results, many of which would not have been identified through individual surveys, indicated that group members strongly recommended direct involvement of key members of the Native American community in conducting outreach and intervention activities, involving Native American people as the sources of information, and utilizing local and tribally relevant forms of delivering the message.
Focus groups serve both as an alternative and as a supplement to survey techniques.
Nominal process groups also involve structured group processes but unlike focus groups, which are generally comprised of homogeneous members having a commonly shared concern, nominal process groups involve heterogeneous groups representing a wide variety of concerns, some shared and some unshared. It is this heterogeneity of the population that is instrumental in defining important needs in the community. Gilmore (1977) presents a detailed description of the nominal process group, including community representation, seating of group members around a table, a ’round-robin’ approach to maximize participation, silent listing of concerns, individual ranking, group ranking, prioritizing, and final selection of key concerns.
A Delphi panel is another technique used to assess social conditions and is used primarily if face-to-face interviews are not practical (Linstone and Turoff 1975). It is particularly useful when accurate, quantitative data are non-existent or where judgemental descriptive information is invaluable. A group of experts in a given topic respond to a series or rounds of questionnaires to be analysed by a single individual. Generally, the initial questionnaire is constructed in a suggestive open-ended format, so as not to restrict creative responses. Successive questionnaires, however, attempt to refine and synthesize information gathered by ranking and prioritizing opinions. The Delphi technique has been applied to a number of research issues including technological forecasting, programme development, and policy analysis. Kar (1990) has used this technique in the identification and ranking of social indicators for primary health care.
According to Judd (1972), there are three distinguishing characteristics of the Delphi process. The first is anonymity of response, which is accomplished through the use of mailed questionnaires and avoiding face-to-face interactions. Modern communication technology, such as anonymous e-mail addresses, has greatly facilitated the Delphi process and allowed an international level of participation. A second feature is multiple interactions, that is, the opportunity for respondents to revise their opinions. Finally, participants are provided with summary feedback of group responses from the previous round of questionnaires. This process facilitates a convergence of the distribution of responses expressed in terms of descriptive statistics.
After this discussion of the different types of assessment techniques, together with their strengths and limitations, this section will move on to the application of these various methods in the assessment of national health objectives for the nation.
Healthy People: objectives for the nation
For over two decades, the American Department of Health and Human Services has used health promotion and disease prevention objectives to improve the health of the American people. The first set of national health objectives was published in 1979 in Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention (US Department of Health, Education, and Welfare 1979). Five challenging goals were set to reduce mortality among four different age groups. Through the combined efforts of public health agencies across the nation, most national targets were achieved. A new set of goals and target objectives were identified for the Healthy People 2000 document, which significantly expanded the 1990 objectives. Major objectives in this document are delineated far more extensively according to demographic and socio-economic dimensions of risk. For example, major goals and objectives addressed the importance of reducing health disparities and increasing the span of healthy life for Americans. The process of formulating these objectives was based on maximum participation and consensus building among experts, professionals, and national advocacy organizations. The draft document was sent out to over 3000 organizations around the country for comment and review. The Institute of Medicine of the National Academy of Sciences carried out a series of eight regional hearings on behalf of a consortium of 300 national membership organizations, the state health departments, and the federal Office of Disease Prevention and Health Promotion. At these regional hearings, local community leaders and professionals from all sectors provided testimony on issues that needed to be addressed (Stoto et al. 1990).
The Healthy People 2010 document reflects the evolution of public health during the previous decade. New preventive therapies, vaccines, pharmaceuticals, and computerized systems have had a tremendous impact on medicine and public health practice. New partnerships are being defined between public health departments and health-care delivery organizations. Simultaneously, demographic changes reflecting an older and more racially diverse population in the United States have created new demands on the health-care system. Development of the year 2010 objectives began as early as 1996, where the stakeholders of year 2000 objectives attended a consortium meeting entitled, ‘Building the prevention agenda for 2010: lessons learned’. This meeting was complemented by numerous focus groups where consortium members discussed the current framework, goals, and objectives to assess the improvements needed to make the 2010 agenda relevant to the first decade of the twenty-first century.
In developing the leading health indicators for 2010, the American Department of Health and Human Services convened a working group of 22 members representing the Office of Public Health and Science and the Department of Health and Human Services. The potential uses of leading health indicators, the criteria to be applied in its selection, and examples of each were documented in a background report. The criteria for these indicators included the following:

audience interpretability (generally understood, relevant, and salient to the general public)

population applicability (reflects an issue that applies in important ways to the diverse national population)

problem impact (addresses a problem of substantial impact, such as increased morbidity, mortality and/or economic costs)

linked to objectives (must be linked to one or more of the 2010 objectives)

representative (reflect the state of the nation or a particular subregion)

measurable (one for which data can be anticipated from an established data source on a regular basis)

multilevel trackability (one for which data can be anticipated at multiple levels and for multiple groups—such as national, state, and country levels, as well as by age, gender and ethnicity)

sensitivity to change (over a reasonably short period of time)

profile balance (the indicators should reflect a balance among targets that does not overemphasize any one group or condition)

relevance to policy and individual action (the set of indicators should be useful in directing public and operational initiatives, that is, changes reported in the status of a measure from one period to the next should offer lessons to the policy domain that are readily interpretable).
Input from the public was critical in developing the leading health indicators. Community and citizen participation was maximized in the finalization of the goals and objectives of Healthy People 2010 by placing a draft copy on the internet and soliciting public comment. As a result of this dynamic and interactive process, leading health indicators have been identified which address important issues to diverse national populations. Each indicator is linked to one or more of the 2010 objectives and is quantified from an established data source on a regular basis. However, conspicuously missing from the 2010 objectives is a separate section dedicated to surveillance and data systems. Table 1 identifies the two broad goals for community health: (a) to increase the quality as well as the years of healthy life; (b) to eliminate disparities in health status, health risks, and use of preventive interventions among population groups. In order to reach these goals, over 360 objectives and a number of subobjectives were developed and organized as part of 26 priority areas. These areas consist of promoting healthy behaviours, promoting healthy and safe communities, improving systems for personal and public health, and preventing and reducing diseases and disorders.

Table 1 Healthy People 2010: goals and priority areas for objective setting

The proposed framework for Healthy People 2010 revolves around the vision ‘healthy people in healthy communities’. This concept is based on the idea that health improvement begins at home with what people do, individually, in families and communities to promote physical, mental, and social health. Schools, worksites, community programmes, religious institutions, voluntary organizations, senior citizen centres, and other organizations can deliver preventive health messages.
Surveillance and data sources
Public health surveillance is the systematic collection, analysis, interpretation, dissemination, and use of health information (see Chapter 6.16). Surveillance data systems provide information on morbidity, mortality, and disability from acute and chronic conditions, injuries, personal, environmental, and occupational risk factors associated with illness and premature death, and preventive and treatment services and costs. This information is used to understand the health status of the population and to plan, implement, describe, and evaluate public health programmes that control and prevent adverse health events. To be of maximum usefulness, public health data must be reasonably accurate, timely, and available in a usable form.
Numerous data sources have been identified in which surveillance information is obtained. These include the national vital statistics system, national hospital discharge data, the Health and Nutrition Examination Survey, the National Health Interview Survey, and the Behavioral Risk Factor Surveillance System, amongst others. These national data sources provide annual, continuous, and periodic measures for three or more of the 365 objectives for the year 2010. The American Public Health Service plays an important role in the development and conduct of surveillance and data collection. American Public Health Service activities include the collection and analyses of health information at the national, regional, and, when possible, state and local levels. They also assist the states and local agencies in conducting public health surveillance and evaluation of data by providing standards, definitions, methods, computer software, training, and co-ordination.
Although the American Public Health Service takes the leading role in national public health data collection activities, it is only one partner within the larger structure necessary to collect national public health data. The national vital statistics system obtains information on births, deaths, marriages, and divorces from all 50 states, New York City, the District of Columbia, Puerto Rico, the American Virgin Islands, and Guam. Programmes in each state collect vital information from many sources in local communities, including medical examiners, coroners, hospitals, and justices of the peace. Other data collection systems are based on sample surveys and depend upon the participation of thousands of private citizens nationwide. For example, the National Health Interview Survey is a continuing nationwide sample survey in which data are collected through personal household interviews. In 1987, the personal and demographic characteristics, illnesses, chronic and acute conditions, use of health resources, and other health topics were collected for approximately 123 000 individuals (NCHS 1989). In order to determine the frequency and predictors of receipt of HIV test results, over 19 000 adults were interviewed in 1994 and 1995 for the American National Health Interview Survey. Investigators used predictive modelling to determine factors independently associated with decreased likelihood of receiving HIV test results. The results indicated that an estimated 2.3 million of the 17.5 million people tested annually for HIV infection did not receive their test results (Tao et al. 1999).
Theoretical models used in community-based research
Needs analysis/assessment of the target population is the indespensable condition in the conceptualization, development, design, implementation, and evaluation of community-based programmes. Without this component, investigators would not know what particular determinants are responsible for the health-related risk-taking behaviours of their targeted populations. These determinants can be broadly categorized into internal cognitive factors (such as levels of knowledge, attitudes, beliefs, values, and predispositions) and external factors (such as access, availability, and affordability of health services, social norms, and environmental reinforcements). Health promotion and disease prevention planners know their populations and have ideas about what determines client behaviours as well as their strengths and needs as individuals and as a community.
This ‘hands-on’ knowledge about what works is termed ‘informal theory’. Whether implicit or explicit, some form of theory generally provides the foundation of prevention interventions. Formal theory is made up of principles and methods about prevention and behaviour change that have already proven useful in some areas of disease prevention and behaviour change. Theories can give programme planners a framework for establishing the rationale guiding specific intervention approaches, or help to explain aspects of risk-taking behaviour when working with a new population. Using theories to design prevention interventions can help improve programmes, saving valuable time and resources (Valdiserri 1989).
Role of theory in behavioural assessment
Theory is one of many tools that can have a significant influence on the planning of intervention programmes, based on the assessment and interpretation of needs analysis data. Many may claim that behavioural assessment is atheoretical, merely collecting data on risk factors and causes of disease. The underlying theoretical assumptions of collecting data on risk factors that have been causally linked to or associated with major diseases have rarely been examined. However, without a theoretical or conceptual framework guiding the collection of factors, determinants, and indicators of risk, an inappropriate intervention programme may be set in place, resulting in null or negative effects.
Theories generally begin their focus on the individual’s psychological process, such as attitudes and beliefs, then go into theories emphasizing social relationships, and end with structural factors to explain human behaviour. Many of the theories discussed below are used in combination with other theories, such as cognitive theories, social influence approaches, and sociostructural/environmental theories working together to address personal beliefs and attitudes as well as external influences on behaviours, such as peer influences and health provider reinforcement, and access, availability, and affordability of health services. This combination of approaches provides a strong foundation for effective programme planning and implementation. The problem of AIDS as a global epidemic concern is used as an example in each of the theoretical perspectives.
The health belief model
The health belief model, social cognitive theory, and the theory of reasoned action are examples of intrapsychic theories directed towards individual perceptions. The health belief model, developed in the 1950s (Hochbaum 1956, 1959), holds that health behaviour is a function of individual’s sociodemographic characteristics, knowledge, and attitudes. Catania et al. (1990) have conceptualized components of this model into their AIDS risk reduction model with application to the behaviour of condom use for HIV prevention. According to this model, a person must hold the following beliefs in order to be able to change behaviour:

perceived susceptibility to a particular health problem (‘Am I at risk for AIDS?’)

perceived seriousness of the condition (‘How serious is AIDS’ or ‘How hard would my life be if I got AIDS?’)

belief in the effectiveness of the new behaviour (‘If I use condoms, then I will not get AIDS’)

cues to action (witnessing the death or illness of a close friend or relative due to AIDS)

perceived benefits of preventive action (‘If I start using condoms, I can avoid HIV infection’)

barriers to taking action (‘I don’t like using condoms’).
In this value-expectancy model, promoting action to change one’s behaviour includes changing individual personal beliefs. Individuals weigh the benefits against the perceived costs and barriers to change. For change to occur, benefits must outweigh costs. With respect to HIV, interventions often target perception of risk, beliefs in severity of AIDS (‘there is no cure’), beliefs in effectiveness of condom use, and benefits of condom use or delaying onset of sexual relations.
Social cognitive theory
Social cognitive theory or social learning theory states that new behaviours are learned either by modelling the behaviour of others or by direct experience. Social learning theory focuses on the important roles played by vicarious, symbolic, and self-regulatory processes in psychological functioning and looks at human behaviour as a continuous interaction between cognitive, behavioural, and environmental determinants (Bandura 1977). Central tenets of the social cognitive theory are self-efficacy—the belief in the ability to implement the necessary behaviour (‘I know I can insist on condom use with my partner’)—and outcome expectancies—beliefs about outcomes such as the belief that using condoms correctly will prevent HIV infection.
Programmes built on social cognitive theory integrate information and attitudinal change to enhance motivation and reinforcement of risk reduction skills and self-efficacy. Specifically, activities focus on the experience people have in talking to their partners about sex and condom use, the positive and negative beliefs about adopting condom use, and the types of environmental barriers to risk reduction. A meta-analysis of HIV risk-reduction interventions that used social cognitive theory in controlled experimental trials found that 12 published interventions with mostly uninfected individuals all obtained positive changes in risk behaviour (Greenberg 1996).
Theory of reasoned action
Ajzen and Fishbein (1975) popularized the theory of reasoned action in the mid-1960s. This theory is based on the assumptions that individuals are usually quite rational and make systematic use of the information available to them. People consider the implications of their actions in a given context at a given time before they decide to engage or not engage in a given behaviour, and that most actions of social relevance are under volitional control (Ajzen and Fishbein 1975). The theory of reasoned action is conceptually similar to the health belief model but adds the construct of behavioural intention as a determinant of health behaviour. Both theories focus on perceived susceptibility, perceived benefits, and constraints to changing behaviour. The theory of reasoned action specifically focuses on the role of personal intention in determining whether a behaviour will occur. A person’s intention is a function of two basic determinants:

attitude (towards the behaviour)

‘subjective norms’ (that is, social influence).
‘Normative’ beliefs play a central role in the theory, and generally focus on what an individual believes other people, especially influential people, would expect him or her to do. For example, for a person to start using condoms, his or her attitude might be ‘Having sex with condoms is just as good as having sex without condoms’ and subjective norms (or the normative belief) could be ‘Most of my peers are using condoms; they would expect me to do so as well.’ Interventions using this theory to guide activities focus on attitudes about risk reduction, response to social norms, and intentions to change risky behaviours.
Stages of change model
The stages of change model (sometimes called the transtheoretical model), developed early in the 1990s specifically for smoking cessation by Prochaska and colleagues (Prochaska and DiClemente 1992; Prochaska et al. 1992), posits six stages that individuals or groups pass through when changing behaviour: precontemplation, contemplation, preparation, action, maintenance, and relapse. With respect to condom use behaviour, the stages could be described as follows.

Has not considered using condoms (precontemplation).

Recognizes the need to use condoms (contemplation).

Thinking about using condoms in the next months (preparation).

Using condoms consistently for less than 6 months (action).

Using condoms consistently for 6 months or more (maintenance).

Slipping-up with respect to condom use (relapse).
In order for an intervention to be successful it must target the appropriate stage of the individual or group, for example raising awareness between stages 1 and 2. Groups and individuals pass through all stages, but do not necessarily move in a linear fashion (Prochaska and DiClemente 1992). As with previous theories, the stages of change model emphasizes the importance of cognitive processes and uses Bandura’s concept of self-efficacy. Movement between stages depends on cognitive–behavioural processes.
Diffusion of innovation model
The diffusion of innovation model provides an understanding of how new ideas or behaviours are introduced and become accepted by a community. People in the same community adopt new behaviours at different rates and respond to different methods of intervention (Rogers 1983). The diffusion of innovation model provides a useful framework for examining the adoption of a new behaviour. This model categorizes individual behaviour change into five stages: awareness, interest, persuasion, decision, and adoption. Individuals pass through these stages and adopt new behaviours at different rates. The model classifies these different rates of change by dividing the population into five groups: innovators, early adopters, early majority, late majority, and laggards. When a new behaviour is introduced into a population, the cumulative curve follows an S-shaped pattern, as more individuals reach the fifth stage and adopt or internalize the new behaviour.
The diffusion of innovation theory is closely linked to the stages of change model of behaviour change. Both the diffusion of innovation theory and the stages of change models are based on the assumption that individuals pass through several stages before successfully achieving behaviour change. The major distinction between these two models is that the stages of change model limits examination of behaviour change to the individual level, while diffusion of innovation goes beyond the individual to describe behaviour change in a population. The stages of change model explains the process of behaviour change, from not being aware of the negative effects of a behaviour, to maintaining safer behaviours. The stages of change model has traditionally been used to analyse the cessation of addictive behaviour from a psychological perspective. However, if the stages of change model is expanded and viewed from a community/public health perspective, the two models appear to have many shared components. Figure 1 presents the comparative features of these two theoretical constructs and potential linkages of stages of behavioural change in the models.

Fig. 1 An integrative model of diffusion of innovation and the transtheorectical model.

Community assessment of HIV/AIDS in the Philippines
Asia has been identified as the next epidemic zone for AIDS in the world, following sub-Saharan Africa. The countries in Asia with the highest estimate of HIV/AIDS are India, Thailand, Cambodia, Myanmar, and Vietnam (UNAIDS 2000). However, there is considerable variability with respect to the number of reported cases within Asia. For example, as of January 2000, the Philippines, with an estimated population of 75 million, reports a total of 1336 AIDS documented cases. The estimated number of HIV-infected people amounts to 40 000. In contrast, Thailand with a population of approximately 61 million reports over 70 000 cases as of 1997 and an estimated 800 000 people infected with HIV. Sentinel surveillance involving serological testing of high-risk populations has been conducted in each of these countries. However, in the Philippines, seroprevalence assessment has been discontinued in two regions and replaced with behavioural sentinel surveillance assessments owing to the small numbers of high-risk groups and very low seropositivity rates. There are a number of reasons speculated by researchers for the significantly lower infection rate in the Philippines, including the lack of a viral pool, very low levels of injectible drug use, geographical dispersion of the population in an archipelago of over 7100 islands compared with one contiguous country, low number of weekly sexual partners among commercial sex workers, and the presence of government-sponsored social hygiene clinics throughout the country.
In 1994, a community behaviour assessment was conducted in four communities in the southern Philippines, as part of a 4-year National Institute of Allergy and Infectious Diseases funded research on behavioural interventions in support of HIV/AIDS prevention (Morisky et al. 1995). The study was undertaken in areas where many of the high-risk workers are employed and where interventions focusing on behavioural aspects of HIV/AIDS prevention were not adequately developed. The behavioural assessment conducted during the first year of the research study served as a basis for the development and conceptualization of targeted educational interventions directed towards managers and supervisors of commercial business establishments (such as bars, night clubs, karaoke clubs, and so on) and their female employees, also known as guest relation officers. Table 2 identifies the various needs assessment strategies conducted in each locality, beginning with a situational analysis of the community. This assessment procedure provides invaluable information on the resources related to AIDS prevention in the community, including existing services provided by governmental and non-governmental agencies. The social hygiene clinic, under the City Health Department, provides weekly clinic examinations for all guest relation officers. The City Health Department requires that all employees of bars, night clubs, karaoke centres, and massage parlours be registered in the local social hygiene clinic and undergo weekly examinations. The social hygiene clinic is staffed with a doctor, nurse/midwife, and medical technologist. All guest relation officers attend the same weekly schedule according to the type of establishment. Unobtrusive observations were conducted in each social hygiene clinic in order to assess registration/attendance procedures, interpersonal communication techniques between client and staff, and opportunities for educational interventions in the clinic during examination waiting time. Independent focus group discussions were conducted for guest relation officers and their managers or supervisors of the various establishments to assess knowledge of HIV/AIDS, attitudes regarding AIDS prevention, satisfaction with social hygiene clinic visits, condom use behaviour, and the role of the manager/supervisor in reinforcement of safe sexual behaviours (Tiglao et al. 1996). Retrospective record reviews of all currently registered guest relation officers were conducted in each clinic to provide baseline data on clinic attendance, and the results of the clinic examination. Structured personal interviews were held with both managers/supervisors and guest relation officers. Finally, continued monitoring of weekly social hygiene clinic attendance by the guest relation officers and examination results provided ongoing assessment information. Social hygiene clinic attendance was conceptualized as a ratio of number of weeks attended during the month and the number of weeks actually worked during that month. This measure quantifies clinic attendance based on ‘at-risk behaviour’.

Table 2 Community assessment techniques: HIV/AIDS prevention in the Philippines

The needs assessment was instrumental in identifying educational and organizational behaviour change strategies to be tested using a quasi-experimental design in the four communities. It was apparent that the managers/supervisors of the establishments played a critical role in the reinforcement of AIDS-related knowledge, attitudes, and safe sexual behaviours. It was also identified in the interviews that a small group of guest relation officers were interested in being trained in HIV prevention techniques to serve as peer educators in their respective establishment. Consequently, from this broad community assessment, a four-group quasi-experimental design was implemented in the four study sites, consisting of a peer education strategy, manager/supervisor training, the combination of peer educator and manager training, and a standard control site.
Programme monitoring is an essential ingredient in ongoing community assessment. Both process assessments (documentation that activities took place, such as training programmes, distribution of educational materials) and formative evaluation assessments (reviewing clinic records for completion, ensuring completion of interviews, monitoring attendance) are critical to the success of the programme. Process assessment is not evaluative in the sense that it provides information as to whether or not the outcome was successful or unsuccessful, it only provides information that the activity or intervention took place. However, this type of assessment is of major importance because if at the end of the programme no effect is found, then a question remains over whether the programme was implemented as originally conceptualized. Documenting the time, place, and amount provides an audit trail in which the investigator can assess critical links in the chain of events that make a programme successful. Formative assessment is evaluative in the sense that data collection instruments are assessed immediately in order to ensure that information is recorded accurately and whether or not changes in impact (knowledge, attitudes, or beliefs) are being noted as a result of the intervention activities. If this is found not to be true, then the programme manager needs to modify the intervention activities, such as making group sessions more convenient so as to maximize attendance or provide child care to participants who cannot otherwise attend because of household responsibilities.
Predictors of appointment-keeping behaviour included knowledge of HIV transmission, self-efficacy in communication skills, and positive reinforcement from establishment managers (Sneed and Morisky 1998). Guest relation officers were more than twice as likely to report consistent use of condoms if managers made these available at the establishment, in the presence of an establishment rule concerning the use of condoms with customers, and if they had ever attended an educational seminar on AIDS prevention. The significance of an organizational policy regarding safe sexual practices among guest relation officers is evidenced by the lower rate of sexually transmitted diseases among establishments having an educational policy. The sexually transmitted disease rate was 40 per cent lower among guest relation officers working in establishments in which educational policy was enacted and enforced (3.5 per 100 clinic visits versus 4.9; p < 0.001).
Behavioural assessment is a critical component in the conceptualization and design of community-based intervention programmes. It is often identified as one of the most important aspects of public health surveillance. As indicated in this chapter, surveillance is at the centre of an epidemiological approach to public health and community assessment of behavioural indicators occupies a key role in the social science concerns of public health. Regardless of the perspective, the perceived need is clear for systematic information relating to the mission of public health to promote, protect, and preserve the health of the public. If progress is to continue in meeting the goals and objectives for the nation in 2010, particularly with respect to the improvement of quality of life for all and removal of health disparities, the most scientifically valid and culturally appropriate techniques must be employed for community assessment. New partnerships are being realized between data collectors, data analysers, and data users as well as between governmental and non-governmental organizations. The challenge to these partnerships is to refine these data surveillance techniques in order to provide the most accurate, valid, and useful indicators resulting from community behavioural assessment. Once this is accomplished, the findings need to be translated into treatment and prevention interventions that can be incorporated into community health delivery systems.
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