Chapter 8: Utilize epidemiology data

8.1 Community health diagnosis

Community health diagnosis is the process of using data and the views of community members to describe the health of a defined community, find its main health problems and their causes, and rank those problems so that action can be planned. A clinician examines one patient and names the illness; a community health assistant examines a whole community and names the problems that most need attention. The result is a short written statement and a ranked list of problems that the community health unit, the community health committee and the nearest health facility can use to plan their work.

A community health unit usually serves about 1,000 households, roughly 5,000 people, and each community health promoter (CHP) visits about 100 households. This is the natural size for a community health diagnosis: small enough for the promoters to know every household, large enough for the figures to show real patterns.

Community health diagnosis compared with clinical diagnosis

What the diagnosis describes

• The population: how many people live in the area, their ages, sex, occupations, household sizes and where they live, because every rate needs a population to divide by.
• Health problems: the illnesses, deaths, nutrition problems and gaps in services such as low immunisation coverage, each stated with a number.
• Determinants: the conditions that cause or sustain the problems, such as unsafe water, few latrines, crowded housing, low income, long distances to a health facility and harmful beliefs.
• Strengths and resources: the people, groups, services and local customs that can help, such as an active community health committee, a protected water point or a women's group.

Who takes part

The community health assistant leads the work and the CHPs supply household information from their registers. The community health committee, village elders, local administration, faith and youth leaders and women's groups give their views and help the findings to be accepted. Staff of the nearest health facility share their records and receive the findings. Household and patient information is confidential: results are shared as totals for the whole community or village, never with names.

8.1.1 Steps in community health diagnosis

The diagnosis follows a fixed order so that nothing is missed and the final statement rests on evidence. Methods of collecting data such as observation, interviews, questionnaires and focus group discussions are taught under Identification of data collection methods. Here they are used within the steps.

1. Define the community and prepare. Mark the boundaries of the community health unit, list its villages and households from the CHPs' registers and count the population by age group and sex. Meet the community health committee and local leaders, explain why the diagnosis is being done and agree on who will help.

2. Collect the data. Start with records that already exist: the household register, immunisation and antenatal records, the community health information system and the figures of the nearest health facility. Add what is missing by observing water points, latrines and hand-washing facilities, visiting households and holding discussions with groups. Record who gave each piece of information and when.

3. Organise and analyse the data. Count cases and deaths, then turn the counts into rates and proportions so that villages of different sizes can be compared fairly. Describe each problem by person, place and time: who is affected, where, and in which months. The worked example after these steps shows the calculation.

4. Identify the problems and their determinants. List the problems the data show and ask why each one occurs. Look at water source and treatment, sanitation, hand washing, nutrition, housing, income, distance to services and local beliefs. The worked example after these steps shows what the promoters found.

5. Set priorities. Rank the problems with criteria that everyone can see. Common criteria are how many people are affected, how serious the problem is, whether it can be prevented or treated with the means available and how strongly the community feels about it. A simple grid gives each criterion a score from 1 (low) to 3 (high). The scores are a guide to discussion, not a final answer.

6. Write the community health diagnosis statement. A good statement names the problem, the group affected, the place, a measure and the main causes in one or two sentences.

7. Share the findings with the community and confirm them. Present the results at a community dialogue meeting in plain language, with charts or maps the community can read. Listen to corrections, add what people know that the data missed and agree together on the priority problems. A problem the community has agreed on is far more likely to be acted on.

8. Hand over for planning and repeat. Give the agreed statement and priority list to the community health committee and the health facility team so that they can plan the response. Keep the data and the statement on file as the baseline against which later results are compared, and repeat the diagnosis when the data change or whenever the community health committee and the health facility team agree that it is due.

Worked example: diarrhoea in a community health unit

A community health unit has 800 children under five. In the last three months, 60 of them had at least one episode of diarrhoea. In Village A, 45 of 450 children were affected; in Village B, 15 of 350.

Proportion in the unit = 60 ÷ 800 × 100 = 7.5%

Proportion in Village A = 45 ÷ 450 × 100 = 10%

Proportion in Village B = 15 ÷ 350 × 100 = 4.3%

The comparison shows that Village A carries most of the problem, and the search for causes turns to that village. The promoters find that most households in Village A draw water from an unprotected spring and few have a hand-washing facility near the latrine.

Diarrhoea is then ranked with the other problems the data showed. Each problem is scored from 1 (low) to 3 (high) on each criterion:

Diarrhoea in children under five ranks first. The community health diagnosis statement for the unit reads: "Diarrhoea affected 10% of children under five in Village A and 4.3% in Village B in the last three months, linked to the use of an unprotected spring and the lack of hand-washing facilities."