Chapter 3

Starting Well: Beginning a Community

Health Nursing Project and Assessement—
Steps 1 and 2

A
pplying the community health nursing process within the context of a community
project provides the framework for this chapter. For student teams, getting started
involves developing collegial relationships, becoming oriented to the community
project and the sponsoring organization, and taking the first steps toward learning about
the community through an assessment of secondary data. The steps are expanded in
Box 3.1 below.
Entering the community and learning how to practice nursing in this new and what
may appear to be relatively unstructured setting can be unnerving for students and new
practitioners alike. What challenges might you anticipate? Even though you know what
it is like to live in a community, you require an orientation to the world of community
health nurses. This involves many new relationships—with the student team, mentors in
the community organization, and community members. Getting to know the community
and learning about the place and the people in order to promote healthy communities is
an important focus. Learning how to conduct a community needs assessment introdu-
ces the skills and knowledge that will prepare you for practice. In this chapter, students
are introduced to the epidemiological constructs used to describe the health of popu-
lations. They are directed to essential information resources such as policy documents
and learn how to draw the information together to guide practice. This chapter draws
on the themes of teamwork outlined in Chapter 2 and provides students with strategies
for organization, decision making, and evaluation. The scenarios in this chapter feature
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students in a community health center learning how to include activity in a health pro-
motion program for older adults.

Learning Objectives Key Terms and Concepts

census data • epidemiology • gatekeepers •
After reading this chapter and answering the questions incidence rate • morbidity data • mortality
throughout the chapter, you should be able to: data • preferred health situation • present
health situation • prevalence rate • primary
and secondary data • sociodemographic data
1. Establish working relationships within a community
project.

69

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 SCENARIO: Physical Activity and Older Adults
Today, the students will meet their community advisor links between activity and the prevention of chronic
at the Summertown Community Health Center (SCHC) disease, such as type 2 diabetes. Knowing there is a
for the first time. In preparation for the assignment, high prevalence of diabetes in older adults, they plan to
their faculty clinical instructor advised them that their discuss prevention in the project proposal to increase
project concerned health promotion with older adults the possibility of obtaining support from agencies that
and directed them to the organization’s website. The fund diabetes prevention.
students feel excited and a little apprehensive when
they report to their advisor, Jeanine, the nurse manager As part of their orientation, the students will review the
of health promotion services. existing data on the population and the health issue.
Further details of the project will be worked out over
After making introductions, Jeanine explains her role the next two weeks. After orienting themselves to the
and gives the students a brief orientation to the health health center, the students leave feeling they have
center before reviewing the expectations for the clinical jumped in at the deep end but are eager to get started.
placement. The students learn that SCHC is the lead On their next clinical day they will meet with the nurses
organization in a community coalition of health services who lead a health and wellness group for older adults at
and community groups to promote active living. The the health center.
coalition is well organized and has coordinated several
community projects over the past five years. Currently, Discussion Topics and Questions
the coalition is developing a project to increase the 1. As a member of the student group in the above
participation of older adults in community groups scenario, what information would you seek out at
that promote active living as a way to prevent chronic the orientation to the community organization?
disease. The steering group for the project includes 2. Discuss the role community members might play in
a member of the SCHC board, two representatives developing programs on priority health issues.
from the Council on Aging (COA), a fitness instructor
from the city Recreation Department, Jeanine, and a For suggested responses, please see the Answer Key at
nurse practitioner from the health center. The COA has the back of the book.
compiled recent research about the evidence of strong

2. Understand the different perspectives of the community and appreciate the

relevance of community assessment to community projects.
3. Identify the theories, concepts, and components of a comprehensive community
health assessment.
4. Appreciate the responsibility of the community health nurse to involve
communities in health assessment.
5. Explain how to locate and analyze sociodemographic and epidemiological data
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and key policy documents.

6. Conduct a document review and organize information according to the
community health nursing process.

Orient to the Community Project (Step 1)

The first steps of a community assessment—getting oriented to the community and

developing the knowledge and skill for community assessment—are foundational to all
community projects. These first two steps are expanded in Box 3.1 below. Subsequent

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 BOX 3.1
Steps 1 and 2 in Completing the Community Health Nursing Project

ASSESS 3. Assess physical and social environment

1. Orient to community project 4. Assess primary data
a. Establish relationships 5. Analyze assessment data
b. Define the project, population group, and issue
2. Assess secondary data PLAN
a. Review sociodemographic data 6. Plan action
b. Review epidemiological data on health status
c. Review previously conducted community ACT
surveys and program statistics 7. Take action
d. Review national and local policy documents
e. Review literature and best practice guidelines EVALUATE
f. Summarize secondary data 8. Evaluate results and complete project
9. Evaluate teamwork

steps in the community health nursing project are emphasized in later chapters as you
learn more about community health promotion.
A community project, as conceived in this text, is sponsored by a community organ-
ization and conducted with community members. The projects, which are designed to
enable students and new practitioners to learn about community health nursing, pro-
vide an entry to a complex world. Since these projects take a considerable amount of
time, resources, and coordination, it is important to prepare well. Advance planning
provides direction for the project and, if done with community input, allows you to
draw on the experiences of others. As well, talking things through ahead of time helps
to ensure that the resulting action will be relevant, supported, and sustained. A system-
atic approach is essential.
The majority of student projects are embedded in broad community health initia-
tives and relationships that extend beyond the timelines of a student clinical experience.
Usually, health providers and/or members of a community group or organization have
done some preliminary work on their own before they consult with the nursing faculty
to identify settings and topics that student projects might address. Therefore, learning
about the history of your project and the context of practice is an important aspect of
orientation. In addition to becoming familiar with the placement or sponsoring agency
at this first meeting, students will be initiating work relationships and finding out how
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to establish contact with the community group. These activities will help to clarify the
focus of the project so that it can be shaped to meet the needs of both the community
and student learners.

Establish Relationships (Step 1a)

The faculty clinical instructor responsible for your student group will link you to the
community organization and to your community advisor. A primary consideration is to
clarify roles and relationships. You may find that the advisor will supervise the project
as part of his or her workload as a public or community health nurse. Or, in settings

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 where an experienced community health nurse is not available, your instructor may
co-supervise with a responsible person from the organization, considered an advisor,
mentor, or community contact. For example, if you were working with a class of students
learning English, the teacher and instructor might share supervision. In this way, your
student group has access to nursing expertise as well as community “know-how.”
Plan to learn as much as you can about your community organization. Although your
community advisor is your main resource, you will probably have contact with others
within the organization. As well, certain aspects of your work may require you to follow
organizational procedures, which can take time. For instance, in health organizations,
activities involving community members will probably be governed by protocols and
may require managerial approval. Getting to know the organization, its mandate, and
how it functions will help you to understand the working environment and help to make
your community experience run smoothly.
Effective communication is crucial to the success of community projects, so start
out by scheduling regular face-to-face meetings with your team and advisors. Frequent
meetings are needed initially. Later on, meetings can be shorter or more spread out, but
are still necessary to monitor progress and to plan. If meetings are not prescheduled,
you may find that you lose valuable time trying to have a decision approved. Meeting
face-to-face provides the opportunity for the advisors and team to establish relation-
ships, develop trust, and learn from each other. Such opportunities may be limited in
community settings where practitioners work independently and are not always on-site,
so it is better to arrange regular meetings from the start.
You are likely to meet many new people in different settings in the first few days in
the community, which can be confusing. Keep track of all those involved in the project
and understand your responsibility to them and their responsibility to you. For example,
at organization meetings, record the names and positions of people who are present,
or who are identified, by name, contact information, and their relationship to the pro-
ject (see example in Table 3.1 below). People do not mind signing a sheet or telling you
who they are and how you can contact them. Your advisor can help you to do this. Since
changes often occur, keep the list up to date.
As discussed in Chapter 2, patterns of communication and documentation systems
vary from organization to organization. From the outset, it is important to clarify expect-
ations regarding the usual methods of communication, for example, face-to-face meet-
ings, email, or telephone, and the expected response time to messages. As well, confirm
the process for submitting weekly reports, which summarize progress and flag future
direction, at this time. Regular, timely, and relevant communication is basic to main-
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taining good relationships with everyone concerned with the project.

Identify Community Contacts

Some student teams will work directly with a community group, while others will be
based in an organization such as a public health department or community health
center that has ongoing links with a number of groups in the community. If there is no
opportunity to meet with community contacts at orientation, the student team needs to
explore how to engage with community members in the first weeks of the project. This
requires some forward planning. Your advisor can facilitate entry to the community, for
example, by providing contact information and by introducing students at a meeting.
These early meetings with community members will assist in your team’s orientation

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 to the community and are a first step toward building relationships that can progress
into collaboration with a community group.
Keep in mind that this process takes time. It is important to keep track of your inter-
actions with community members to identify people who can help your project in some
way, sometimes called gatekeepers. Gatekeepers are people in formal or informal pos-
itions who control access to the community group. Examples of gatekeepers are school
principals, teachers, the manager of a business or firm, or volunteers active in community
organizations such as tenants’ associations. Remembering names and learning “who’s
who” helps in the orientation to any work setting.

Define the Project, Population Group, and Issue (Step 1b)

At the orientation meeting with the community organization, it is customary to discuss

the rationale for your project and to reach agreement on the specific goals. Usually, this
will include a review of the historical perspective and key events that led to the initiation
of the project. For example, you may find that the project is addressing an emerging
health issue or that the organization has initiated the project in response to requests
from a community group. Although this may not seem significant at the time, it will
help you to understand the broad influences on community health.
Additional background information will be uncovered over time. Since student pro-
jects are not usually fully defined at the outset, ask questions to clarify your purpose.
You may feel uncomfortable doing this, particularly when taking on a new role in an
unfamiliar setting (and perhaps not wishing to appear inexperienced). Although these
feelings are understandable, remaining silent does not give the project organizers or
community contacts an indication of your interests, or of what you know and what
you want to know. One method to get past any awkwardness is for each team member
to prepare one question for meetings with different groups. Questions can encourage
a discussion and lead to greater understanding while demonstrating the team’s interest
in the project.
As well as learning specifically about the project, you need to learn about other com-
munity organizations or agencies involved in the project and their particular interests.
The mission statement or mandate of the lead and other organizations and the priority
for the project are usually well documented, and it would not be unusual to find that
many community agencies have a long history of working together. Although mandates
tend to be written in broad terms, they provide context and direction. For example, if
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an organization is funded to provide health promotion services for a defined geograph-

ical area and the goal of your project is to increase mobility in older adults, then the
project will have to be relevant to all older adults in the area, not just those who attend
a particular health center.

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 SCENARIO: Attending the First Community Meeting
The steering group meeting starts promptly. There is a The students are eager to start. They feel they will have
printed agenda, and the nurse practitioner volunteers time to contribute some of the necessary statistics,
to record the minutes. After introductions, Jeanine which they need for their own project. Acting on a
provides a brief overview of the coalition for the recommendation from the health center board member,
students’ benefit. Members from the Council on Aging the dates for the steering group meetings are set before
(COA) talk about their organization and the importance they adjourn. After the meeting, the students arrange
of mobility for healthy aging. Clearly they are very weekly meeting times with Jeanine and start to put
excited about the student involvement and provide four together the contact list, as shown in Table 3.1.
copies of physical activity guidelines for older adults
(Canadian Society for Exercise Physiology [CSEP], 2012; On the way to the bus, the students agree that Jeanine
US Department of Health and Human Services, 2008; is very well organized, and they feel confident in her
World Health Organization, 2010a) for the students to ability to guide their project. Darren says, “I can’t believe
take away and read. it; they really were pleased to have us helping.” Lise
agrees, but says, “This increases the pressure to do well.
Jeanine leads a discussion on roles and responsibilities. I know I will feel better once we get started, but right
She explains that under her guidance the students will now, I wish I felt more certain about what to do. What if
begin by reviewing previously collected demographic we gather the wrong information?”
data and existing information on the health status of
older adults in the community. This will help to inform Discussion Topics and Questions
the proposal. The working group developing the project 3. Think about the community where you live,
proposal would like to include these statistics in the and identify what community groups might be
first draft, which is due in four weeks. They invite the interested in participating in a coalition to promote
students to attend the meeting where the draft will be active living.
discussed. Other committee members will read and 4. The students have been asked to contribute to the
comment on draft reports and attend meetings every presentation of statistics at the coalition meeting.
other week to discuss progress. Identify what skills they might bring to this task.

Community Health Assessment

Assessment refers to the process of gathering information from a variety of sources to

understand the present situation of a community group and its preferred health situa-
tion to generate information for health planning. The present health situation includes
community assets or strengths, such as people with skill in solving community problems,
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or other resources, such as an unpolluted environment. As well, it includes barriers to

good health, or potential areas for improvement. The preferred health situation refers
to the changes or improvements in health desired by the community group. Health
providers often use the term “needs assessment,” but this term tends to focus attention
on problems to be solved, rather than on abilities that might be strengthened (Heaven,
2014; McKnight & Kretzmann, 1997). Both perspectives are important.
As with the assessment of individual and family health status, community assess-
ment is an iterative process, although considerably more time-consuming and com-
plicated. Communities are complex social systems when compared with individuals
and families. There are many different aspects of a community that the team needs to
consider, and there are many different sources of information to draw upon. Gathering

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 Table 3.1: Project Contact List

Project Contact List

Name Position Email and Phone/ Relationship to Project
Reporting Frequency
Jeanine Roger Community health nurse; jroger@work Clinical Advisor
manager of health promotion 555-6666 ext. 226 Provides direction for project
services Include in weekly summary. (in person and by email).
Chair of community coalition.
Jan Surrey University faculty jsurrey@university Faculty Clinical Instructor
444-3333 ext. 123 Provides direction in person
Include in weekly summary. and by email. Responsible for
student evaluation.
Jean Morrow Manager of community jmorrow@work Approves staff time for
programs 444-3333 ext. 345 (ext. 346 student project.
Exec. Assistant Simon) Reports to executive.
Fax 333-4444 Approves questionnaires.
Kerri Czabo Fitness instructor, Recreation kczabo@city Director of fitness programs
Department in city apartment buildings.
Developed chair exercises for
less active older adults.
Rita Valli Nurse practitioner rvalli@work Runs fall prevention clinic.
555-6666 ext. 543 Knowledgeable about
Works 2 p.m. to 8 p.m. physical activity and older
weekdays. adults.
Ruth Hemliner Executive Director, Council rhemliner@agency Founding member of
on Aging 456-7890 ext. 456 community coalition.
Works Monday–Thursday. Knows everyone! Contact for
Steering group only. information on coalition.
Ed Jones Member of SCHC Board ejones@home Chair of planning committee
Steering group only. (retired city planner). Contact
for copy of last community
needs assessment.
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this information provides the opportunity for community members to engage in a col-
laborative process and thereby increase the relevance of health planning. In turn, this
is expected to improve health outcomes, as noted in a comprehensive introduction to
the key principles in planning, designing, and implementing community engagement
efforts (see McCloskey et al., 2011).
Community participation is a key principle of primary health care; however, health
providers report that it is not easy to engage communities in the assessment, planning,
and evaluation of health programs. This is consistent with the evidence that the nature
and level of community involvement varies widely (Rifkin, 2009). Putting resources into
building knowledge and skills so that individuals and communities can participate in

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 decision making about health is arguably a necessary step toward improving health equity
(Brennan Ramirez, Baker, & Metzler, 2008; Edwards & Moyer, 2000; Rissel & Bracht,
1999). In this text, collaboration with the community is seen as an essential part of the
community health nursing process. At the same time, we acknowledge that the potential
for collaboration can vary considerably from one community to another. To be effective
and achieve results, collaborating with the community requires sustained effort.

Conceptualizing Community for a Community Health Assessment

Perspectives of community and community health help to frame a community assessment.

While there is no universally accepted definition of “community,” the term usually refers
to a group of people who live within a geographical area, or who have a common interest,
and are part of a complex system of networks and associational ties (Hampton & Heaven,
2014; Israel, Checkoway, Schultz, & Zimmerman, 1994). Two different perspectives of
community and community health that underpin community health practice are the
community as social setting and the community as client.
Originally explicated by Hawe (1994), these two perspectives are not easy to untan-
gle. The first perspective views the community as a social setting with a powerful and
incompletely understood influence on individual and group health and health behavior.
According to Hawe, the social setting encourages or rewards certain behavior. By impli-
cation, when seeking to change health behaviors, like smoking or activity levels, it is
not sufficient to ask individuals to change behavior; rather, it is necessary to change the
social and physical environment that supports the behavior. For example, laws against
smoking in public places, increases to the price of cigarettes, and bans on the sale of
tobacco to adolescents combine to create an environment that discourages the initiation
of smoking in youth. By changing the environmental cues, in a phrase coined by Milio
(1976), the healthy choices become the easy choices. Working within this perspective of
community as social setting, health providers encourage community participation with
a view to changing the social environment. Following community organizing principles,
they gain entry to the community, engage residents, and harness community resources to
achieve professionally defined health goals, such as smoking cessation and active living.
The second perspective described by Hawe (1994) is the community as a complex
human system in dynamic and mutually influencing interaction with its environment.
From this perspective, community health refers to the ability of the community as a
social system to take control, solve problems, and adapt to change (Goodman et al.,
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1998). Building on earlier work by Bronfenbrenner (1979), ecological models of health

acknowledge that human subsystems—individuals, families, groups, and organiza-
tions—form an integral part of the whole, but view the community as greater than the
sum of its parts (McLeroy, Bibeau, Steckler, & Glanz, 1988; Sallis, Owen, & Fisher, 2008;
Stokols, 1992, 1996). This is the same as viewing an individual as more than his or her
physiological, psychological, social, and spiritual systems and a family as more than the
sum of its individual family members. The overarching goal of health action from this
perspective of community is to strengthen the capacity of the community to function
effectively as an integrated whole and to be healthy. From this perspective, the health status
of individuals, families, and groups is just one measure of the health of the community.

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 Clearly, the way you think about community and community health provides a
framework for determining what data is collected in the community assessment and
how it is collected. In the first model described, the community assessment process is
more likely to be professionally driven and focus on identifying the resources for, or need
for, specific evidence-based health promotion and prevention interventions. Capacity
building may be seen as a means to an end. In the second model, capacity building is
the central aim. Community assessment is used as a means to engage the community
in a capacity-building or problem-solving process that will identify opportunities for
mobilizing resources and building community capacity (Labonte, Woodard, Chad,
& Laverack, 2002). Approaches such as CHANGE—Community Health Assessment
aNd Group Evaluation (Centers for Disease Control and Prevention [CDC], 2010), and
the Community Health Needs Assessment for Canadian First Nations and Inuit com-
munities (Health Canada, 2000)—seek to be more community-driven. However, health
providers are usually involved and can take advantage of the opportunity for capacity
building. More and more, both approaches are entwined.

Components of a Community Health Assessment

Community health is a multidimensional concept, and, traditionally, a community

assessment contains the following components: a demographic profile of the popula-
tion; a description of the patterns and variations in health status; and information on
the physical, sociocultural, and political aspects of the community that impact health
(Anderson & McFarlane, 2010; CDC, 2010; Rissel & Bracht, 1999). These socioenviron-
mental factors, commonly referred to as the determinants of health, or social determinants
of health, were introduced in Chapter 1.
A comprehensive community assessment is a large and costly undertaking and is
usually facilitated by professional teams. Fortunately, much of the information that
is required to inform health planning can be assembled from a range of existing data
sources; for example, data collected by government on an ongoing basis, such as births,
deaths, records of childhood immunization; census data; and data collected routinely
by health authorities to inform planning. Often referred to as secondary data, because
the data were originally collected for other purposes, they may not answer specific ques-
tions that are of interest to you. Primary data, on the other hand, is collected directly
from community residents and health service providers to provide specific information.
Gathering secondary data is not unlike the inquiry a community health nurse might
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undertake when starting a new position, or the process that a community group might
undertake before developing an agenda for health action. Gathering information is a
learning process, and knowledge is power.

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 Assess Secondary Data (Step 2)

The purpose of assessing secondary data is to learn what is already known about the
population and health issues of interest, and about the determinants of health relevant
to that population. The following list provides the six substeps of this component of
the community assessment. The order of the first five is not significant and may be
adjusted according to need:

a. Review sociodemographic data

b. Review epidemiological data on health status
c. Review previously conducted community surveys and program statistics
d. Review national and local policy documents
e. Review literature and best practice guidelines
f. Summarize secondary data

Review Sociodemographic Data (Step 2a)

Sociodemographic data includes characteristics of the population and information on

social patterns, especially age structure, which are crucial for health planning at national,
regional, or provincial and local levels. The census, which is conducted on a regular basis,
is a key source of this data. Census data, collected by household, includes the number
of people in the household by age, sex, marital status, occupation, and other variables,
such as income and ethnicity. Census reports provide a profile of the population as a
whole at one point in time and allow comparison between and within different regions
of the country (see US Census Bureau and Statistics Canada in “Website Resources” for
this chapter). The census can also be used to identify trends and make projections about
what the population will look like in the near future. When reviewing demographic
data, remember that some groups, for example, the homeless and illegal immigrants,
are not accurately represented in the census. In addition, some numbers are based on
self-identification and therefore may be unreliable for health planning. For instance, there
is reliable evidence that Aboriginal peoples may not self-identify or are incompletely
enumerated (Smylie, 2000).
It is much easier to assemble sociodemographic information when the commun-
ity or population of interest is identified geographically using the commonly accepted
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boundaries defined by the census. Census information is aggregated from the census
divisions to provide community-level data. Usually these boundaries correspond to
recognizable neighborhoods, but it is essential to check. There is easy access to aggre-
gated census data for cities and planning regions in the United States and Canada, but
it may not be necessary to consult these sources. Departments of public health, regional
health authorities, or local planning groups compile community profiles routinely to
guide decision making.
When beginning a community project, knowing the boundaries of your commun-
ity of interest is important. Planning a search strategy and documenting it accurately
saves time in the end. Once you identify what data will be useful to your project and
where to find it, develop a set of questions to guide your search for sociodemographic

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 data. Box 3.2 provides a sample set of questions that can BOX 3.2
help to structure the search and provide a framework for Sample Questions on the Community
collating the information that you find. and Population

• What are the boundaries of my

community of interest?
Review Epidemiological Data: Measuring
• What groups in the community are of
Health Outcomes, Risk Factors, Health
particular interest to me (e.g., men and
Practices, and the Social Determinants of
women aged 65 years and older; new
Health (Step 2b) immigrants)?
• What is the profile of this subgroup
Reading and interpreting health surveys and reports to (e.g., by gender, language, education,
gather information on the health status of your popu- income, housing, and living conditions)?
lation of interest and health determinants is a key part How does this profile compare with the
of the community assessment. This requires a working community as a whole?
knowledge of epidemiology, the science concerned with the • Will the size of this subgroup increase or
patterns of health and illness in the population. According decrease in the next 10 years?
to Last, epidemiology is “the study of the distribution and • Where does this subgroup live in the
community? Are members spread evenly
determinants of health-related states or events in specified
throughout the community, or do they
populations and the application of this study to the preven-
tend to settle in some areas rather than
tion and control of health problems” (as cited in Bonita,
others?
Beaglehole, & Kjellström, 2006). You may find it useful to
consult a basic epidemiology text (e.g., Bonita et al., 2006)
if you are not familiar with epidemiological concepts and methods. The self-study courses
listed in “Website Resources” at the end of this chapter are another option.
A basic method of epidemiology is to count the frequency of health outcomes, or
events such as live births, and to estimate proportions or rates in populations. By com-
paring the rates between different people, places, and times, it is possible to identify the
patterns of health and illness and look for trends. The two most commonly used rates,
which all nurses should understand, are the prevalence rate and the incidence rate.
The prevalence rate is a measure of the number of persons with a condition in a
group or population at a given time. This is expressed as a rate per unit of population
(K), for instance, the number of cases per 100,000:

Prevalence = Number of existing cases in place at point in time × K

Number of persons in place at midpoint of year
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Prevalence rates provide a useful snapshot of chronic health conditions, such as diabetes.
Applying the rate to a population of interest gives a working estimate for the purpose
of planning health resources. In order to make comparisons, prevalence rates have to
be adjusted for age because the prevalence of disease varies by age. For example, in
2010, the prevalence of diabetes in US residents, 20 years and older, was 11.3 percent,
compared to a prevalence rate of 26.9 percent in people 65 years and older (National
Diabetes Information Clearinghouse, 2013). The higher rate reflects that type 2 diabetes
is a disease associated with aging. Standardization of the rates, usually by age, enables
comparison across place and time. For instance, a report from a national surveillance
system, using age-standardized data, shows the prevalence of diagnosed diabetes in
Canadians 1 year of age and older has increased by 70 percent, from 3.3 percent in

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 1998/99 to 5.6 percent in 2008/09 (Public Health Agency of Canada, 2011, p. 17). This
comparison confirms that the burden of diabetes in the population, and on the health
care system, is steadily increasing.
Incidence rate is a measure of all new cases arising in a population at risk during a
defined period, usually one year.

Incidence = Number of new cases in place during time of observation × K

Population in place at midpoint of time

Incidence provides information about the rate of development of a condition in a

population, that is, the increase in new cases over a specified period of time. Birth rates
and death rates are special cases of incidence referring to the number of people being
born or dying in a specific place and at a specific time.
Measures of morbidity, mortality, and well-being provide a snapshot of health and
disease in the population. Mortality data are compiled from death certificates and have
long been used as a proxy measure of health or life expectancy. When standardized for
age, the data can be used to pinpoint the primary causes of death by life stages. Other
measures, such as untimely death or potential years of life lost (PYLL), are calculated
from mortality data. This tells you how many years of life a person has lost, compared
to the average for the population (usually taken as 75 years). PYLL can be used to com-
pare the benefits of different types of interventions to extend life.
Morbidity data provide information on the major burden of illness in the population.
For example, incidence data on common communicable diseases such as measles and
chickenpox and seasonal influenza (flu) is collected locally and aggregated to inform
health service planning, locally, nationally, and internationally. National public health
surveillance systems, such as the US Centers for Disease Control and Prevention (CDC)
and the Public Health Agency of Canada (PHAC), compile the information, track the
incidence rates, and submit to the World Health Organization as part of a global track-
ing system. Monitoring the trends provides advance warning of outbreaks. Data on the
incidence and/or prevalence of conditions such as sexually transmitted infections (STI)
and chronic disease, symptoms of ill health, and risk behaviors (e.g., smoking or engaging
in unprotected sex), together with indirect measures of ill health, such as days of work
lost, provide comparative measures of ill health in a population. Similarly, information
is collected on indicators of health and wellness, such as perceived health and health
practices (e.g., regular visits to a doctor or midwife during pregnancy), together with
information on lifestyle behaviors known to promote or pose a risk to health (e.g., eat-
Copyright © 2015. Canadian Scholars. All rights reserved.

ing habits, daily exercise, social relationships). Together, these measures of health and
illness provide a comprehensive picture of the health of a population.

Gathering Information on the Social Determinants of Health

Data on the social determinants of health, such as poverty, gender, and the environment,
are constructed from census data and routine household surveys. When using the
data to compare populations, it is important to understand how the constructs were
conceptualized and measured. For example, the United States has an official measure of
poverty (US Census Bureau, 2014). However, in Canada, as in most countries, poverty is
measured in a variety of ways; no one measure is used consistently (Canadian Council
on Social Development, 2001). As an example, one study exploring the relationship

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 Figure 3.1: Activity Limitations in Adults 65 Years and Older by Socioeconomic Status (SES)

100%
Percentage of Activity Limitations

80%

60% 66.2%
55.2%
40%

33.9%
20%

0%
High SES Average SES Low SES

Source: Adapted from Predy, G. N., Edwards, J., Fraser-Lee, N., Ladd, B., Moore, K., Lightfoot, P., & Spinola, C. (2008,
November). Poverty and health in Edmonton (p. 26). Edmonton, AB: Public Health Division, Alberta Health Services
(Edmonton Area). Retrieved from [Link]/poph/hi-poph-surv-hsa-poverty-and-health-in-
[Link]

between poverty and health in an urban population (Predy et al., 2008, p. 26) uses
socioeconomic status (SES) to examine the impact of poverty on the health of adults, 65
years and older. In the population studied, approximately two-thirds of the respondents
with low SES had activity limitations, compared with only one-third of adults with high
SES (see Figure 3.1). Although the relationship was not statistically significant, the figure
graphically illustrates that poverty is an important determinant of health, measured
here as activity limitations.
There is abundant evidence that health is strongly influenced by social factors but
the pathways are not self-evident. Understanding the mechanisms underlying the rela-
tionship between socioeconomic status and other social determinants of health is the
subject of intense study. The World Health Organization framework for action on the
social determinants of health (Solar & Irwin, 2007) summarizes the competing argu-
ments used to explain the relationship between the unequal distribution of income and
health in Table 3.2.

Sources of Secondary Data

There are many sources of routinely collected data pertinent to health. As previously noted,
Copyright © 2015. Canadian Scholars. All rights reserved.

the census, vital statistics, and national disease surveillance systems monitor health and
illness. In addition, national agencies, such as Statistics Canada and the US Centers for
Disease Control National Center for Health Statistics monitor a broad range of social,
economic, and environmental topics (see “Website Resources” at the end of this chapter).
Some important sources and types of data are summarized in Table 3.3 below. Becoming
familiar with key data sources is essential learning for community health nurses.
Departments of public health, regional health authorities, or local planning groups
often have responsibility for assembling and publishing regional or community profiles
to guide health policy and decision making. The reports usually draw together infor-
mation on health and the determinants and on a broad range of risk and protective
health behaviors from national, regional, and local health surveys. These reports may be

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 Table 3.2: Explanations for the Relationship between Income Inequality and Health

Explanation Synopsis of the Argument

Psychosocial (micro): Social Income inequality results in “invidious processes of social comparison” that enforce
status social hierarchies, causing chronic stress and leading to poorer health outcomes for
those at the bottom.
Psychosocial (macro): Social Income inequality erodes social bonds that allow people to work together, decreases
cohesion social resources, and results in less trust and civic participation, greater crime, and
other unhealthy conditions.
Neo-material (micro): Income inequality means fewer economic resources among the poorest, resulting in
Individual income lessened ability to avoid risks, cure injury or disease, and/or prevent illness.
Neo-material (macro): Social Income inequality results in less investment in social and environmental conditions
disinvestment (safe housing, good schools, etc.) necessary for promoting health among the poorest.
Statistical artifact The poorest in any society are usually the sickest. A society with high levels of income
inequality has high numbers of poor and, consequently, will have more people who
are sick.
Health selection People are not sick because they are poor. Rather, poor health lowers one’s income
and limits one’s earning potential.

Source: Solar & Irwin, 2007, Table 1, p. 31, attributed to Macinko, Shi, Starfield and Wulu, 2003.

organized by population group—children; pregnant women; adults, and seniors (Chief

Provincial Public Health Officer, 2011)—or by social determinants, such as poverty
(Predy et al., 2008).
More and more health information is available online from interactive databases. For
example, the Illinois Project for Local Assessment of Needs (IPLAN) database assembles
county- and community-level reports based on a health assessment and planning pro-
cess that is conducted every five years by local health jurisdictions (Illinois Department
of Public Health, 2009). IPLAN reports can be displayed for a single health indicator,
or a range of indicators, by state or county or community. Similarly, the Canadian
Community Health Survey (Statistics Canada, 2013) collects data at the sub-provincial
level on health status, health care utilization, and health determinants. A core question-
naire on over 300 topics enables comparison across reports. Summary tables and reports
on the various topics, by health region(s), can be accessed on the Canadian Institute for
Health Information (CIHI) website.
Online health information databases are increasingly being used to identify priorities
and support health planning at the community level. Having access to such data enables
Copyright © 2015. Canadian Scholars. All rights reserved.

community participation. For example, the websites of the US Department of Health

and Human Services Community Health Status Indicators (2009) and the Robert Wood
Johnson Foundation and Wisconsin Population Health Institute (2012) provide access
to county health rankings, together with tools to design a roadmap to health planning.
(See “Website Resources” in this chapter.)

Review Local Surveys and Program Statistics (Step 2c)

Local public health units, community health agencies, and health and social planning
departments periodically assess community needs and resources to inform planning.

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 Table 3.3: Sources of Readily Available Health Data

Type of Data Data Source Comments

Sociodemographic variables (e.g., Census data – Census uses standard questions
age, gender, by geographical area) – Data are available for the whole
Some data on health determinants population
(e.g., income and education)
Mortality by cause of death, age, and Vital statistics (e.g., registry of deaths) – Comprehensive
gender – Not a sensitive measure of health
but provides information on ill
health and preventable causes of
death
Morbidity data Communicable and Notifiable – Disease registries are limited to a
– Incidence and prevalence of Disease Reports (e.g., Influenza few conditions
specific conditions surveillance; Cancer Register)
Proxy measures of morbidity Hospital discharge data – Emphasis on conditions requiring
Drug utilization data medical treatment
Workplace injuries
Health behavior and practices National or regional health and social – Provides a profile of the
(e.g., type and level of exercise and surveys population as a whole, but the
activity; patterns of mammography sample sizes may not be large
uptake) enough to provide details for a
specific area
Physical, social, and environmental National data on Education, Housing, – Relevant to population/
determinants of health and Employment community as a whole
Air pollution index
Crime statistics
Needs assessments of communities Local surveys and research reports – Can be tailored to a specific focus
and population groups – Data may not be comparable

These assessments are tailored to local needs and thereby provide more detailed infor-
mation on a community, or particular segments of it, than national reports. Consultation
with the community is a key part of the assessment process, and the resulting reports are
rich repositories of up-to-date health information that may not be available elsewhere.
Routinely collected data on the utilization of health services and program evaluations
are another valuable source of community data.
The collection of health and wellness data presents many methodological difficulties,
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which should be kept in mind when reading health reports. For instance, when the pres-
ence or absence of illness is determined through self-reporting, as in many community
studies, it may contain inaccuracies. As well, health behavior may be overestimated or
underestimated, perhaps because of a desire to present a good picture, or because it is
difficult to remember accurately. For these reasons, well-designed national and regional
surveys with large samples and standardized approaches are required to ensure reliable
and valid data. Smaller-scale surveys may provide equally valid and reliable data, but the
measures may not be comparable to those used in previous studies or in other regions.
All this is to say that it is important to review data collection methods to know what
questions were asked in a study and how the data were processed.
Before initiating any costly data collection process, it is wise to review the existing

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 SCENARIO: Collecting Statistical Data
After the steering group meeting, the students students report that there are 73,520 adults, 65 years
begin to draw together the secondary data that will and over, in their region. They put together a population
inform their project. They intend to have it ready for pyramid and numerous tables to show a further
discussion at the next meeting. Following advice, they breakdown of the population by 10-year intervals,
familiarize themselves with a recent report that includes gender, income, living arrangements, and other
demographic and health data on adults 65 years and characteristics. A key find is a report classifying city
older for the health region, which includes both the city neighborhoods by socioeconomic status (see example
where the Summertown Community Health Center is in Predy et al., 2008, Appendix A).
located and the surrounding rural area. This will provide
a sufficiently large population for obtaining meaningful Discussion Topics and Questions
health statistics. After a lively discussion on the best way 5. Identify your community. In a small group, discuss
to proceed, the students develop questions to guide the boundaries and explain what community means
their search and then split up to work in pairs. Robin and to you.
Darren choose to review the demographic information, 6. Using your own community as an example, discuss
leaving the review of health data to Lise and Mika. ways in which the community reinforces healthy or
At the end of the second week on the project, the unhealthy behavior, such as physical activity.

data. Not only does a systematic analysis of what is already known save time and avoid
duplication of effort, but it also helps to focus the inquiry. Since secondary data were
collected for other reasons, it will be necessary to think carefully about what information
you need. Formulate questions to guide your search. Then identify and locate suitable
data sources, extract pertinent information, and assemble it in such a way as to tell a
story. The “story” you want to tell will comprise the summary of secondary data referred
to in Box 3.1, which will be used to inform your project. Think of it as building a jigsaw
puzzle. The order in which you retrieve the information is not crucial; you can start at
any point and gradually fill in the pieces until, at the end of this exercise, you have as
complete a picture as possible and understand how the pieces fit together. A thorough
examination of existing data will help you to understand the patterns of health and ill-
ness in your community or population.

Review Policy Documents (Step 2d)

National and regional governments provide broad direction for health through public
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policy documents and strategic plans that direct funding. These policy frameworks ensure
a common understanding and promote consistent approaches toward achieving health
goals. A review of policy documents relevant to your population of interest and health focus
will help to situate your project in relation to the broader community health concerns.
Becoming familiar with these key documents is important because they are likely
to contain the most pertinent and up-to-date research on the topic. The World Health
Organization (WHO) pursuit of the goal of “Health for All” (WHO, 1978), with its
emphasis on health promotion, is a good example. Over the last 30 years there has been a
shift in emphasis from the provision of health services to the provision of a broader range
of resources for population health. Compelling evidence, such as the fact that globally,
a quarter of all preventable illnesses are the result of the environmental conditions in

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 which people live, later underpinned the Adelaide Statement on Health in All Policies
(WHO, 2010a). In this statement, all sectors of government are encouraged to include
health and well-being as a key component of policy development. In this way, policies,
based on evidence and grounded in common values, facilitate decision making about
health across different sectors.
In recent years, governments in Western countries have produced a number of policy
documents that endorse a population health approach. Typically, these documents
acknowledge the need to invest in improving living and working conditions, as well as
health services, for a healthy population. They also signal the intent to use comprehensive
and collaborative approaches to improve health outcomes through action on the deter-
minants of health. For example, a population health framework and action guidelines
can be found on the Public Health Agency of Canada (2012) website, and the concepts
are carried forward in collaborative federal, provincial, and territorial government initia-
tives, such as the Integrated Pan-Canadian Healthy Living Strategy (Secretariat for the
Intersectoral Healthy Living Network, 2005) and in health planning documents (British
Columbia [BC] Office of the Provincial Health Officer, 2010, p. 21).
The United States and England take this planning a step farther. In addition to articu-
lating national population health strategies, they identify priority areas, and set national
goals or targets with timelines for achievement. For example, the recently updated US
Healthy People 2020: Framework (US Department of Health and Human Services, 2010)
identifies four overarching goals that are intended to inform national and state health
planning. Similarly, in England, the most recent public health strategy, Healthy Lives,
Healthy People (Secretary of State for Health, United Kingdom, 2010), commits to pro-
tecting the population from serious health threats; helping people live longer, health-
ier, and more fulfilling lives; and improving the health of the poorest, fastest. These
approaches build on the framework for addressing health inequities in the final report
of the WHO Commission on Social Determinants of Health, led by Sir Michael Marmot
(Commission on Social Determinants of Health, 2008).
In turn, the international and national strategy documents provide direction for
state, provincial, and territorial planning authorities. For example, Healthy People 2020
encourages states, cities, and communities to set health goals based on national object-
ives. In Canada, federal, provincial, and territorial Ministers of Health agreed to a set
of broad health goals in 2005, which are expected to inform provincial and territorial
public health objectives (PHAC, 2006a). The next steps are being examined (Chia &
Phillips, 2010). As noted above, health goals guide the development of some health policy
frameworks (BC Office of the Provincial Health Officer, 2010, p. 21).
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Other useful sources of health policy documents are the World Health Organization
and the Pan American Health Organization (PAHO). Voluntary and nongovernmental
organizations, special interest groups, and professional bodies also produce health policy
documents for their own ends and to influence government policy. Nowadays, many
of these documents are available on the Internet. At the local level, most organizations
have policy documents, and strategic and operational plans that guide planning deci-
sions. It is not realistic to try to provide a comprehensive list of data sources because the
production of health information is an iterative process. At the end of this chapter, you
will find a list of key national websites, which will provide an entry point for locating
health strategy documents.
These health strategy documents and work plans are a valuable resource. Not only

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 do they articulate the conceptual models of health that are guiding decision making,
but they also present up-to-date analyses of the epidemiological and experimental evi-
dence on which population health needs and priorities are based. Considerable work
has gone into putting together this evidence base to guide health planning and policy.
In addition to identifying priorities, and providing detailed and specific direction on
effective interventions, the documents also guide funding allocations. Understanding
policy frameworks and aligning new programs with priority areas increases the prob-
ability of gaining support for community health initiatives.

Determining a Population-Based or Issue-Based Direction for Community Projects

At this point it is useful to reflect on the many different starting points for community
health projects. Sometimes a project starts with questions about a geographically defined
population, for example, the residents of a rural community, perhaps further defined
by age (e.g., all adults older than age 65 living in the rural area of a community) or by
developmental stage (e.g., adolescents, or pregnant women and their families). A variation
of this approach is to focus on community settings such as workplaces and schools that
provide access to certain populations and, like communities, provide an environment
that influences health and well-being. Alternatively, projects might take as their starting
point a population group such as single parents or Aboriginal men thought to be at
high risk because of lifestyle or other risk factors, or through inequitable access to the
social determinants of health.
Other starting points are a health issue or concern, such as homelessness, a disease,
or a condition such as diabetes, or health-related practices, such as the use of family
planning methods. Within these categories, you may also define the population by age,
as in teenage smokers. Regardless of whether your project starts with a people-based
or issue-based question, you will need to clarify the geographical boundaries of your
population and its defining characteristics, such as age or gender, to focus your inquiry
and gather pertinent sociodemographic and epidemiological data.

Review Literature (Step 2e)

It is not usually necessary to conduct an exhaustive review of the literature on a health

issue as part of a community assessment, other than to fill in any gaps in your knowledge.
However, to appreciate the meaning and importance of health data, it is necessary to under-
stand the complex relationships that contribute to wellness and illness. Epidemiologists
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have long used a model of the interaction of genetics and the environment to explain the
natural history of disease development and understand causation, which is essential for
prevention (Bonita et al., 2006, p. 4). A web of causation (Brunt & Sheilds, 2000) uses the
metaphor of the spider’s web to conceptualize the multiple interacting factors, social and
biological, that influence health and wellness. Although such models are used to explain
disease causation, they can also be used to visualize the relationships that support health.
The conceptual framework underpinning the work of the WHO Commission on Social
Determinants of Health provides a more complicated view of the dynamic interplay of
the multiple factors that influence health inequities (Blas & Sivasankara Kurup, 2010).
Broadly speaking, inequities in health are conceptualized as arising from the social con-
text interacting with individuals/populations throughout life, resulting in differential

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 SCENARIO: Collecting Statistical Data
The search for health data takes longer than anticipated search they come across a guide to creating cities that
but is productive. Following a link provided by their support active aging (WHO, 2007), which could prove
advisor, Lise and Mika find a WHO policy document useful later on. Mika says, “At least we know how to
related to older adults and active living (WHO, 2010b). navigate the WHO site now and have links to specific US
The document summarizes global recommendations and Canadian resources. Plus, we have identified some
for physical activity to enhance health and prevent keywords to describe physical activity.”
non-communicable disease for three age groups, one
of which is adults 65 years and over. Just what they Discussion Topics and Questions
want! The paper provides links to many other resources 7. Complete Table 3.4 to show the connections
and includes definitions of key concepts used in the between one or two social determinants of health
activity guidelines: frequency, duration, intensity, type, and the ability to maintain age-appropriate physical
and total amount of physical activity. This they find activity levels (see Wilkinson & Marmot, 2003).
particularly useful. 8. Obtain a community needs assessment from a
community clinic, public health department, or
Additional finds are detailed national reports on the regional health authority in your area. Locate
state of aging and health (CDC, 2013; PHAC, 2006b). The information in the assessment pertaining to one
US resource has an interactive database; the Canadian of the social determinants of health examined in
resource includes a demographic profile and health Question 7, and discuss how the information is
assessment, complete with tables and graphs. They or might be used to inform a health promotion
forward the references to their colleagues. During their program.

Table 3.4: Determinants of Health and Physical Activity

Determinant of Health Rationale

Social Support Helps give people the emotional and practical
(support from family, friends, and social relations) resources they need to solve problems, deal with
adversity, and maintain a sense of mastery and
control over life circumstances. This has a powerful
protective effect on health and may act as a buffer
against health problems. Supportive relationships
may also encourage healthier behavior patterns, such
as participation in regular physical activity.
Education and Literacy
Social Environments
Physical Environments
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Personal Health Practices and Coping Skills

Healthy Child Development
Biology and Genetic Endowment
Health Services
Gender
Culture

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 BOX 3.3 exposure, vulnerability, outcomes, and consequences in
Sample Questions on Health and the health. To be fully informed about these causal links, you
Determinants will need to become familiar with the models and review
the medical and nursing evidence, including best prac-
• What are the indicators of wellness in the tice guidelines that guide interventions (see Chapter 7).
community of interest?
Sometimes you will find that the information on a par-
• What is the prevalence/incidence of
ticular health topic has been critically reviewed in national
preventable ill health and disability
and regional strategy documents. The questions listed in
in this population? How do the rates
compare with other like communities?
Box 3.3 can be used to guide your inquiry.
• How does the health problem or issue
impact on other problems identified as a Managing Information and References
priority in the community? A systematic process will facilitate the review of exist-
• Are some population groups affected ing information. As you locate and read the numerous
more than others? documents, reports, and Web-based materials, you will
• Select an indicator of wellness/ accumulate a lot of information. Keeping track of your
preventable ill health. How is it findings will be easier if you keep a complete record of
influenced by socioenvironmental all the written and Web-based resources you consult, with
determinants?
notes. Any photocopies or printed material should be
clearly marked with full reference information in case you need to return to the source.
Similar to any academic paper, the information must be referenced. This is no different
from keeping study notes or conducting a review of the literature. However, because
this is a group effort, you will need to agree to a process that works for all members of
the group and avoids unnecessary duplication. Reference management software can be
used to record references, including personal notes. If linked to a word processor, the
references can be inserted into a document or generated as a bibliography.
Time management is important to consider when seeking and reviewing second-
ary data. For some issues, such as smoking, there will be an overwhelming number of
studies and reports. In those cases, look for a review of studies (meta-analysis) or best
practice guidelines (see Chapter 7). For other issues, a considerable amount of time can
be spent with few results. To use time efficiently, seek advice from the project organizers
on key words, data sources, and an approximate amount of time to spend searching.

Summarize Secondary Data (Step 2f)

The most difficult part of a review of the secondary data can be summarizing the
Copyright © 2015. Canadian Scholars. All rights reserved.

information. Aim for a short paragraph of four or five sentences for the student projects.
One way to help condense the information is to identify and combine those references
that have the same or similar information. For example: “Several sources identify that
people over 65 are x percent less active and have a greater number of illnesses related
to immobility than people 55 to 64 (list of references to support this data).” As well,
it is important to identify data, such as high levels of need, that provide a compelling
reason for working with the community group or issue. Also important is research-based
evidence from best practice guidelines that recommends a specific approach. A helpful
way to sort through the information is to ask if a piece of information is interesting to
know or important to know in working with the community group. It may be necessary
to go through a couple of revisions to shorten the summary.

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 SCENARIO: Understanding Epidemiological Data
Mika and Lise share information on the different After reviewing their work, they identify one gap
patterns of physical activity with aging, shown in because they have no information on the ethnic
Table 3.5. The table generates a lot of discussion. Kerri, composition of their population. They have learned that
a fitness instructor, comments that the findings fit certain subpopulations are identified as being at high
with her experience with exercise groups in apartment risk for type 2 diabetes, know that their health center
buildings. She wonders if it would be useful to look serves many different ethnic groups, and feel certain
more closely at the 65–74 year age groupings to see that they will be able to provide this information. As
whether the decline in intensity of physical activity is well, the team will keep ethnicity in mind as they begin
the same for men and women. They speculate on what to plan the next steps of their project, steps 4 and 5 of
factors might be influencing the large drop in physical the assessment, the collection of primary data (to be
activity at the end of the teenage years. As well, they discussed in Chapter 4).
start to identify what factors in the physical and social
environment might be influencing physical activity in The group members agree that efforts to date have
older adults. been successful beyond their wildest dreams. “Maybe
we have been too successful,” says Darren. “How are we
Mika and Lise quickly scan the websites and locate going to keep track of this information?”
information on physical activity and chronic disease,
as well as a number of policy documents on chronic Discussion Topics and Questions
disease prevention. One of the most comprehensive 9. Identify factors in the social and physical
identifies disease prevention and health promotion environment that might explain the decreasing rates
as major elements of the strategy (Haydon, Roerecke, of activity in the age groups presented in Table 3.5.
Giesbrecht, Rehm, & Kobus-Mathews, 2006). Looking at 10. The Commission on Social Determinants of Health
their results, Jeanine mentions that interest in diabetes (CDSH, 2008) advocates for urban planning to create
prevention has increased rapidly since the presentation “healthy places.” Recommendations include the
of the results of two international intervention projects, following: “design urban areas to promote physical
which provided strong evidence that type 2 diabetes activity through investment in active transport;
might be prevented through lifestyle interventions encourage healthy eating through retail planning
that include physical activity. Mika agrees to locate the to manage the availability of and access to food;
papers at the university library. The group is pleased and reduce violence and crime through good
to find that so much information is available. They feel environmental design and regulatory controls,
better prepared to move forward with the community including control of the number of alcohol outlets”
project. They discuss how the situation would be quite (p. 202). Thinking about the neighborhood around
different in the case of emerging health issues, such as your school or workplace, discuss how it might be
the environmental impact of pesticides on health or improved to create a healthy place using the CDSH
severe acute respiratory syndrome (SARS), when the recommendations.
evidence base for diagnosis and treatment is lacking
and few policy documents are in place.
Copyright © 2015. Canadian Scholars. All rights reserved.

Table 3.5: Intensity of Leisure-Time Physical Activity by Age, Canada, 2005

Age Range
Intensity 12–17 18–24 45–54 55–64 65+
Active 50.9% 38.3% 22.0% 22.6% 18.5%
Moderate 22.6% 23.5% 25.6% 26.3% 24.5%
Inactive 26.5% 38.2% 52.4% 51.1% 57.0%

Note: Broken line between “18–24” and “45–54” age groups indicates break in data.
Source: Gilmour, 2007, p. 46.

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 Table 3.6: Simple Reference Tracking Method

Reference Tracking Information

Topic Reference Key Ideas
National Public Health Agency of Canada. (2011). Diabetes The report offers the most recent diabetes
diabetes in Canada: Facts and figures from a public health statistics in Canada, giving rates of disease
statistics perspective. Available from [Link]/ by age group, sex, place, and time. The
cd-mc/diabetes-diabete/pub_stats-[Link] health consequences of diabetes, health care
utilization, and statistics on risk factors for
developing diabetes and its complications,
including obesity/overweight, unhealthy diet,
physical inactivity, and smoking, are provided.
Physical US Department of Health and Human Services. The report summarizes research findings on the
activity (2008). 2008 physical activity guidelines for health benefits of exercise and provides activity
guidelines for Americans. Washington, DC: Secretary of Health guidelines for different age groups (children
Americans and Human Services. and adolescents, adults, older adults); for safe
physical activity; and for groups with special
needs (pregnant women, adults with disabilities,
and people with chronic medical conditions).
Guidelines for WHO. (2007). Global age-friendly cities: A guide. The report presents the concept of healthy aging
creating age- Geneva, Switzerland: WHO. Available from www. and provides guidelines for creating age-friendly
friendly cities [Link]/ageing/publications/Global_age_ cities.
friendly_cities_Guide_English.pdf
The guidelines are informed by discussions with
older adults, caregivers, and service providers in
33 cities across the world.
Cooperative Local survey. Utilization of diabetes clinics by city.
survey of
diabetes
education
centers

Teamwork during Steps 1 and 2 of a Community Project

The orientation to the community project and to the student team happen simultaneously.
By necessity, students have to agree, in a relatively short space of time, how they will
function as a team and begin the assessment on which to base their community project.
Copyright © 2015. Canadian Scholars. All rights reserved.

This critical period for developing morale, or in other words, the relationships and team
spirit, will help the team prosper and succeed. It is useful for students to meet as a group
before the first visit to the placement organization. This provides an opportunity to get
to know each other and make initial decisions about how the team will present itself
and function as a unit at the orientation to the organization. This “warm-up” session
provides opportunity to share first impressions, air views, and start organizing the
team, including the selection of a group leader. Team members may prefer to appoint a
temporary leader and defer the final decision about leadership until they have a better
understanding of each other and the project requirements. The time can be considered
well spent if it helps to establish a positive impression of the whole team right from the
beginning. First impressions are important.

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 As described in Chapter 2, team members have to decide on roles and responsibilities
during the first few weeks of the community experience. During this formative phase
of team development, members of the team are also becoming oriented to the project
and placement. Typically, in the first few weeks of the community experience, the team
will have to accomplish the following tasks:

1. Team Organization and Decision Making

• Negotiate the roles and responsibilities of team members.
• Consider the initial work plan and timelines, including a strategy for involving
community members.
• Set up a routine for completing the weekly report.
2. Team Rapport
• Get to know each other and develop a trusting relationship.
3. Evaluation
• Reflect on and evaluate team performance, as an individual and group, as set
out in the course requirements.

Team Organization and Decision Making

One of the first steps is to establish a base and decide how you will communicate, by phone
or email. Regular meeting times are important, so set a schedule from the start. This will
provide time to organize and time to develop an effective working relationship. It is also
important to think through how the team will accomplish its work. One approach is to
draft a list of tasks, based on preliminary guidelines, to provide a common road map
of activities and timelines for the community project and a framework for reporting on
progress. Compiling the routine reports will encourage the group to reflect on progress
in relation to the plan. In effect, these reports summarize team activities, the decisions
made, and the rationale behind them. Your advisor and instructor should be able to
follow your progress by reviewing the documentation and give feedback.
Familiarizing yourself with the community organization and the different ways
of working in the community can be challenging at first, especially when you have
responsibilities as a new team member. Keeping track of who is doing what and the
different lines of inquiry by team members is essential. A work plan, sometimes termed
“action plan,” is a useful tool for summarizing the collective goal and planned action. In
its simplest form, the plan lists the goal-related activities, indicating responsibility for
Copyright © 2015. Canadian Scholars. All rights reserved.

each activity, with timelines for start and completion. Sometimes the activities are dis-
played in a Gantt chart or timeline, a type of bar chart (to be described in Chapter 4).
Having the overall plan in mind provides a benchmark for monitoring progress. Progress
toward the goals can be briefly summarized on the work plan, or detailed in the weekly
report, as required by clinical instructors and advisors. Plans are bound to change, given
the great many factors that influence them. These changes are much easier to accom-
modate without losing sight of the goal when documented in a work plan with time-
lines. Table 3.7 illustrates a simple work plan (more structured examples are provided
in Chapter 4 and in Appendix A.3.1).

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 Table 3.7: Draft Work Plan

Assessment Work Plan for Project: Physical Activity and Older Adults
Revision Date: September 10, 2015
Steps, Activities, and Time Results Summary, with Completion Date
Frame
1. Establish relationships within Complete Sept. 21
project and community,
Sept. 8–21
a-1. Establish relationship Sept. 8: Met Jeanine, the project leader, and reviewed the project proposal. Roles
with project organizers and responsibilities discussed and agreed upon. We will meet face-to-face every
second week and correspond by email weekly.
a-2. Meet community Sept. 8: Met SCHC staff and coalition members at orientation. Next meeting: Sept.
contacts 14 at 2 p.m. Coalition communication method is by email.
b. Define the project, Sept. 8 and 9: Reviewed background documents provided by SCHC and COA.
population group, and The project will focus on activity levels of adults, 65 years and older, living in the
issue, Sept. 8–16 city.
2. Assess secondary data, Will submit summary on Oct. 10.
Sept. 8–Oct. 10
a. Review sociodemographic
data, Sept. 8–16 (Robin &
Darren)
– develop guiding
questions
– locate sources
– review, extract
information
b. Review national, regional, and Sept. 9: On hold until after the review of health status.
local policy documents,
Sept. 8–16 (Lise & Mika)

Evaluation

A debriefing session after the orientation to the organization will allow the team to
share first impressions and reflect on the experience. In addition to bringing the team
together as a unit, it paves the way for thinking ahead and planning in a more informed
Copyright © 2015. Canadian Scholars. All rights reserved.

way. One hour should be enough. As the team moves on, evaluation is a continuing item
on the agenda and in the weekly report. Initially, team members may find it useful to
reflect on how the team is familiarizing itself with people in the placement setting and
community. All team members should be encouraged to contribute impressions, both
positive and negative. When team members routinely share perspectives, they develop
a team identity, a sense of accomplishment, and create an environment where concerns
can be addressed as they arise. Over time, the approach to evaluation will evolve as the
team matures, and in relation to course requirements.

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 Summary

Community assessment is the first step in understanding community needs and resources,
and an essential component of community health planning. The assessment also serves
other, less tangible purposes, such as raising awareness of health issues and building com-
munity participation. By providing an entry point for citizen involvement, community
assessment creates an opportunity to engage citizens in identifying health needs and
potential solutions. The examination of secondary or existing data lays the foundation
for community assessment. Gathering sociodemographic and epidemiological data on
the population of interest and examining relevant policy documents and other sources
of evidence provides a well-grounded basis for a shared understanding of community
health issues. Achieving this shared understanding is a good start to the project and
prepares you for assembling your own primary data in the community, which is the
focus of Chapter 4.
Contributing as a team member is key to getting started on a community project.
The first few weeks are crucial for team development: appointing a leader, defining
team structure, and establishing effective modes of communication are all necessary for
effective team decision making and morale. Early investment in team building sets the
stage for interactions with the community and provides a good start for your project.

Classroom and Seminar Exercises

1. With two or three other students, compare two communities using one of the
following two definitions of community capacity:
a. Labonte and Laverack (2001, p. 113) say, “Community capacity is not an inher-
ent property of a particular locality, nor the individuals or groups within it, but
of the interactions between both. It is also a function of the resource opportun-
ities or constraints, such as the economic, political and environmental, of the
conditions in which people and groups live.”
b. Goodman et al. (1998, p. 258) use the following definition of community cap-
acity to guide their work: “The characteristics of communities that affect their
ability to identify, mobilize, and address social and public health problems.”
2. You have been selected to present findings to the steering group. From the data
Copyright © 2015. Canadian Scholars. All rights reserved.

presented in this chapter, prepare key messages for three overheads.

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Website Resources

There are many useful Web resources for health data. A few key sites are listed in this section.
Many of the national and international sites are interconnected on particular topics, such as flu
surveillance. Be aware that websites are frequently restructured to meet changing needs. If you
are unable to gain access to specific pages within a website, go to the main site and either follow
the links or try to locate the information by using the appropriate keywords. If you have the
title of a publication, you can enter it in a search engine to search the Web.

Health Indicators

Centers for Disease Control and Prevention, Community Health Status Indicators: [Link].
gov/CommunityHealth/[Link]
This site provides access to key community health status indicators for public health profes-
sionals and community members interested in the health of their community. The indicators
are available by year, state, and county. A mapping function is planned.
The home page provides a link to a 2009 report by the Community Health Status Indicators
Project Working Group, Data Sources, Definitions and Notes for CHSI 2009 (Washington, DC:
Department of Health and Human Services).

Public Health Agency of Canada (PHAC), Canadian Best Practices Portal: [Link]
[Link]/
Under “Resources” you will find links to “Evidence-Informed Decision-Making: Information
and Tools,” “Health Indicators,” “Public Health Competencies: Information and Tools,” and
“Planning Public Health Programs: Information and Tools.” All but the last connect to a fur-
ther network of links. For example: under “Health Indicators” you will find links to Canadian
Health Indicators, Provincial/Territorial, International Organisations, and Health Indicators
from Other Countries.
To give you an idea of what this means, under “Canadian Health Indicators,” there are several
links, each briefly described: PHAC, Statistics Canada and the Canadian Institute for Health
Copyright © 2015. Canadian Scholars. All rights reserved.

Informatics (CIHI), Health Canada, The Pan-Canadian Public Health Network, Aboriginal
Affairs and Northern Development, and the Federation of Canadian Municipalities (FCM). Of
note, the last three sites have links to measures of health inequalities, well-being, and quality of
life, respectively.

National Center for Health Statistics: [Link]/nchs/

“FastStats” provides quick access to statistics on topics of public health importance, includ-
ing diseases and conditions, injuries, life stages and populations, and health care and insurance.

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Diem, Elizabeth, and Alwyn Moyer. Community and Public Health Nursing, Second Edition : Learning to Make a Difference Through Teamwork,
[Link] 97 Central, [Link]
Canadian Scholars, 2015. ProQuest Ebook 2015-11-04 11:09 AM
Created from humber on 2023-09-06 [Link].
 US Census Bureau: [Link]/
The census bureau is the leading source of data on the people and the economy of the US.
For quick facts about people, business, and geography, go to “Data/Data Tools and Apps” and
follow the links.

World Health Organization, Health Statistics and Health Information Systems: Country
Measurement and Evaluation: [Link]/healthinfo/systems/en/
This site provides links to a range of population-based and health facility–based data sources
for participating countries.

Health Topics

The national and international sites listed above have an alphabetical link to resources on a vast
number of health topics. For example, each topic included in the PHAC Best Practices Portal
link to “Public Health Topics” offers further links to Data, Strategies, Guidance, and Systematic
Reviews of the Literature.
Similarly, the Centers for Disease Control and Prevention provide a link to the “Healthy
People 2020” site at [Link]/nchs/healthy_people/[Link].
As noted, the sites are embedded in a maze of interconnections and the “Healthy People
2020” site, which is interactive, can also be reached at [Link]/.

Interactive Sites Providing Regional Data to Guide Community Action

Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute,
County Health Rankings and Roadmaps: [Link]/
The County Health Rankings measure the health of nearly all counties in the US and rank
them within states. The indicators are informed by a model of population health that links
social and environmental determinants—influencing factors—and health. County health rank-
ings are linked to elements of the model.
The Roadmaps section provides an action model, tools, and resources that communities can
use to improve community health by taking action on selected health indicators.

Epidemiology Resources Online

Centers for Disease Control and Prevention, CDC Learning Connection: [Link]/learning/
CDC TRAIN offers thousands of courses and requires log-in. The site also provides access
to other learning resources, including e-learning products. For example, under “Epidemiology,
Surveillance, Information and Statistics,” there is a link to the Division of Scientific Education
and Professional Development (DSEPD) website, which provides numerous educational
Copyright © 2015. Canadian Scholars. All rights reserved.

resources for the training and development of the public health workforce.

Public Health Agency of Canada (PHAC), Skills Online: [Link]/php-psp/ccph-

cesp/[Link]
Skills Online is a continuing education program. The self-directed or facilitated modules
available on this site are designed to strengthen the core competencies of public health practi-
tioners in Canada.

The National Collaborating Centre for Methods and Tools: [Link]/[Link]

See the “Quick Link to Multimedia (videos),” where you will find 10 short videos on
epidemiological concepts to help you understand research evidence.

98 Part 2: The Community Health Nursing Process and Community Health Nursing Projects

Diem, Elizabeth, and Alwyn Moyer. Community and Public Health Nursing, Second Edition : Learning to Make a Difference Through Teamwork,
[Link] 98 Central, [Link]
Canadian Scholars, 2015. ProQuest Ebook 2015-11-04 11:09 AM
Created from humber on 2023-09-06 [Link].