3: Assessment in the Community

Assessment in the Community

Jane E.M. Steffensen, RDH, BS, MPH, CHES

Opening Statements

National Leading Health Indicators

Indicators Related Statistic*
• Access to health insurance • 17% of children and adults (younger than 65 years) do not have health insurance (2008)
• Access to personal health care • 4% of children and adults do not have a source of ongoing primary health care (2008)
• Prenatal care • 16% of pregnant women have not received prenatal care during the first trimester (2002)
• Child immunizations • 81% of young children (aged 19 to 35 months) are fully immunized (2006)
• Physical activity • 67% of adults are not physically active on a regular basis (2008)
• Overweight and obesity • 33% of adults are obese (2006)
• Tobacco use • 21% of adults smoke cigarettes (2008)
• Substance abuse • 20% of adolescents have used alcohol or illicit drugs during the past month (2007)
• Environmental quality • 39% of Americans are exposed to harmful air pollutants (2004)
• Adult immunizations • 67% of high risk older adults (65 years and older) not living in institutions are fully immunized for influenza and pneumonia (2008)

*Statistics from Healthy People 2010 Database. Available at wonder.cdc.gov/data2010/. Accessed February 2010.

Public Health Practice

Professional work in community health is dynamic because the environment changes continuously. Community health is affected by social, demographic, political, economic, and technologic changes. In this milieu, public health practitioners perform a broad array of duties focused on entire populations, with the overarching goal that people are healthy and live in healthy communities.1,2 The mission of public health is to “fulfill society’s interest in assuring the conditions in which people can be healthy.”3,4 Public health carries out this mission through organized, interdisciplinary efforts that address health problems in communities. Its mission is achieved through the application of health promotion and disease prevention and control efforts designed to improve health and enhance quality of life.14

Public health services incorporate the roles of a myriad of public health professionals in various sectors and from diverse disciplines that form the public health workforce in the United States.4,5 Public health professionals can belong to many professional disciplines, including oral health, nursing, nutrition, social work, health promotion, laboratory science, environmental health, administration, and epidemiology. Public health professionals have expertise in diverse public health practices.5 Several organizations and agencies have called for an increase in the visibility of public health and the core workforce that forms its foundation.1,2

As a result, collaborative efforts have been undertaken to enhance the recognition of the public health professions by measuring and improving the competency and consistency of public health workers nationwide. In 2005, the National Board of Public Health Examiners (NBPHE) was established to ensure that graduates from schools and programs of public health accredited by the Council on Education for Public Health (CEPH) have mastered the knowledge and skills relevant to contemporary public health.1 The NBPHE has developed and now administers an examination for the credential, Certified in Public Health (CPH).1 The national examination covers the five core areas of knowledge offered in CEPH–accredited schools and programs, as well as interdisciplinary cross-cutting areas relevant to contemporary public health. The core areas include biostatistics, environmental health sciences, epidemiology, health policy and management, and social and behavioral sciences.1,2 The cross-cutting areas are communication and informatics, diversity and culture, leadership, public health biology, professionalism, programs planning, and systems thinking.1,24646

In addition, the Council on Linkages Between Academia and Public Health Practice has developed a set of core competencies for public health professionals to help strengthen public health workforce development.1,2 The competencies guide academic institutions and training providers to develop curricula and course content and to evaluate public health education and training programs. The competencies are used in practice settings as a framework for hiring and evaluating staff and assessing organization-wide gaps in skills and knowledge. The competencies are divided into the eight domains outlined in Box 3-1. Skills and knowledge are outlined within each domain, linked with important attitudes relevant to the practice of public health. This effort of the Council focuses on core competencies as they apply to three different categories of professional positions: front line staff, senior level staff, and supervisory and management staff.

The core competencies were crafted to transcend the boundaries of specific disciplines and to help unify the public health profession. The list has been cross-walked with the Essential Public Health Services to ensure that the competencies help build the skills necessary for assuring the provision of these services. Academic institutions and health departments nationwide, as well as the Centers for Disease Control and Prevention (CDC), the Centers for Public Health Preparedness (CPHP), and the Health Resources and Services Administration (HRSA)-funded Public Health Training Centers, have used the core competencies to extend capacity and to ensure that public health professionals have expertise in key public health services.

Successful provision of public health services requires collaboration among public, nonprofit, and private partners within a given community and across various levels of government.4 To fulfill these goals, partnerships must have broad-based representation of constituency and stakeholder groups, including private, voluntary, nonprofit, and public agencies or organizations involved in health, mental health, substance abuse, environmental health protection, and public health.6 Examples of organizations and agencies that can be engaged in coalitions and collaborative partnerships to improve health in communities are presented in Appendix C.

Assessment: A Core Public Health Function

The contemporary principles of public health practice and science have been highlighted in several national reports.3-5 These consensus reports, published by the Institute of Medicine (IOM), detail past contributions and identify challenges to public health. They outline recommendations to improve the nation’s public health system and to ensure universal access to necessary public health services.

The Future of Public Health report specified three core public health functions that shape the basic practice of public health at the federal, state, and local levels.3 Health agencies and health departments must perform these functions to protect and promote health, wellness, and quality of life and to prevent disease, injury, disability, and death. These functions (as noted in Chapter 1) are (1) assessment, (2) policy development, and (3) assurance.3 This chapter emphasizes the core public health function of assessment in the community.

The IOM report called for public health agencies to promote, to facilitate, and—when necessary and appropriate—to perform community health assessments and to monitor change in key measures to evaluate performance. Assessment is defined as the regular and systematic collection, assemblage, analysis, and communication on the health of the community.3 The IOM report stated that assessment includes statistics on health status, community health needs, and epidemiologic and other studies of health problems.3

Roles of Public Health Professionals in Assessment

The effective use of information in the twenty-first century is crucial to ensure that healthy children and adults are living in healthy communities. Technologies available to public health professionals influence the capacity and ability to generate and collect a vast amount of information.1,2 In addition, evidence-based decision making is shaping the development of public health policies, programs, and practices.4 Therefore it is essential for public health practitioners to have skills in collecting, analyzing, disseminating, and effectively using data and information.5 Public health professionals must have the knowledge, skills, and values to do the following5,7:

Public health dental hygienists are expected to play a leadership role in community oral health assessments.9,10 As agencies and organizations take on greater responsibility in conducting periodic assessments, public health dental hygienists will be involved in evaluating assets, needs, problems, and resources of the populations they serve in the community. Dental public health professionals working at the national, state, and local levels will be responsible for community oral health assessment.9 Essential public health services for oral health were developed to describe community oral health assessment (see Chapter 6 and Guiding Principles box).

Dental hygienists working within the public, private, or nonprofit sectors must have skills to assess community oral health problems, as well as evaluate outcomes of oral health population-based and personal oral health services. Dental hygienists working in community settings generally participate in a variety of assessment and evaluation activities. Examples of some of these roles and potential activities are shown in Box 3-2.

BOX 3-2   Examples of Roles of Public Health Dental Hygienists in Assessment

• Public health dental hygienist serves on a committee with the state oral health coalition. The committee collaborates with the state health oral program to develop a comprehensive document describing the burden of oral disease. The report includes chapters on the prevalence of disease and unmet needs, oral health disparities, and the societal impact of oral disease.

• Oral health program director evaluates the State Oral Health Plan by assessing the attainment of goals and specific objectives related to oral health promotion, disease prevention and control, and specific risk factors.

• Oral health policy analyst determines the number and geographic distribution of dentists statewide who participate in the Medicaid and state Children’s Health Insurance Program (CHIP) programs and provide oral health care to children in infancy, early childhood, middle childhood, and adolescence.

• Oral health program administrator with a city health department assesses the oral health assets, needs, and resources of a metropolitan area.

• Oral health educator assesses the knowledge, attitudes, and opinions of a community about community water fluoridation to develop an oral health promotion campaign.

• Public health dental hygienist from a county health department assesses dental sealants in third-grade children in schools throughout the county.

• Oral health program manager evaluates the quality and outcomes of clinical preventive services in a school-based oral health program.

• Oral health service provider monitors oral health indicators in the neighborhood surrounding a community health center.

• A dental hygienist, appointed to a state oral health advisory committee, evaluates the performance measures in a work plan to implement state level programs for community water fluoridation and school-based dental sealants.

Overview of Epidemiology: Population-Based Study of Health

Public health dental hygienists involved in assessment and evaluation should become well versed in the basic concepts of epidemiology, which is a core science of community health. This section provides a broad overview of epidemiology. Table 3-1 provides the definitions of terms used in epidemiology and community health assessments.

Table 3-1

Common Terms Used in Epidemiology

Term Definition
Acute Referring to a health effect, brief exposure of high intensity
Case Epidemiologic study that compares persons with a disease or condition (“cases”) with another group of people from the same population without the disease or condition (“controls”). The study is used to identify risks and trends, suggest some possible causes for disease, or for particular outcomes.
Chronic Referring to a health-related state lasting a long time.
Cohort study The method of epidemiologic study in which subsets of a defined population can be identified and observed for a sufficient number of person-years to generate reliable incidence or mortality rates in the population subsets; usually a large population, study for a prolonged period (years), or both. (Synonym: concurrent, follow-up, incidence, longitudinal, prospective study.)
Cross-sectional study A study that examines the relationship between diseases (or other health-related characteristics) and other variables of interest as they exist in a defined population at one particular time.
Dichotomous scale A measurement scale that arranges items into either of two mutually exclusive categories.
Ecoepidemiology Conceptual approach that unifies molecular, social, and population-based epidemiology in a multilevel application of methods aimed at identifying causes, categorizing risks, and controlling public health problems.
Ecologic study Epidemiologic study in which the units of analysis are populations or groups of people rather than individuals.
Endemic disease The constant presence of a disease or infectious agent within a given geographic area or population group.
Epidemic Occurrence in a community or region of cases of an illness, specific health-related behavior, or other health-related events clearly in excess of normal expectancy. (From Greek epi [upon], demos [people].)
Eradication (of disease) Termination of all transmission of infection by extermination of the infectious agent through surveillance and containment.
Etiology Science of causes, causality; in common use, cause
Incidence Number of instances of illness commencing, or of persons falling ill, during a given period in a specified population; more generally, the number of new events (e.g., new cases of a disease in a defined population) within a specified period of time. (Synonym: incident number.)
Index In epidemiology and related sciences, usually refers to a rating scale or a set of numbers derived from a series of observations of specified variables (e.g., health status index, scoring systems for severity or stage of cancer, heart murmurs, mental retardation).
Monitoring Intermittent performance and analysis of routine measurements aimed at detecting changes in the environment or health status of populations; not to be confused with surveillance, which is a continuous process.
Morbidity Any departure, subjective or objective, from a state of physiologic or psychologic well-being; in this sense, sickness, illness, and morbid condition are similarly defined and synonymous.
Mortality Related to death.
Multifactorial etiology Referring to the concept that a given disease or other outcome may have more than one cause; a combination of causes or alternative combinations of causes may be required to produce the effect.
Occurrence In epidemiology, a general term describing the frequency of a disease or other attribute or event in a population without distinguishing between incidence and prevalence.
Pandemic An epidemic occurring over a very wide area and usually affecting a large proportion of the population.
Prevalence Number of instances of a given disease or other condition in a given population at a designated time; when used without qualification, term usually refers to the situation at a specified point in time (point prevalence).
Prospective A research design used that looks forward.
Retrospective A research design that uses a review of past events.
Sensitivity Proportion of truly diseased persons as identified by the screening test; the measure of the probability of a correct diagnosis or the probability that any given case will be identified by the test. (Synonym: true-positive rate).
Specificity Proportion of truly nondiseased persons identified by the screening test; a measure of the probability of correctly identifying a nondiseased person with a screening test. (Synonym: true-negative rate.)
Surveillance Ongoing systematic collection, analysis, interpretation of health data essential to planning, implementation, and evaluation of public health practice. Generally using methods distinguished by their practicability, uniformity, and rapidity. Closely integrated with the timely dissemination of health information to responsible parties. Application of data in public health decision making and use of data to prevent and control diseases and conditions. Surveillance is the essential feature of epidemiology.
Surveillance system Functional capacity for data collection, analysis, and dissemination linked to public health programs.
Trend A long-term movement in an ordered series (e.g., a time series); an essential feature is that the movement, while possibly irregular in the short term, shows movement consistently in the same direction over a long term.

Adapted from Porta M, editor. A Dictionary of Epidemiology. 5th ed. New York: Oxford University Press; 2008.

Epidemiology is the study of the distribution and determinants of health-related states and events in specified populations and the application of this study to the prevention and control of health problems.11 Epidemiologists consider the interactions and relationships among the multiple factors that influence health status and health problems.12 Methods used in epidemiology and research are combined to focus on comparisons between groups or defined populations. Epidemiologists make comparisons by examining the occurrences of the health events, locations, times, and variations to assess the distribution and determinants of health events.13 The principal factors analyzed in epidemiology are as follows:

Epidemiology is based on a multifactorial perspective, with consideration given to the interacting relationships among host factors, agent factors, and environmental factors.12,14

Uses of Epidemiology

Health represents a general balance among host, agent, and environmental factors; health problems occur when the balance is threatened by changes in host, agent, or environment.14 Prevention is concerned with maintaining or initiating a balance of these factors. Disease or health status depends on multiple factors such as exposure to a specific agent, strength of the agent, susceptibility of the host, and environmental conditions.12

Epidemiology can be used to provide different types of data and information.17 Epidemiologists in public health agencies are responsible for surveillance, investigation, analysis, and evaluation.12,14 The various uses of epidemiology are illustrated in Box 3-3. The three classifications of epidemiologic studies are outlined in the Guiding Principles box.

Changing Perspectives of Health

During the twentieth century, major transformations took place in the concepts of health and the understanding of the determinants of diseases, disabilities, and injuries. Many historic developments contributed to these expanded visions and had a profound effect on the health of individuals and populations.1,2,18 These developments contributed to changes in clinical health care and public health practice. Box 3-4 outlines broad trends that influenced the conceptions of health in the twentieth century.

Reports from studies have identified many factors that influence the health of individuals and populations.4,1923,2531 Several of these factors are generally recognized as broader determinants of health (e.g., employment; education; environment; income; shelter; food; social justice and equity; family, friends, and social supports; peace and safety; culture and race relations).14,2224,3133 Other factors (e.g., language, learning, meaningful work, recreation, self-esteem, personal control) are considered contributors to well-being. These factors may also be classified as follows14:

There has been a broadening of the concepts of health promotion and disease prevention from an individual focus toward a human ecologic perspective.17 Health became much more than just the absence of disability and disease. In 1948, The World Health Organization (WHO) Constitution defined health as “a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity.” The fundamental conditions and resources for health were described in 1986 by the Ottawa Charter for Health Promotion (Box 3-5). Improvement in health requires a secure foundation in these basic prerequisites.

Health promotion was discussed as the process of enabling people to increase control over and to improve their health. To reach a state of complete physical, mental, and social well-being, an individual or group must be able to identify and realize aspirations, satisfy needs, and change or cope with the environment. Health was therefore seen as a resource for everyday life not the objective of living. Health was a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore health promotion is not just the responsibility of the health sector but goes beyond healthy lifestyles to well-being.

Conceptual Models of the Determinants of Health

Many models describing the multiple factors that influence the broader dimensions of health in individuals and populations were developed in the second half of the twentieth century.4 Multicausal perspectives of health and disease began to take precedence over monocausal models.12 The epidemiologic triangle model waned as the emphasis on infectious diseases diminished in the later part of the centu/>

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