03

Hashem Jaddou

Neveen Alomoush

Asham Alsalkhadi
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 Community Diagnosis As A base for Community Health
Planning & Action
Ch. VII of Alma Ata Declaration
Community and Community Health:
 Community means the people who→ live within a relatively limited geographical
area, have certain common needs, and a sense of minimum common interests. *Ex:
medical students’ community, a city, a country…
 community health is a discipline that concerns itself with the study and
betterment/improvement of the health characteristics of communities.
 here we have 3 communities, the 3rd one has a better health than the others.
 health means an optimal state of physical, psychological, and social wellbeing and
not merely the absence of disease.

Community Vs. Individual:

 Individual Medicine, Individual Health status/problems& Individual Diagnosis:
→As medical students our community is our patients, and we are concerned with
diagnosing the individuals and their individual health status.
 Community Medicine Community Health status/problems & Community
Diagnosis:
→ people who are involved in community health are concerned with diagnosing
health problems of the community and improving its health.
 The Unit of Analysis in the community health is the community whereas the unit
of analysis for us as medical students is the individual persons.

Individual Diagnosis:
you must follow this systemic process:
First ask about:
1. Personal data: socio-demographic data→ Age, sex, residence, occupation…
2. Chief Complaint: why did the patient come to you?
3. History of Present Illness.
4. Past medical & Family History.
Clinical Examination: palpation. Auscultation…
Investigations: X ray, labs…
Application of Knowledge & Expertise to build the provisional diagnosis ( ‫التشخيص‬
‫)المبدئي‬.
Diagnosis.
Treatment.
Follow-up Evaluation….

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N.B.: Medical treatment without a specific individualized diagnosis of the patient is
quackery (health fraud).

Community Diagnosis:
 It should be the first stage in planning health programs (treatment)for any
community or the society at large that includes (Health education, environmental
health (air pollution, safe drinking water, food safety), maternal and child health,
occupational health, injury control, …). All of these are part of the Alma Ata
declaration.
 It includes definition of the community’s:
1. demographic characteristics.
2. environment.
3. health status.
4. availability and utilization of health and social services.
 Remember: communities can differ as widely in health status and needs as do
individuals.

Aspects of Community diagnosis:

I. Community health status which is defined as:

A. The assessment of levels of health of the community or area being studied, which
include:
1. Measures associated with the health status of persons and population →by looking
to the incidence/prevalence of diseases.
2. Measures related to environmental conditions with some assumed association with
health status of the population.
3. Measures concerned with the presence and utilization of:
✓ personnel (doctors, nurses…). ‫*هل عدد الكوادر كافي لخدمة كوميونيتي معين؟‬
✓ services and facilities involved in the promotion, prevention, or restoration of
health.
*Promotion means how to get the healthy person healthier
B. The documentation of the qualitative and quantitative adequacy of the resources
available to the population and essential to health.

C. The application of the best possible professional (doctors, nurses…) and other
informed opinion (community leaders) as to the key features of community health
status and the priorities for planning recommendations and implementation.

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II. The Demography of the Community:
▪Total Population
▪ Urban-rural distribution.
▪ Age, sex, educational status, health insurance, marital status, # of households, type
of family (extended or nuclear family).

III. Communications:
-We must look at the types of communication to educate the public about certain
diseases. Ex: The press, Radio and Television and Other Media of Communication

IV. Economic Life of the Community:

▪ Economic Structure of the Community (incidence of poverty).

▪ Occupational Analysis of the Working Population.
▪ Indicators of Economic Status (per-capita income, employment rates…).
V. Housing:
▪ Housing Conditions in the Community (size, drinking water sources).
▪ Neighborhood.
VI. Education: more educated communities are healthier communities!

▪ Structure and Administration of the community.

▪ Teachers may act as supporters.
▪ Special Services.
▪ Adult Education (‫)زي محو األمية‬.
▪ Libraries and Museums.
▪ Higher Education.
VII. Recreation:
▪ Public Recreation, like spaces for doing sport.
▪ Private and semi-public recreation and cultural facilities.
▪ Commercial facilities.
VIII. Religious Activities:

▪ Numbers of Mosques, Churches.

▪ Clergymen (‫)رجال الدين‬.

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Identification and Setting priorities of community health
problems:
Community diagnosis provides an appraisal of the community’s major health-related
problems based on:
1. epidemiological and clinical data.
2. community and professional input

FACTORS IN DETERMINATION OF PRIORITIES IN

PLANNING HEALTH PROGRAMS:
A. Factors inherent in the disease (or other problem) itself of community health
importance because of:
1. Number of people involved (or susceptible): *The more people involved the more important
is the disease!
✓ Epidemic: can be infectious epidemic → common source epidemic (ex: water as a
sources of infection), propagated epidemic (like covid 19, measles).
Or noninfectious: DM and hypertension are epidemic in Jordan, and we are still
in the ascending part of the epidemic curve and did not yet reach the top of this
curve.
✓ Endemic (persistent with decrease and increase in its rate).
✓ Sporadic.
2. Seriousness in terms of Mortality and Morbidity.
- Ex: Rabies (high fatality rate but low prevalence) vs Upper Respiratory
Infection or chicken pox.

B. Technical resources for dealing with the health problem:

1. Availability for application at reasonable cost → Scan(mammogram) vs. BSE (breast
self-exam, less expensive) …
2. Availability of professional and technical personnel, facilities, transportation, etc.
3. By-products of control of a disease → may other health problems be affected
(favorably).
→STDs diagnosis is the by-product of the efforts in trying to control AIDS, STDS
before AIDS were considered very stigmatizing and they could not know their
magnitude, after AIDS this has changed.
4. Is “eradication” a possibility? We give the priority if the disease can be eradicated
→Malaria vs. polio (‫)قربنا ننهيه باألردن‬, Thalassemia (eradicated by premarital testing
in Cyprus) vs. STDs.

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C. Reaction of the public:
-do what the community need and want; working with people is constructive while
working for people is destructive.
1. Expectation – does the public expect an organized program to be undertaken?
Water pollution & government action.
2. How widely disseminated is public knowledge of the health problem? Dental caries,
Hypertension & Dyslipidemia.
3. How much change in cultural patterns must be made to make the control program
effective? Family planning.
‫* اول ما ظهر موضوع تحديد النسل باألردن الناس عارضوا والبرامج يلي عملوها كانت ع الفاضي لحد ما‬
.‫توصلوا لتنظيم النسل يلي فيما بعد تقبله المجتمع‬

4. Are changes in “pleasant” habit patterns required? Weight reduction vs. leaving
bad eating habits.
5. Is it relatively simple to get the individual to realize that his personal interests are
at stake/risk? Car accident vs. Sedentary life.
*The reaction of the public is important to educate the public to be aware about the health
problems that they live with without noticing it.
D. Economic aspects:
1. To what extent will the productive period of life be extended by the control
program? Immunization vs. diet.
2. Is the control program one which the local community can support over the long-
term? Mammogram vs. immunization.

E. Reaction of the health professions:

1. Degree of involvement of private practice (in areas where private practice is an
important proportion of the total health service): Ex → STDs reporting by private
professionals.
2. Degree of interference with “free choice”.
- Ex: Notification of communicable diseases (under recorded in Jordan), Premarital
testing.
3. Degree of interference with patient-physician relationship. AIDS.

F. Legal requirement that a control program be undertaken.

-Testing for AIDS. Premarital testing

N.B.: The rule of thumb for community health development is that "working with
people is creative but doing things for people might be destructive.
N.B.: Applying this principle in health education intervention programs, priority

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health problems will then be the problems identified and ranked by the community
as their major health problems.

At first during community diagnosis, we identify the community leaders, How

to list major health problems of a community?

A. NOMINAL GROUP PROCESS; by Van de Ven and Delbecq :

1. Call for a community meeting through the community leaders ( ‫حلقة الوصل مع‬
‫)الكوميونيتي‬.
-Those selected as participants should be representative of, and knowledgeable
about, the community in question.
2. Arrange the participants into groups of six or seven members, Members of each
group introduce themselves to each other.
3. Pose a single question to the group:
-Use Flip chart, blackboard, or sheet of paper “"What do you consider to be the
major health problems you are facing at this time"?
➢ Pass out nominal (silent) activity forms.
➢ Give example of response desired (writing problem not solution).
➢ Short, specific written responses (2-3 words).
4. Have the participants of each small group write down their responses. (15
minutes)
➢ Group leader ensures complete silence.
5. Elicit individual responses in a round-robin fashion( ‫نسجل اول مشكلة لكل القروب ونرقمهم بعدين‬
‫)نسجل ثاني مشكلة وهكذا‬.
➢ Responses are written by the group leader on a white board or flip chart.
➢ Each item being given a number (1,2,3...
➢ No discussion permitted regarding form, format, or meaning of a participant's
response.

6. Clarify the meaning of responses:

➢ The group leader must ensure that only clarification takes place.
➢ This is not the time for argumentation and lobbying.
7. Conduct preliminary vote:
➢ the group leader then records the ranking assigned to the statement selected by
each participant and sums up the votes after all participants have contributed their
rankings
➢If we want to assess the major 5 problems, we give each participant 5 cards and

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ask them to write the most important problem and write down its number and give
it a mark from 5 and then we sum the marks for each of the selected problems.

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Water pollution Car accidents
5
4
8. Discuss the preliminary vote. ➢
Discussion regarding the high vote-getters and low vote-getters may be of value.
➢ Discuss to make sure that all participants are clear on the meaning of selected
items.

9. Conduct a final vote.

➢ If there are FIVE major items selected, each one of them could be rated on a scale
of zero (not important) up to ten (very important).
➢ This procedure then provides insight regarding the actual magnitude of
differences between major items.
*It is now a priority to deal with the decision of the community.

B. The Delphi Method:

1. Define the issue: planners develop clear and concise statement.
2. Select the participants: knowledgeable on the issue; 15-30. (No need for community
leaders and meeting)
3. Develop and send 1st questionnaire: open-ended; 2 weeks deadline.
4. Develop 2nd questionnaire: 123 items grouped to 20 categories are sent back to
select the top 7 barrier categories and rank them.
5. Develop 3rd questionnaire: values to each category are added forming the “initial
vote”; summary comment on each category are prepared and sent back for
another round of ranking “final voting”.
6. Final consideration: may issue a 4th vote.
*The method accounts for power differences:
‫بالطريقة األول أصحاب السلطة او الوجهاء ممكن يأثروا ع اراء المشاركين فبمجرد وجود المختار مثال‬
.‫واختياره لمشكلة معينة يلي ممكن تكون مش مهمة بنظر المشاركين بس يمكن يتماشوا معه بمجرد مركزه‬

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Social Determinants of Health:
 Age, sex, race, and Socio-economic status are the most important variables
correlated with health and life expectancy. It represents important differences
between people on these issues.

 Age:
▪ Improved conditions (nutrition, sanitation, med care, housing…) prolong life.
▪ Life expectancy in Jordan jumped to 73.5 years in 2011 from 46 in early 50’s(also
due to reduction in infants mortality). This trend will bring change in health
system.
▪ Aged need more care as minor ailments/illnesses might turn serious or linger
longer.
▪ Pressure on SS (social security) system: for every 8.6 tax payers there was one
SS beneficiary in 1955, 2.7 in 2005, and 1.9 in 2035 leading to serious difficulties.
▪ The key to a positive quality of life of the old appears to be that of maintain
one's health as long as possible and as close as possible
to the time of one's death.(the green curve is the best and
it represents the longest life and shortest period of illness
before death while the red one is the most dangerous with
the shortest life and longest period of illness).
▪ The most prevalent chronic disease among 65 y+ are arthritis, HBP, hearing loss,
heart diseases, cataract.
▪ elderly require greater attention and demands.

 Gender:
▪ Economic development benefited women the most. ‫ألنه أيام المجاعات كانوا يفضلوا الرجال‬
‫على النساء واألطفال‬
▪ Men exceed females in death rates at all age, and for leading causes of
death.
▪ Women tend to suffer more frequent illnesses and disabilities, but they are not as
threatening as it is for men.
▪ The distinction of diseases by gender is in the frequency and the pace to death. e.g.
CVD is # 1 for men from age 39 and for women from age 66.
▪ Life expectancy in Jordan 2011 (74.9 vs. 72.2 years) in favor of women.
▪ Men has shorter life expectancy because:
a. biological effect (weaker physiologically as demonstrated by higher mortality
from the prenatal and neonatal stages forward.
-Chances of dying at prenatal stage is 12% higher among males.
-Neonatal disorders common to males are hyaline membrane disease, pyloric
stenosis, coarctation of aorta, subjected to more severe bacterial infections,
hemophilia, leukemia.
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 b. social-psychological influence: accidents due to higher exposure to
dangerous activities, airplane pilot, metal worker, taxi driver, construction labor,
electric worker, truck driver, farmer.
c. occupational competition and job pressure is another factor contribute to
male mortality: -Building career and drive toward success→ to stress.
-Middle-aged professional males is considered a high-risk group, particularly if
they smoke, are overweight, tend to overwork.
-This trend changes when females move to high-risk occupation and become
more ambitious.
▪ Males more alcohol consumers → liver diseases, car accidents.
▪ Drive at high speed, engage in violent sport.
▪ Males have higher level of blood pressure.
*So, gender is a distinctive factor for the distribution of illnesses from the prenatal
age to older age.
▪ Females have higher rate of acute illness (11 times more than males) except for
injuries.
▪ Females stay more in bed once sick.
▪ Females are more thyroid, anemia, gallbladder, chronic colitis, migraine, arthritis,
diabetes, urinary diseases.
▪ Males are more for susceptible for loss of limbs, gout, emphysema, AIDS,
coronary.
▪ Youngest and oldest (extremes of age) males have higher incidence of cancer
while it is higher for females 20-55 years old. (2 peaks vs. 1 peak)
▪ Females have higher incidence of chronic disease that are not leading causes of
death (except for diabetes).
▪ Women use health services more.

 Social class:
▪ To be poor is to have less of the things (including health) produced by the
society.
▪ Medical and nursing students take care of the poor.
▪ Health care professionals do not take into account that people live their lives
different from their assumptions of regular meals, keep healthy, plan for the
future.
▪ Research indicates that:
✓Poverty is positively related to lack of access to good medical care.
✓H. care professionals are likely to “prefer” upper class patients.
✓On every measure, SES is one of the most consistent predictors of a
person’s health and life expectancy.
✓Highest education and occupation have lowest mortality rates from chronic
diseases.

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▪ SES consists of measures of:
1. Income
2. occupation status/prestige
3. education.
→Each reflects different dimensions of person’s position in class structure:
✓income=spending power, housing, diet, medical care;
✓occupation status=responsibility, physical activity, and occupation health risk;
✓Education=skills for acquiring positive social, psychological, and economic
resources.

▪ Studies show that education is the strongest single predictor of good health.
▪ Well educated are well informed about merits of lifestyle involving exercise,
smoking, healthy diet, advantages of preventive care.
- All pathways from education to health are positive.
- Research (Ross 1995) explains why the relationship between education and
health is strong as it indicates that well-educated are more likely to acquire:
1. Rewarding jobs, High income, less economic hardship.
2. Greater sense of control over their lives, Less likely to smoke, More likely to
exercise, Get periodic medical checkups.
▪ People living in poverty have greatest exposure to risk factors that produce
ill health: physical (poor sanitation, overcrowding, extreme temperatures),
chemical (pollution), biological (bacteria, viruses), psychological (stress), and
lifestyle (diet, smoking).
▪ SES & Koos study:
- Koos study of three social class and ability to recognize a list of medical symptoms
as important and warrant medical help seeking.
- Class III were the lowest in recognizing the symptoms as important.
- Explanations:
1. Financial: cost is high, income low, and no insurance.
2. Culture (Culture of poverty (COP)):
✓The poor have attitudes and norms (e.g. fatalism/‫ )القدرية‬that retard use of
care.
✓The Poor view medical practices as less than positive as a result of their life
experiences.
✓The poor may be more willing to ignore illness or not define it as such
because they must continue to work.

3. social barriers/ Systems barrier (SB):

-SB viewed as the strongest explanation for low use of services by the
poor in relation to need.
-It focused on organizational barriers as an inherent attribute of public service
sector used the most by the poor.
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 -Barriers include:
a. Difficulty in locating and traveling to a particular source of care.
b. Impersonal and alienating atmosphere of the treatment setting.
-The poor in such settings receive: less preventive services ,more waiting
time, poor Patient-Physician relationship→ imposing a highly significant
barrier that discourage them from seeking care (normal response to an
unpleasant experience).
4. regular source of care:
the findings from Dutton study that people with regular source of care were
more likely to use preventive services which is not the case for the poor whose
source is the physician on duty.

"‫"يعطيكم العافية‬

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