Making a community diagnosis
A community profile or diagnosis is needed to plan hygiene education activities. Planning the survey involves making decisions about:
• What information is required.
• How that information should be collected to obtain a true picture of the situation and to avoid bias and errors.
Types of information required for cholera prevention programmes
Basic information on the community
This will include: size and composition of the population, groups at risk, income, educational level, religion, and socioeconomic group.
Current hygiene practices
Information gathered at the initial stage of making the community profile gives baseline data against which to set objectives and evaluate the programme.
Perceived needs of the community
Health educators will use medical criteria to identify the needs of the community. They must, however, find out what members of the community feel are their priority health needs. These may be expressed needs that have already been put forward by the community or by the voluntary and government workers in the area, or felt needs that have not yet been expressed, and can only be determined when time is spent in discussion of these issues.
Existing channels of communication within a community
These may be informal channels, such as neighbourhood social networks, opinion leaders, shopkeepers and tea shops, or formal channels, such as schools, health workers, community workers and youth leaders.
Also important are details of what media are available and popular, for example newspapers, magazines, and radio and television programmes, current hygiene practices
Find out what health information is already being conveyed through these existing channels of communication. Does it agree with or contradict the needed health and hygiene messages? Can these communication channels be mobilized?
Influences on health behaviour
Influences may operate at the individual, family, community or higher level. They include: the physical conditions of the area, such as housing and environment, and the availability and quality of services such as water supply, clinics and schools; the local norms, beliefs, attitudes, values and knowledge that make up the community culture; and the power structure, both formal through elected politicians and officials, and informal through community leaders, opinion leaders and others.
• Use more than one method or source of information and then check if the information obtained from the different methods agrees; this is called triangulation.
• Choose people to talk to (the sample) that are representative, in terms of age, sex, education, income and so on, of the group being investigated. Do not just interview people who are easier to contact because, for example, they live nearby or come to clinics. One way of sampling the population is to make a random sample. This can be done, for example, by writing down the names of all the people on separate sheets of paper and picking them out of a box.
Another simple approach is to select every third house (although this may sometimes result in bias).
• Take time to explain why the information is being sought. People are more likely to answer truthfully if they trust the interviewer and believe that he or she is going to use the information to help them. Be honest about how the information will be used and emphasize that any information provided will be confidential. It may be better to ask someone else to do the interviewing if it is likely to provide more truthful answers. For example, a young person can interview another young person; a woman can interview a woman; an older person can interview an older person.
• Find out whether, in the community, there are subjects that are considered taboo and impolite to talk of or ask questions about. If this is the type of information that is needed, careful consideration will have to be given to how to ask these questions. One approach is to emphasize the confidentiality of the information.
• Avoid leading persons to answer in particular ways by the questions asked. Explain that the point of the interview is to find out what they themselves think. Wherever possible, ask open questions that allow people to give frank opinions in their own words and say what they think is important.
• Involve the local communities themselves in planning the survey and doing the interviewing. This approach is called participatory research. This is a good way to encourage community participation and ensure that the community profile includes data that the local community feel are important.
Qualitative and quantitative methods
Quantitative research methods collect specific information and facts that can be expressed as numbers. The numbers can then be treated mathematically to produce overall data for the community, for instance, the number of households with different types of excreta disposal facilities, the number of children, specific knowledge about nutrition, the number of people who hold a particular belief about the spread of cholera.
Quantitative information can be obtained through observation, by looking for specific practices. Quantitative data can also be obtained from questionnaires and interviews that ask closed questions. These are questions that have to be answered in a specific way, with numbers, by saying yes or no or agreeing/ disagreeing with statements on a list.
Example of closed question:
Do you agree that cholera is prevented by hand washing? Yes/no.
Example of open-ended question:
What do you think are the causes of diarrhoea?
Qualitative research methods ask open-ended questions where the community answer in their own words and are given freedom to expand and give their thoughts on the subject. Interviews and observation are used, as well as focused group discussion.
Qualitative research methods can give rich insights into the local situation and peoples' feelings. It is, however, difficult to summarize the information obtained and to obtain a complete picture of a community. Interpretation of qualitative data depends a great deal on the honesty and skill of the person doing the interviews. It is easy to introduce bias by letting personal feelings and interests influence how the data are interpreted.
Qualitative research is particularly useful for rapid appraisals of the situation. It is also used a great deal in helping to develop appropriate communication messages. It can be of use, for example, to find out the views of young people, test out (or pre-test) media such as posters and radio programmes, and get a feel for the impact of a health education programme. Quantitative data are, however, necessary to get some idea of the size of a problem or to convince policy makers of the need to take action.
In practice, it is best to try to include a combination of qualitative and quantitative methods. One approach is to use qualitative methods to get a feel for the situation and to identify issues to include in follow-up quantitative surveys.
Sources of data
Published sources, records and interviews with field staff. Start with existing sources, such as the census, previous surveys, and records and files of agencies operating in the area. It is surprising how much useful information can be obtained from the most unlikely sources, such as government reports, minutes of meetings and newspaper reports. Much of the available information may, however, be of poor quality, irrelevant and out of date. Health data from clinic and hospital records can give a useful picture of the local situation, but only represent cases where people have come for treatment. They will miss out cases where people have been treated at home or taken to private or traditional healers.
Look out for field staff from health and other services who have worked in the community and can give the benefit of their experience. Try to meet them and find out what they feel, and compare this with what the community themselves say.
Interviews in the community: The next stage of data collection is to go to the area and meet the people that live and work there.
A useful approach is to interview members of the community and workers in various government and voluntary organizations - the key informants. This both provides information about the area, and is an opportunity to introduce the researcher and present health education interests. Give careful thought to who can be interviewed to get a balanced and true picture.
Focused group discussions. These are discussions with groups of people in the community carried out in a systematic way to provide information on a topic. Groups of people sharing the same characteristics are brought together. A group discussion is guided by questions asked by the interviewer. These should be open-ended and designed to make people respond and discuss. The involvement of the interviewer should be limited to that of a facilitator. Discussion between the group members should be encouraged so that the interviewer can observe the language used and the feelings of the group.
Observation. Another way to get to know a community is observation. This involves casual observations and informal conversations with residents of the area on doorsteps and in public places and shops. It is also possible to have a structured observation, with a check list of points to look out for, so that the observation is carried out in a systematic way.
Action-research approaches. The feelings of the community can be elicited by carrying out some health education and asking for comments and feedback. For example, people can be asked for their opinions about a leaflet, poster or film. The researcher might try setting up an advice stall and monitoring what requests for information come from the community.
Planning a survey
Surveys can use any of the data collection methods described above on all, or a sample, of the people in a community. Before doing a full-scale survey of a community, it is better to carry out first a small scale pilot survey, such as interviews and focused group discussions. This will give an idea of what topics and questions to include in the larger survey. In planning the survey, the researcher can follow the steps outlined below.
Questions to ask in planning community health surveys
Stage 1: Define aims and scope of the study
• Why is a survey needed?
• What are the needs and problems to be investigated?
• How will the information obtained be used?
• Can the information be obtained in any other way?
Stage 2: Decide upon the information requirements
• What information is required to deal with the community's needs and problems?
• What information is needed for proposing a solution or for allocating resources to health and community needs?
• What do the local fieldworkers feel should be included in the survey?
• What does the community feel should be included in the survey?
• If funds are limited, what are the most important questions to ask?
Stage 3: Find out whether the required information is already available
• Has a survey already been carried out in the community which might contain useful information?
• Are there any books or published reports which deal with similar issues in other communities, at a regional or national level?
Stage 4: Assess whether the survey can succeed
• Will a survey provide the information needed?
• Are there sufficient resources (money, field staff) and time to carry out the survey?
Stage 5: Making decisions on data collection, sampling and implementation
• How will the data be collected - observation, interviews, focused group discussions?
• If using observation, what will be on the check list?
• If asking questions, what wording will be used and how will the questions be tested to make sure they are understood and acceptable?
• How are the communities and people in the sample to be selected?
• How many are to be included? How long will each interview/observation visit take?
• When will the data collection take place - time of day, day of week, season? How long will the survey take to complete?
• Who will carry out the interviewing?
• Can local fieldworkers, volunteers or members of the community be involved?
• Will they need training?
• What arrangements are needed to get the interviewers to the field?
• How is the community going to be involved in the survey?
• How much time is needed to complete all the fieldwork, including visiting and interviewing?
• How will the data be analysed and presented?
Stage 6: Estimating the cost of the survey and preparing a budget
• How much will it cost to undertake the survey, including transport, staffing and other help?
• Are there non-essential questions that can be left out of the survey to reduce the cost?
• Could the number of people or geographical area of the sample be reduced?