1 Sources of information about communities and populations

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Contents

Unit 1: Assessing the health of communities and populations

Objectives

When you have completed this unit you should be able to:

1-1 What is a community?

A community is a group of people that have something in common. Often, a “community” refers to people living in the same geographic space and using the same facilities, such as a neighbourhood in a town, a zone in an informal settlement, or a village in a rural area. But a community can also mean people who share things other than a geographic space such as values, interests or lifestyle. For example, the Muslim community, a sports club, or the community of Somali migrants in South Africa. People who share something in common identify themselves as belonging to a community.

A community is a group of people who have something in common such as a neighbourhood, religion, sport or cultural interest.

1-2 What is a population?

The term “population” refers to a larger group of people who do not necessarily have much in common. For example the population of Cape Town, people who listen to the radio in rural areas or women in South Africa.

1-3 How can one find out about the health problems in a community?

It is possible to gather meaningful information about a community’s health risks and needs by asking the right questions and by involving community members themselves. Therefore information is usually collected by speaking to members of that community.

Because communities share identities and, often a geographic area, the members are also likely to share health risks, beliefs, needs and priorities.

Members of a community often share the same health risks and health needs.

1-4 What is the approach to understanding health problems at the population level?

In contrast to communities, the individuals in a population may have little in common, so useful information about populations is mostly limited to routinely collected data from a number of sources. These include:

Data is a term used for a collection of information such as the number of children under the age of five or the number of houses in a community.

1-5 Why are these population measures useful?

These measures are useful because:

However, they need to be interpreted with caution because population level measures can hide problems in individual communities. For example, measures of the overall population health in a particular city might look quite good, even though there is an informal settlement community within the city that has poor health.

1-6 Why assess community health?

There is often an unmet need for health services in a community. It is important to realise that the number of people coming to clinics or hospitals and the types of problems they have represents the demand for services. However the demand for services is not necessarily the same as the need for services. In many cases, health in the community can be considered as an iceberg, with a large part submerged as the need exceeds the demand.

Figure 1-1: Viewing health needs as an iceberg.

Figure 1-1: Viewing health needs as an iceberg.

In a community the need for healthcare is often much greater than the demand.

1-7 Why might people have unmet healthcare needs?

There are many reasons why there might be unmet healthcare needs:

It is very important that the unmet health needs of a community are identified.

The demand for services at hospitals and clinics is not the same as the need for healthcare. Identifying the need for healthcare is an important part of public health.

1-8 Why is it important to identify unmet healthcare needs in a community?

Public health has 2 important underlying principles:

Note
Some academics argue about which of these principles should guide the planning of health services, but both are important.

Identifying and trying to meet health needs at community level goes a long way to meeting these 2 principles because:

It is important to identify the needs of the poorest and most marginalised in a community, because they are usually the least likely to make their needs known.

1-9 What methods are used to identify and tackle unmet health needs in communities?

There are several approaches to community health assessment, which overlap:

Community diagnosis, community orientated primary care and community mapping are used to identify and tackle unmet health needs.

1-10 How is a community diagnosis made?

A community diagnosis can be made using a process similar to diagnosing a health problem in an individual:

  1. Taking a history: Much information about communities can be found just by talking to people. It is important to find out who the important role players in a community are, what the local facilities are like, and how people understand local history and politics. Important information may not be volunteered the first time of asking.

  2. Examination: Additional information is found by driving or walking around if it is safe to do so. This is the best way of finding out about water drainage in the rainy season, the sanitary condition of shared toilets, the safety of roads and other aspects of community life

  3. Special investigations: Sometimes the necessary information about an important issue is not readily available and it may be necessary to collect it as part of the community diagnosis. This might involve surveys, or some focus group discussions. In most countries, there is a national census every 10 years where every household is visited and data collected about the size and age structure of each community and population, household incomes, schooling and many other factors including some health statistics. This information is usually publicly available.

Group discussions, personal observation and surveys can be important ways of identifying the needs in a community.

When this information has been collected and considered, the next step is to draw up a problem list and a management plan. This should be done in partnership with individuals or organisations in the community.

1-11 What is community orientated primary care?

Community orientated primary care is a term used by different people to mean different things. The 3 main approaches are:

  1. Community healthcare workers visit every home in a defined community to map out who lives there and what their health problems are. They work in a team with healthcare professionals and have a very strong focus on prevention and ongoing care. This approach is used successfully in Cuba and Brazil. It has been proposed that South Africa move to a system of “ward-based health teams” to provide this kind of primary healthcare.

  2. Another approach is to have a process of consultation between healthcare professionals and community leaders to list priority problems and draw up a joint plan of action. This can be very effective, but is also challenging and may require a long process of trust building, particularly in poorer and marginalised communities. Health providers using this approach often find that they are presented with problems they are not equipped to deal with, such as stray dogs or illegal drinking taverns. The more powerful individuals in the community are also able to push agendas that do not necessarily represent the interests of the poorer and more marginalised.

  3. A third approach is to use population information to estimate the likely number of people with a particular problem or condition in a community and to compare this with how many are actually in care, and whether the care is effective. This gives the “gap in effective coverage” of services. Reasons for the gap and strategies to close it can then be planned.

Community healthcare workers can bring primary care to the home of every community member.

1-12 What is community mapping?

Health providers and community members can make their own maps of the problems and needs in a community. Community mapping is used in 2 ways in public health:

  1. Maps are created and used by health teams. The health issues in various households can be placed on a map so that services can be targeted. For example, recording gastroenteritis cases on a map makes it possible to see clusters of cases in particular areas. This makes it possible to identify water sources that should be checked, or communities where pre-mixed oral rehydration mixture could be distributed in advance of the “gastroenteritis season”.

  2. Communities can be assisted in producing their own maps indicating land use, customary land rights and other issues of importance to them. This gives them power when they communicate with authorities. For example, a community map might indicate a site where sexual assaults are common and this might persuade a municipality to improve street lighting there, or close an illegal tavern. This is called participatory mapping.

Community mapping can empower a community to identify their problems.

1-13 Are there different types of communities?

Yes. There are many different ways of classifying communities, for example urban and rural. The following classification offers a useful way of thinking about communities if we want to interact with them on a personal or professional level:

“Hidden” communities can be difficult to work with because of a lack of trust and a lack of community organisation.

Unit 2: Demographics and sources of population health data

Objectives

When you have completed this unit you should be able to:

2-1 What is demography?

Demography is the study of populations:

Public Health is principally concerned with demographic information that helps the planning of health services by predicting need, and indicating how well current health services are covering that need.

Demography describes the structure of a population and guides the planning of health services.

2-2 What are some important demographic measures?

2-3 What is meant by “the demographic transition”?

The change in the structure of a population by age groups over time is called the demographic transition. In most countries in the world, with economic development people are living longer and having fewer children. This means that the age structure of the population is changing. The structure of a population can be described using a chart called a population pyramid that shows the number of people in each age group for males and females.

  1. A country at an early stage of development has a population pyramid that has many young children and fewer older people.

  2. As a country develops, there are fewer young people and more older people.

Demographic transition is the change in the structure of a population by age groups as the developmental status of the population changes.

2-4 What are the consequences of the demographic transition?

The demographic transition results in changes in the way people live and work, and also in the expected patterns of illness. Fewer children mean that:

More older people mean:

2-5 Where are the main sources of demographic information?

Demographic information comes from 2 types of sources:

These 2 sources of data are combined to estimate the size of the population in any particular year.

2-6 How is census data recorded?

The census in South Africa is done every 10 years by Statistics South Africa (Stats-SA). Every household in the country is visited to find out who lives there, and to ask several questions about household income, services, education and some health questions. It is very expensive to do a census, so it is not possible to do one more often. The 2011 census in South Africa cost over one billion rand. Obviously the population in a particular community may grow or shrink over the 10 years between each census. Sometimes a partial survey is done in between. Stats-SA did a Community Survey in 2007, looking at about 275 000 households. Stats-SA completed the second Community Survey in 2016, looking at about 1.3 million households.

In South Africa, a national census is conducted every 10 years when every household is visited to collect population data.

Note
Much of the census data is publicly available on the Stats-SA website (www.statssa.gov.za). Information that is broken down into particular districts, subdistricts and electoral wards can be found on the Stats-SA website by going to the “Tools” bar at the bottom of the page and clicking on Nesstar.

2-7 How are “flows” of a population recorded?

Population flows are recorded by “vital registration systems”. In South Africa, these are recorded by registrations of births, death and immigrations at the Department of Home Affairs. Data from various registers are then compiled and processed by Stats-SA to produce reports that are publicly available on their website. As registration of births and deaths becomes more complete and more reliable, it is possible that South Africa may be able to move away from a 10-yearly census and instead use a “real-time” population register to determine the size of the population in each age group. However it is difficult to accurately record the number of people entering and leaving South Africa undocumented.

2-8 What is a mid-year population estimate?

It is important to know the size of the population in different age and gender groups so that services can be planned. Because populations change over time, Stats-SA produces a yearly report of “mid-year population estimates”. This is a table of the expected size of the population, broken down into gender and age groups with a 5-year interval. The mid-year population estimates are calculated by using the previous census as a starting point, and then calculating the changes using birth and death rates from vital registration systems for each age group. It is an estimate, because it is calculated from the previous census rather than being directly measured. Stats-SA provides this information for national, provincial and district levels so that it can be used for health planning.

The mid-year population estimate provides the expected population size for each year.

2-9 What is a household survey?

Household surveys are carried out on a sample of households and give important data on health trends. Because they collect information from a sample that is much smaller than the census, they are less expensive but they usually only give information at a national or provincial level. They do not usually provide data at district level.

Important household surveys include:

2-10 What other nationally collected statistics about particular health services in South Africa are publicly available?

The District Health Information System (DHIS) is the official South African System for collecting routine information about activities and outcomes in government health facilities. The Health Systems Trust (HST) compiles a yearly report called the District Health Barometer that compares trends in important health activities and outcomes between different health districts and over time. These reports are available on the Health Systems Trust website.

The Perinatal Problem Identification Programme (PPIP) is a tool for capturing and analysing maternal deaths, stillbirths and neonatal deaths in hospital. It is intended to guide facilities through problem identification so that they can improve their own services, as well as providing national data.

The Child Healthcare Problem Identification Programme (Child PIP) is a similar tool for identifying the cause of death in all children under the age of 18.

The Medical Research Council compiles national reports based on PPIP and Child PIP.