Chapter 1 Sources of information about communities and populations

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Contents

• Unit 1: Assessing the health of communities and populations
• Objectives
• Unit 2: Demographics and sources of population health data
• Objectives

Unit 1: Assessing the health of communities and populations

Objectives

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

• Define communities and populations.
• Contrast the way in which health needs are measured in communities and populations.
• List the reasons why the needs may differ from the demand for healthcare.
• Explain why different types of communities may need different types of approaches.
• Make a community diagnosis.

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:

• Demographic information
• Household surveys
• Disease notification data
• Data from health facilities

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:

• They guide in the planning of services. For example, knowing how many children are being born guides the planning of immunisation services.
• They allow changes in health problems to be tracked over time.
• They may show inequalities in health between population groups that need to be addressed.

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.

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:

• Services may not be available.
• Services may not be affordable.
• Facilities may not be offering the best standard of care.
• Services offering a good standard of care may be available but people are not seeking care because:
  • They do not realise they have a problem. For example somebody with undiagnosed hypertension.
  • They do not know that there is treatment available. For example blindness from cataract in the elderly or cerebral palsy in children.
  • They do not trust the health service or fear they will be shouted at.
  • They have difficulty getting to the health facility.
  • They are under the care of a health facility but are not sticking to the agreed management plan, because they don’t understand it or because they have their own health beliefs or because it seems like too much effort.
  • People who are in a vulnerable situation, for example undocumented migrants, may be worried that interacting with “the authorities” will get them into trouble.

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:

• Available resources must be spent in such a way that the best health for the most people can be achieved.
• All people have the right to the highest standard of health possible.

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:

• Providing prevention and effective early treatment is usually much cheaper than treating advanced and complicated disease:
  • Health risks can be identified and perhaps prevented.
  • Barriers to the effective use of health services can be identified and tackled.
  • Community level support helps people to adhere to chronic treatments.
• With good community level care, it is possible to identify the needs of the poorest and most marginalised groups who may not otherwise be able to make their needs known.

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
• Community mapping

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:

• Communities with a strong middle class. In these communities, people have time and money to spend on community action. They tend to organise themselves and proactively take action on problems that they identify for themselves, for example on the environment. In Europe and North America, these communities also tend to be very active in monitoring the standard of public services, although this is less so in South Africa where most of the middle class do not use public health facilities. Because these communities tend to be proactive about solving problems and usually have quite good access to the media, they often need little outside help in problem solving. It is important to note that established community leaders will expect to be given leadership roles at an early stage.
• Communities composed mainly of working class people, where there is often a strong sense of community values. There are community groups, often organised around churches, mosques or temples. However, while they may be well aware of problems in their community, they are often less politically able to use “the system”. These sorts of communities can generally be accessed by approaching community groups and organisations.
• The most difficult communities to work with are the poorest communities found in low-income areas around towns or cities. These have been called “hidden” communities. Here people are focussed on day-to-day survival and do not have the resources or energy for group activities. The lack of community organisation and leadership means that gangs may be the only form of organised activity. As trust may be low, it can be extremely difficult to work with these communities without a long period of trust building. Working with individuals or individual households to solve problems may be the best approach in these communities.

“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:

• Explain what demography is and why it is useful.
• Describe the important sources of demographic information in South Africa.
• Describe the type of information contributed by household surveys.

2-1 What is demography?

Demography is the study of populations:

• How the population is structured.
• How it has changed over time.
• How it is predicted to change in the future.

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?

• Size of the population: It is important to know the size of the population so that services can be planned. Population size is calculated using the “demographic equation”, which is: Population size at any time = starting population size plus births and migration in, minus deaths and migration out.

• Population density: This is the number of people living on a unit of land. Population density is usually expressed per km². An example of a high-density area is Hillbrow in Johannesburg, where the population density is estimated at about 67 000 people per km². Services such as water, sanitation and schools usually cannot accommodate this kind of population density and problems related to overcrowding such as violence and TB are highly probable. An example of a low-density area is the Northern Cape Province, where the population density is 3 people per km². In a low-density area, the problem is how to give people access to services in a way that is affordable and without them having to travel unreasonable distances.

• Sex ratio: It might be expected that males and females would make up roughly equal proportions of the population. However, in some parts of the world the ratio of females to males in much lower than expected. It is likely that this is due to a preference for boy children leading to sex selective abortion and relative neglect of girl children. The sex ratio is South Africa is almost equal at 99 males to 100 females indicating little gender discrimination in care.

• Age dependency ratio: This is the ratio of people who are either too young or too old to work, divided by the number of people of working age (15-64 years old). It is intended to give an idea of the pressures the economy faces supporting people who are not economically active but is less useful when there is high unemployment. Therefore it is of limited use in South Africa.

• Maternal mortality ratio: This is the number of maternal deaths per 100 000 live births. It includes all women who have died during pregnancy, delivery or in the first 6 weeks after delivery. It also identifies pregnancy related causes of maternal death such as post-partum haemorrhage. It tells us how healthy women are and how good the maternity services are. The maternal mortality ratio will be low if most women are healthy and the health services are good.

• Infant and child mortality rates: The infant mortality rate (IMR) is the number of deaths in infants under the age of one year while the child mortality rate is the number of deaths under 5 years of age (under 5 mortality rate). The IMR and the under 5 mortality rate are both expressed per 1000 live births and are commonly used indicators of health and living standards and the quality of healthcare services in different countries. The rates are low in populations with high living standards, healthy children and good healthcare services.

• Age specific death rates: This is the number of deaths in a particular age group divided by the total number of people in that age group. It can help to indicate where particular health problems lie.

• Age specific fertility rate: This is the total number of births per year to women in a particular age group divided by the number of women in that age group in that population. It tells us how fast the population can be expected to grow, but also gives an idea about whether women are in a position to control their own fertility. The total fertility rate is the number of children women have in their lifetime. In South Africa this is 2 to 3 children per woman.

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:

• Children are likely to receive better education and nutrition.
• Women are more likely to have paid work (which also means they are likely to have fewer children).

More older people mean:

• People have to work for longer.
• The number of people with chronic diseases is likely to rise.

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

Demographic information comes from 2 types of sources:

• There are data that provide a “snapshot” of what is happening in the population at any particular time. The most accurate of these is a census because it aims to record information from all people in a population.
• There are data that tell us how many people are flowing in and out of a population over time. These come from vital statistics – birth and death registrations, and the registration of immigrants.

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:

• Demographic and health surveys (DHS) are supported by USAID and collect data on health and nutrition. These have been done in over 90 countries. The last South African DHS was in 2016 when 15 000 households were sampled.
• Stats-SA publishes a yearly General Household Survey (GHS). For the GHS, about 25 000 households are sampled and the report indicates trends in health, education and living standards. This information is available on the Stats-SA website.

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.