HCAD 630 Public Health Administration:

Public health assessment; Education and Health Promotion

Unit Objectives: 1. Explain how public health issues are assessed, selecting a relevant national standard from a recognized public health assessment tool.

Readings: Novick, Morrow and Mays - Chapters 15 and 21

Focus questions: you do not need to submit a response to these questions, but if you would like further discussion, please post a question in this week's conference area or email me. 1. How does our text define assessment? 2. When choosing an appropriate focus for an assessment effort, what must public health organizations consider? 3. What are the factors, discussed in our text, that have been found to be important to the successful development and management of public health assessment activities? What other important factors should be considered? 4. What are the phases included in the Mobilizing for Action through Planning and Partnerships program?

Assignment: 1. Be sure to participate in this week's conference. 2. Be sure you've completed the assigned readings

Public Health Assessment

Public health assessment is the regular collection, analysis, and dissemination of information concerning the health of the community.  The data collected and analyzed allows for the identification of public health problems within the community or within subpopulations of the community.  There are a number of activities that can be part of the assessment process.

Assessment is a core function of public health agencies.  Without assessment, how would it be determined what is needed to be done?  What plans, what interventions, for what populations would a public health organization take action?  Obviously, the vital first step in meeting the needs of the population is to determine what those needs are.  However, there is no single way to do assessment.  There are many variations.  The Institute of Medicine (IOM) and the Centers for Disease Control and Prevention (CDC) have developed frameworks for assessment that include assessment, investigation, and analysis.  The text lists a number of indicators that reflect public health activities that are part of the assessment process including the existence of an assessment process, the regular survey, timely investigations, availability of laboratory services, analysis of risks, availability of care, and regular analyses of preventive and screening services.

It should be clear that we are talking about assessment of community needs, not the self-assessment of the internal operations of a public health organization.  These are two different issues.  Of course, the operation of a public health organization must be those activities that are related to the needs of the community.  To choose the focus for a particular assessment effort, the public health organization must keep in mind a number of factors.  They are:  the nature of the public health problem targeted, the strengths and weaknesses of the organization and its ability to address that problem, the roles all of other entities, and the public health organization’s relationship with them.  Of course, the public health organization must also consider the level of resources it has for this activity, in relationship to the sum total of its resources.  Far too often this is not addressed, including in your text's discussion.  A public health organization, like any other organization, has a budget that specifies a finite level of resources that can be expended.  Therefore, expenditures must be carefully weighed so that funds can be spent in the most cost-effective manner.

In many cases, public health organizations initiate the assessment process, either because a problem is recognized in the community or in a segment of the community by the public health organization, or the political process directs the public health organization to carry out assessment.  Public health organizations may also convene major stakeholders in order to generate the necessary co-operation and buy-in from all concerned parties in order to make the assessment process work and to assure that the interventions that result are effective, are well received and supported by the community.  Public health organizations can also play a role in managing or governing the process.  Frequently, because public health organizations are seen as working purely in the public interest, other interested entities in the community, and at large, will place leadership responsibility in the public health organization.  The public health organization is seen as a more neutral advocate for community needs and interests.  On the other hand, sometimes public health organizations participate in the management and oversight of an assessment process, working with a number of other organizations in doing so.  Public health organizations certainly also contribute resources and expertise to a community-based assessment for a number of reasons.  First, that's the role of a public health organization.  Second, that's what the resources are for.  The third, that's what other organizations want.

A number of elements help public health organizations conduct community assessments, including:
            --          the existence of community planning and priorities' setting tools
            --          community health report cards
            --          public health practice guidelines and standards
            --          public health information networks
            --          performance-based contracting systems 
            --          public health performance measurement systems.

The agreement all of mechanisms for planning and setting priorities in the community is absolutely essential, otherwise time and energy are wasted in arguing about what should be done, by whom, when, how, etc.  Community health report cards are also an excellent way to compare one community's status to others or to the norm.  This assists in identifying potential areas of problems that need to be addressed by the public health organization.  Public health practice guidelines and standards, information networks, and the other mechanisms all assist in getting the job of assessment done.

It is essential, in order for assessment to be successful, that the process involve the community, and be of interest to the community.  If one identifies a problem for the community, rather than with the community, failure is almost guaranteed.  The assessment process, like other processes and public health, must ensure that decisions are made by community members, and not by the public health organization.  The assessment process must be sensitive to local issues and priorities, as well as local politics.  This is frequently not addressed, but is essential to success.

The assessment process is not an end in itself.  It is merely the first step in addressing a public health problem.  When undertaking an assessment one must keep in mind that this is done in order to plan and implement a public health intervention.  If one finds a problem, and has no concept of what to do about it, and in fact does nothing, then the assessment was wasted.

Public Health Education and Health Promotion

Along with genetics, behavior or lifestyle accounts for a significant portion in determining a person’s health status.  Behavior is both individual and collective.  That is, an individual's behavior accounts for much of his or her health status.  That individual's engaging in behaviors that are classified as risk behaviors, such as smoking, substance abuse, lack of exercise, overeating, etc., has a direct bearing on his or her health.  In a collective sense, behaviors common to a population, such as the tendency to engage in particular behaviors that impact health or to act collectively to change the environment either adversely or positively, can also significantly impact not only an individual's health but also the community's health.  And, of course, the distribution and availability of health care services in the community, especially preventive services, has significant impact on the community’s health and health status.

Voluntary behavioral changes are those that people undertake by choice.  This choice is made by an individual in order to improve health status or to avoid eventual degradation of health.  Such voluntary behavioral changes include smoking cessation, increased exercise, healthy nutrition, etc.  This means that people must understand the consequences of their current behaviors and consciously choose to change those in order to avoid the consequences.  The knowledge of alternatives and consequences of risky health behaviors are frequently conveyed through health education by public health organizations.  Health education is a field itself, and is a major activity of public health organizations.  In order for health education to be undertaken by a public health organization it must be determined that the behavior is amenable to voluntary change.  For example, smoking, a behavior that significantly increases the risk of lung cancer, is amenable to educational intervention through smoking cessation classes.  Of course, there are varying degrees of success, but it does work.  Similarly, obesity and exercise are amenable to educational intervention, showing persons the benefits of proper exercise and nutrition, and the consequences of lack of exercise and healthy diet.  The second factor necessary for a public health education activity is evidence that the change in behavior will make a significant difference in the problem identified.  The literature shows, for example, that quitting smoking significantly reduces the risk of lung cancer.  The incidence rate for lung cancer is far lower for nonsmokers than for smokers.  Therefore, for smoking, educational interventions are feasible activities for public health organizations.

Educational interventions, or public health education, are no different than other activities.  One  simply does not begin to do things without a plan.  The text tells you that in order for a health education intervention to be effective, it must follow particular stages.  These include social assessment, epidemiologic, behavioral and environmental assessment, educational and ecological assessment, and administrative assessment.  All of these assessments are aimed at tailoring public health education campaign to the specific problem and to the specific population.  Without these, it is highly unlikely that the public health intervention will be successful.

Public health education basically has three strategies.  The first is direct communication with a target population to change behaviors.  An example would be a smoking cessation class for people who currently smoke.  This direct communication process is targeted at getting smokers to stop smoking and decrease their risk of illness.  The second strategy is to enable or reinforce behaviors that are positive (e.g., not starting to smoke).  The third is to support behaviors that are conducive to health (e.g., healthy diet and exercise).

Behavior is a manifestation of lifestyle.  Lifestyle describes a behavioral pattern, in part influenced significantly by the community.  Therefore, the greatest impact on healthy behavior change is through community support and policies for more healthy lifestyles.  Health promotion through the community is far more effective than on an individual basis.  One may be able to get an individual to stop smoking, but to reinforce that by community support and environmental changes impacts more than a single individual.  In fact, health promotion goals can be primary, secondary, or tertiary in terms of prevention.  They can be educational, informing and educating the public.  They can be automatic and protective, such as controlling environmental factors.  Finally, they can be coercive, using legal and other sanctions to control individual behavior.

Public health education, as part of health promotion can be effective for individuals and for communities.  However, this means that individuals and communities must take some responsibility for changing their behavior, lowering risks, and reaping the benefits of more positive behaviors.

Course content developed by Dr. Jacob Tenenbaum for UMUC ©2007.