ERIC EJ1085282: Using Community Health Assessment to Teach and Explore Health Status Disparities

2014·0.25 MB·English

by  ERIC

Journal of Health Education Teaching, 2014; 5(1): 20-27 Copyright: www.jhetonline.com
All rights reserved
Using Community Health Assessment to Teach and
Explore Health Status Disparities

Authors:
Dr. Marianne Sullivan, DrPH
Assistant Professor
Department of Public Health
Hunziker Wing 149
William Patterson University
Wayne, NJ 07470
Telephone: [phone]
Email: [email protected]

Dr. Jack Levine, MD
Nassau University Medical Center
Department of Pediatrics
Assistant Clinical Professor of Pediatrics
Hofstra University Medical School
East Meadow, NY 11554
Email: [email protected]
Telephone: [phone]

ABSTRACT
Introduction: Community health assessment (CHA) is a useful tool for identifying health status disparities
at the community level. Developing the skills of master’s level public health students to conduct CHA
addresses a number of the Association of Schools of Public Health Core competencies for graduate
public health education. Teaching Procedures: This article reports on the experience of conducting and
analyzing a CHA of disparities in access to autism services among low-income Latinos in Nassau County,
NY. Discussion: Conducting a CHA as part of the course helped to illustrate academic concepts, and
revealed how disparities in access to services and service provision may ultimately lead to disparities in
outcomes for low-income Latino children with ASDs.

INTRODUCTION Community health assessment (CHA) is a
useful tool for public health workers who want to
Health status disparities are one of the most understand and address health status disparities
important public health challenges facing the at the community level. To conduct CHA, public
United States. Since 2000, addressing health health practitioners identify and examine existing
status disparities has been articulated as a key secondary data and then determine if primary
aim of the federal government’s Healthy People data collection is necessary to answer the
initiative. The prioritization of health disparities at assessment questions of interest (National
the federal level, reinforces the importance of Association of County and City Health Officers,
focusing on health disparities in both substantive n.d.). Often the first step in developing
and methods courses developed for master’s community-based interventions, CHA allows
level public health students (U.S. Department of practitioners to develop an understanding of the
Health and Human Services, n.d.). needs and assets of a community so that
subsequent interventions will be consistent with
community priorities and capacities. To align
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with Healthy People goals and objectives, (Johnson & Myers, 2007). Early and proper
addressing health status disparities must diagnosis of ASDs (prior to age 3) (Centers for
necessarily be a key area of focus at the Disease Control and Prevention (CDC), n.d.),
community level, therefore, integrating a and timely receipt of behavioral therapies and
disparities perspective into community health other tailored services that aim to improve
assessment is essential. language and communication and to reduce
repetitive behaviors, are essential for improving
Developing the skills of master’s level public outcomes for children with ASDs (Myers &
health students to design, conduct, and analyze Johnson, 2007).
data from a CHA addresses a number of the
Association of Schools of Public Health (ASPH) In recent years, racial/ethnic and socio-
core competencies across domains such as economic disparities in ASD diagnosis, age at
Social and Behavioral Sciences, Informatics, diagnosis, service utilization, and outcomes in
Diversity and Culture, Program Planning, and the United States, particularly with respect to
Systems Thinking (Association of Schools of Latinos, have been documented. Latinos have
Public Health, 2006). Additionally, encouraging been found to have a lower prevalence of ASDs
students to engage with the community and to compared to non-Latinos, both in studies that
hear about disparities directly both from those use active surveillance and parent report. The
who are experiencing them and those who are difference in prevalence is likely due to less
engaged in addressing them can be a powerful diagnosis of the disorder among Latinos, rather
learning experience. than differences in the racial/ethnic distribution
of ASDs (CDC, 2012). This is significant
This article reports on the experience of because of the importance of early and accurate
conducting a CHA of disparities in access to diagnosis to improve outcomes. Latino parents
autism spectrum disorder (ASD) services among are also more likely to regard their child’s ASD
low-income Latino families in Nassau County, as severe and report less access to services
NY as part of a course on CHA. The course on than whites (Liptak et al, 2008). Disparities in
CHA is the first of a three-semester sequence of diagnosis and access to services among Latinos
courses covering CHA, program planning and have been attributed to a number of factors
implementation, and evaluation, taught within a including culture, language barriers, and poverty
department that was transitioning to a Master of (Mandell, Listerud, Levy, & Pinto-Martin, 2002;
Public Health program. This CHA was integrated Liptak et al., 2008).
into the 14-week semester and took students
through the steps in conducting an assessment Setting and Context
focused on health disparities. The class was a Nassau County is located on Long Island in
seminar and included twelve students. The New York State and has a population of 1.3
students were in the second semester of their million people. About 14.6% of the population of
first year of a two-year program. Nassau County (14.6%), is Hispanic/Latino (U.S.
Census Bureau, 2010). Latino families in
The students and professor partnered with a Nassau County are more likely to live in poverty
local pediatrician (this paper’s second author) than families of all races/ethnicities and have a
who specializes in developmental disorders at lower median income. (U.S. Census Bureau,
Nassau University Medical Center, a public 2006-2010a,b & c) Nearly half Nassau County’s
teaching hospital that serves low-income Latino residents were not born in the United
residents of Nassau County, NY. The second States, and over one-third report speaking
author’s practice includes a number of low- English “less than very well (U.S. Census
income Latino children with autism. The second Bureau, 2006-2010c).”
author worked collaboratively with the class and
the first author (the professor) to help design Purpose and CHA Methods
and conduct the assessment and assisted with Our purpose in conducting the assessment
logistical issues. was two-fold: 1) to assess access to ASD
services in Nassau County among low-income
Latinos, ASDs, and Disparities Latino families and 2) to train students to
Autism spectrum disorders may be conduct a CHA while integrating the perspective
diagnosed when children face challenges in of evaluating health disparities. Here, we report
communication, social interaction, and behavior on the process of designing, conducting and
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analyzing the assessment and make During the first week of the semester the
recommendations for incorporating similar class session focused on explaining the purpose
projects into other community assessment and uses of CHA and providing background on
courses. the project that the students would conduct. The
homework assignment for week one was for the
The CHA aimed to identify primary and students to work in groups to identify all ASD
secondary data sources on ASD service service providers in Nassau County. This would
utilization by Latino families; qualitatively assess become the basis for the list of service providers
Latino families’ experiences with ASD services we would use to conduct interviews. Readings
in Nassau County and the perspectives of for the first week included background on CHA
service providers with respect to how well the and an article on disparities in ASD diagnosis
ASD service provision system in Nassau County among Latinos.
is serving low-income Latino families; make
recommendations based on our findings for For week two, students read an example of a
improving service provision to Latino families; CHA that examined health care needs among
and to train students to conduct a community refugees in San Diego and we continued our
health assessment with a disparities focus. discussion of the purpose and use of CHA using
this report as an example that both illustrated a
TEACHING PROCEDURES mixed-methods approach to conducting CHA,
and was rich in relevant content, as it discussed
Because we aimed to conduct the CHA from barriers limited English speakers face accessing
start to finish during the course of a 14-week health care (Brouwer, 2007). Additionally, after a
semester, there was significant planning that short training on using census data to describe
had to occur prior to the beginning of the population demographics, homework for the
semester. This included conducting a literature second week of class involved students using
review on what was known about Latinos and data from U.S. census web sites to describe the
access to ASD services, holding meetings with social and demographic characteristics of the
the second author to clarify the goals and Latino population of Nassau County.
logistics of conducting the assessment, and
meetings with leadership at NUMC to determine During week three, the second author
parameters for collecting data on-site with conducted a training for the students on ASDs
NUMC patients. Additionally the project had to and explained the key features of ASDs, their
be submitted for human subjects approval prior diagnosis, and effective therapies. He also
to the start of the semester, which meant that described the social and economic context of
the design, protocols, questionnaires and the Latino families who have children with ASDs
consent forms had to be developed prior to the seen at NUMC.
commencement of classes. Although we wanted
students to participate in the design of the CHA The next week was focused on planning a
we realized that this would not be possible given CHA by developing the purpose, goals and
the need to submit a fully developed and objectives. For homework, students were tasked
articulated project for human subjects review in with working in groups to develop a concise
time to begin data collection at the mid-point of statement of the purpose, goals and objectives
the semester. The project was reviewed by the of the assessment and to start thinking about the
Hofstra University Institutional Review Board kinds of questions they would ask parents and
and found to be exempt. service providers about the needs of Latino
families who have children with ASDs.
The integration of a CHA project into the
course required a re-design of the course As the semester was progressing, the
syllabus to be able to cover both course professor took the lead in identifying and
concepts and to integrate the required trainings requesting data from administrative agencies on
that would enable the students to become the use of publicly funded services for ASDs by
knowledgeable about ASDs, Latinos in Nassau Latinos in Nassau County. Since ASD services
County and to develop the skills to collect and are administered by several different agencies
analyze data. Table 1 summarizes the tasks there is no central agency responsible for
completed by week of the semester. reporting these data. We also determined that
the data we were primarily interested in, use of
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services by race/ethnicity, were not routinely students had the opportunity to practice
being reported in a publicly accessible format. interviewing and note taking and to discuss any
Therefore, we made data requests to the challenges they encountered.
Nassau County Health Department for data on
enrollment in the county Early Intervention Although we had initially planned that
program by race/ethnicity and we requested students would be involved in interviewing
data from the State Department of Health on Latino parents at NUMC, we were unable to
enrollment in pre-school special education. follow through with this plan due to issues with
Additionally, we requested data from the State the site’s medical requirements for students.
Education Department on enrollment of Latinos Therefore, two graduate research assistants
in school-aged special education in Nassau (one who was fluent in Spanish) and the
County and also requested data from the New professor conducted the interviews, with the
York State Office for Persons with Spanish-fluent graduate research assistant the
Developmental Disabilities (OPWDD) on the lead interviewer and note taker. In a few cases
receipt of the Home and Community Based when the Spanish-speaking research assistant
Service (HCBS) Medicaid waiver by was not available, we relied on a hospital
race/ethnicity and socio-economic status, which interpreter to provide interpretation and the
pays for critically important rehabilitative and professor conducted the interviews. Notes were
non-medical services for children. We found that taken by the interviewer and typed up
for most of these data sources, we needed to immediately following the interview.
make freedom of information law (FOIL)
requests to obtain them. During weeks six through eight, the students
conducted semi-structured interviews with ASD
Aside from the collection of administrative service providers to learn their perspectives on
data on use of publicly funded services, the how well Spanish-speaking families who have
remainder of the assessment called for children with ASDs are being served in Nassau
collecting data through semi-structured County, and if the service delivery system might
interviews with Latino parents of children with be improved to better meet their needs. Each
ASDs being served at NUMC and through semi- student was responsible for interviewing two
structured interviews with Nassau County service providers over the phone within a month-
service providers. The purpose of interviewing long data collection timeframe. Nine service
service providers was to understand their providers agreed to participate.
perspectives on Latino families’ access to and
use of ASD services in Nassau County. All service provider interviews took place
over the phone, and were conducted by the
We chose semi-structured interviews students. Students were required to take as
because their open-ended nature can help to close to verbatim notes as possible and to write
illuminate health issues about which little is up and submit their interview notes within one
known, and provide descriptive data about the day of the interview. Service provider interview
social and cultural context of the health issue questions covered topics such as needs of low-
(Patton, 2002). income Latino families, how well needs are
being met in Nassau County, and barriers and
During week five, students were trained in facilitating factors for accessing services for
following human subjects protocols and seeking these families. Providers were also asked for
informed consent prior to interviewing their recommendations to improve service
participants. They were also trained in provision to low-income Latino families in
conducting semi-structured interviews, including Nassau County.
reading the questions exactly as written and
allowing respondents the time and “space” to During week nine, students were instructed
answer. The use of probes in open-ended on how to develop a code book for coding
interviewing was also modeled for the students. qualitative interviews and their assignment was
Finally, students were trained in note taking and to develop an initial draft of a codebook for
the importance of verbatim note taking was coding the provider and parent interviews.
stressed since we had neither the funding nor Students were divided into small groups and two
the time to tape and transcribe the semi- groups were responsible for developing a
structured interviews. During the class session, codebook for the provider interviews and the
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other two groups were responsible for children with ASDs. The project also allowed for
developing a draft codebook for the parent discussion of cultural competency in the
interviews. The next step was instruction on how provision of public services and the importance
to report and interpret qualitative data, which of assessing equity in service provision as an
included discussions of making appropriate aspect of understanding community based
inferences from a small sample size. Over the health disparities.
next week, with feedback from the professor,
students refined their codebook and coded all of For the students, the ability to interact with
their interviews. community providers who work to address
health status disparities on a daily basis was
During week eleven, students were tasked invaluable. The second author’s participation in
with working in small groups to write up a rough the course was a highlight for many.
draft of their findings. The professor provided Additionally, conducting the interviews and
written and oral feedback on the rough drafts hearing the stories of service providers who
and final written reports were due during week work with low-income Latinos and were of the
thirteen. Students were also required to do an opinion that Latino families in Nassau County
oral presentation of their findings to the class were not being adequately served was a
and to the second author. powerful experience for many of the students.
They were able to hear directly from providers
DISCUSSION about the challenges that Latino families face in
accessing services including language barriers,
Recommendations to include an emphasis transportation, and difficulty accessing public
on health disparities in health-related programs—tangibly extending classroom
coursework are common in the recent public concepts.
health and medical education literature. Some
authors have recommended a focus on Using a qualitative approach to gather data
addressing bias and stereotyping and analyzing from both parents and providers had benefits
how these viewpoints might play out in the and limitations. The benefit of open-ended data
clinical or community setting. Another collection is that respondents can talk at length
recommendation is a focus on understanding about access issues and tell their own stories,
the complex causes of disparities and possible which can illuminate key issues. Also, a
ways to address them, and still another is to qualitative approach allows students to engage
teach cultural competency to future providers as more deeply with some of the complexities of
a way of addressing health disparities (Smith et access barriers as many of the providers
al., 2007). Others have advocated conducting explained these in significant detail. From a
community-based projects, like community learning perspective, using a qualitative
health assessment, as a way to learn more approach has significant advantages. However,
directly about how health disparities are from a research standpoint, having multiple
experienced in low-income communities and in interviewees collecting open-ended data was a
communities of color (Cené, Peek, Jacobs, & challenge. We did not have the funding to tape
Horowitz, 2010; Selig, Tropiano, & Greene- record interviews and to transcribe them and
Moton, 2006). thus had to rely on variable note-taking skills. A
better option might be to use a quantitative
Conducting a CHA project such as this as survey instrument that would allow for greater
part of masters level public health coursework control over data quality with multiple data
aligns with recommendations in the literature as collectors.
well as multiple ASPH core competencies.
Conducting the project during a 14-week Because we had no funding beyond two
semester presented a number of challenges, but graduate research assistants, it was challenging
we believe the benefits were substantial and to conduct a CHA partially in Spanish since we
outweighed the challenges. Importantly, the did not have resources for translating the
project provided vivid context to class questionnaire and consent form, and for hiring
discussions of academic concepts, and tangibly interpreters. Initially we approached the
illustrated how disparities in access to services University’s Spanish department to ask if
and service provision may ultimately lead to Spanish majors could provide translation but this
disparities in outcomes for low-income Latino turned out to not be feasible. Ultimately we
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decided to use Google Translate to translate the Use of Findings
interview and the consent form, aware that it Because of the small sample size for both the
could have limitations. However, to address parent and provider interviews, we view the
possible problems with this method, the findings from the project as a starting point for
Spanish-fluent graduate research assistant understanding access barriers for low-income
back-translated the documents into English and Latino families in Nassau County. Extending the
we reviewed her translation and made the project over multiple semesters and increasing
necessary corrections. She also tested the final the amount of data collected would provide more
translated study documents on two native parent and provider data from which to make
speakers. While it is very important for students recommendations.
to understand the logistics of collecting data in a
language other than English, it can also be A report of findings was distributed to key
challenging in an unfunded project such as this. community leaders working with the Latino
community. We also presented the findings to
One of the most informative parts of the the local Alliance for Latinos with Disabilities.
project was the process of trying to identify and This group has formulated a plan to work on
obtain data from administrative agencies on the some key recommendations of the report such
use of ASD services by Latinos. We found that as increasing the hiring of bilingual staff in key
we had to make direct requests from the agencies serving Latinos with ASDs.
responsible agencies because the data we were Additionally, training workshops for agencies
seeking was not available in published format for that serve Latino families have been developed
Nassau County. on how to access the OPWDD HCBS waiver.

Students were instructed in the idea that data In summary, involving students in a CHA
collected by public agencies is often in the public project specifically focused on evaluating
domain and if community or public health disparities can be a worthwhile learning
workers cannot access data to assess health experience that touches on a number of the
status disparities through agency issued reports, ASPH domains and competencies for graduate
they can make a freedom of information law public health programs. If the project is linked to
(FOIL) request to try to obtain the data, if it the interests of providers in the community who
exists. We made 3 separate FOIL requests, all may be able to use the findings, coursework can
of which were granted, at least in part. From this contribute to the process of addressing health
process we learned about important limits to the status disparities.
data that public agencies are routinely collecting
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Table 1: Community Health Assessment Tasks/Activities Completed by Week of Semester

Week In Class Homework
1 Introduce CHA and Class Identify all ASD Service Providers in Nassau County;
Project make a list with contact information
2 Review CHA example; Use U.S. Census Bureau web site data to describe
Training on U.S. Census social and demographic characteristics of Latinos in
Bureau data for describing Nassau County
population demographics
3 Dr. Levine conducts training NA
on ASDs, diagnosis,
therapies and cultural and
social context
4 Discussion of developing Write a concise statement of goals and objectives for
CHA purpose and goals class CHA project, brainstorm possible questions to
ask providers and parents
5 Training in: NA
Complying with human
subjects procedures;
conducting semi-structured
interviews; verbatim note-
taking
6-8 Other CHA topics covered in Conduct interviews with service providers; write up
class unrelated to project; and submit interview notes within 24 hours of
questions about interviews interview
addressed; student
experiences interviewing
providers discussed
9 Instruction on how to Develop draft code-book
develop a code-book for
qualitative interviews
10 Instruction on refining code- Revise and finalize codebook;
books and coding Code interviews
interviews; instruction on
reporting and interpreting
qualitative data
11 Other CHA topics discussed Write up rough draft of findings
12 Oral and written feedback Revise report
on rough drafts provided to
students
13 Final report due
Oral presentations of final
reports
Note: this table is specific to the CHA project and does not include all topics covered during the semester.

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