Action-oriented community diagnosis

December 13, 2006
Getting involved and knowing the communities they study helps students learn to diagnose problems, plan solutions

Action Oriented Community Diagnosis team

Action Oriented Community Diagnosis team

Students pursuing a masters degree through the Health Behavior and Health Education department at Carolina’s School of Public Health all enroll in “Action-Oriented Community Diagnosis,” a course which requires students to get involved in communities to determine — or diagnose — the public health issues of that particular group by working directly with the people they are studying.

“Action-Oriented Community Diagnosis is not a term that easily rolls off your tongue,” observes Dr. Geni Eng, professor of health behavior and health education at the School. “And it sounds awfully medical for a field that promotes health rather than cures disease. Yet, there is a good reason why we still use these words to describe what has been the cornerstone course for our master’s program for more than 35 years.”

Action-Oriented Community Diagnosis, or AOCD, was a term first coined in the 1940s by a small group of South Africans, including a psychologist named Dr. Guy Steuart, who would eventually join the UNC School of Public Health faculty, Eng explains. The pre-apartheid government of South Africa charged Steuart and his physician colleagues to establish a National Health Corps of young doctors to work in South African community health centers located in poor, Black, rural and urban communities. From 1945 until 1959, Steuart and his colleagues also spearheaded the first studies of how poverty and racism affect health.

This group’s approach was to work with communities, getting their “insider’s view” of problems and combining that perspective with their own knowledge. Drawing from the disciplines of psychology, epidemiology, and anthropology, members of the new National Health Corps spent significant time gaining a nuanced understanding of a community’s dynamics, resources and problems.

“These methods not only gave researchers crucial insight into pathways of health and illness, they also gave community members themselves a powerful tool for identifying untapped strengths and resources,” Eng says.

Steuart and his colleagues had to discontinue their work in South Africa when the new government began applying apartheid policy to the medical professions. The researchers left to pursue work elsewhere. Steuart joined the UNC School of Public Health in 1968 as chair of what was then called the Department of Health Education.

“Guy established AOCD as the centerpiece of the department’s master’s program with Dr. Leonard Dawson (former clinical professor of health behavior and health education who died in September 2006) at the program’s head for 15 years — training graduate students like me on the importance of social networks as community assets on which to build our work in community health education,” Eng says. “And the good fortune has been mine to lead our master’s program for the last 19 years.”

The AOCD course started by Steuart has resulted in many community dialogues. Eng estimates that during the last 35 years, more than 1,000 UNC public health students have worked with over 260 North Carolina communities.

Starting each October, as many as five teams of five or six graduate students work to gain entrée into communities which are defined by geographic region, racial or ethnic background, or by a particular attribute. In the 2005-2006 academic year, for example, students worked with the homeless in Orange County, N.C., with disabled individuals in Franklin County, N.C., and with the burgeoning Latino community in Johnston County, N.C. Throughout the fall, students devote significant time volunteering with various community organizations, eating in local diners and cafes, participating in community events, and meeting with local leaders, all while carrying a full load of courses and carrying out duties as research or teaching assistants.

“In almost all of the community diagnoses we conduct, we are working with poor or otherwise vulnerable communities for upwards of eight months,” Eng says.

Kate Shirah, a graduate of the department’s masters program and now a coinstructor for the course, notes that “students spend a huge amount of time simply getting to know the community. The bond that’s created through this process is intense. Some students will go on to do their summer practica in the communities where they’ve finished their AOCDs because they feel such a deep connection with the people there and because they want to put their hardearned knowledge of these communities to even greater use.”

Three months into the AOCD process, students are ready to take a more formal approach to their assignment. “At that point, they conduct multiple in-depth interviews with community leaders, service providers and community members themselves,” Shirah says. “When they combine the perspectives of all these stakeholders with their own observations and research, our students are able to identify themes that can be acted on.”

Towards the end of each spring semester, each team organizes a community forum that brings all the stakeholders together to discuss findings from the report and to flesh out a plan for the future.

In spring 2006, Eng, Shirah and the students of AOCD were recognized with the University’s Engaged Scholarship Award, established by the UNC Office of the Provost in 2000 to recognize extraordinary public service at the University, particularly service efforts that respond to community concerns and that integrate these endeavors into the teaching and research missions of the University.

Examples of students’ Action-Oriented Community Diagnoses can be found online at www.hsl.unc.edu/phpapers/phpapers_2006.cfm.

Creating Community Conversations

Student-led community forum helps Johnston County Latinos find their place.

Johnston County, N.C., is known best as a primarily rural county southeast of Raleigh. Once, cotton ruled the landscape, and later, tobacco. Now, both agriculture and industry are the economic mainstays.

Johnston’s population nearly doubled during the last three decades of the 20th century. Much of the growth came from Latinos, who now make up nearly eight percent of the population, giving Johnston one of the larger Latino populations in the state.

The Latino population brings its own set of health issues, says Molly McKnight, now a second-year master’s student in the UNC School of Public Health’s Department of Health Behavior and Health Education. Statistics indicate that compared to whites, Latinos in the United States have higher injury rates on the job, lower birth weights for newborns and increased rates of chronic illnesses such as diabetes and asthma.

As the population has increased (400 percent in North Carolina over the last decade, the nation’s fastest growth rate), it also has diversified. “About ten years ago, Latinos in North Carolina were mostly composed of migrant workers,” McKnight says. “Now we’re starting to have a more ‘settled-in’ population. Rather than the pattern of single males leaving their home countries to do seasonal work in the U.S., we’re seeing Latino families calling North Carolina their permanent home.”

McKnight was one of five UNC School of Public Health master’s students who spent the 2005-2006 academic year documenting the strengths and the challenges of the Johnston County Latino community as part of an “Action-Oriented Community Diagnosis” class. Gail Garcia and Gladys House, both of Johnston-Lee-Harnett Community Action — a local non-profit organization addressing the needs of low-income people in their home counties — provided guidance for the students throughout the process. They found that the barriers Latinos face mirror those outlined in state and national findings. “Even though the job base has expanded out from the agricultural industry, they still work very long hours at low-paying jobs, which means they have little time to go to English classes or take on leadership roles in their communities,”McKnight says.

The students also found that rents were high compared to income, and few had health insurance, leaving them vulnerable if they got sick or needed preventive care services. The students found many strengths within the Johnston County Latino community, too.

“Latino immigrants are widely recognized as very hard workers, so many employers are eager to hire them,” McKnight says. “The community also places a high value on helping each other out, so there’s already a strong informal support network in place to build from.”

A community forum held at the end of the AOCD process also produced several significant outcomes. Community members and leaders — with help from the student team — developed an action plan focused on expanding educational opportunities, reducing employment abuse and poor housing conditions, and developing greater leadership and formal collaboration within the community. Specific action steps recommended by forum participants included creating training opportunities to help community members strengthen basic leadership and community organization skills; increasing awareness of courses offered in Spanish at the local community college; and coordinating a Latino health fair.

Listening to those without voices

Students earn trust of homeless to discover and document what works, what’s needed.

In 2005, public service providers in Orange County, N.C., started working on a “Ten-Year Plan to End Homelessness.” To assist them, leaders there asked Dr. Geni Eng, co-director of the Action-Oriented Community Diagnosis (AOCD) class at the UNC School of Public Health, for help from master’s students in this course. Eng is also a professor of health behavior and health education at the School.

“We had partnered with other nearby communities in the past to conduct an AOCD of persons who are homeless,” says course co-director Kate Shirah, “so I think we are a familiar and trusted resource to service providers and clients in Chapel Hill.”

Five first-year master’s students worked on this project throughout the 2005-2006 academic year as part of their AOCD class. Stan Holt of Triangle United Way provided guidance for the students throughout the process. As documented in their report, homelessness represents a pressing public health problem for millions of people. Many within this population suffer from mental illness, alcoholism and malnutrition along with such chronic diseases as diabetes, heart disease and asthma.

In Orange County, students found that many of the homeless are scattered throughout the county, camping in the woods or in the backyards of family and friends. “This was a challenging assignment because we were only able to reach those who had some affiliation with the system — that is, people who were staying at the shelters. But this approach left out a considerable portion of those dealing with homelessness, and probably some essential information in understanding the concerns of the community,” says Rebecca Davis, one of the students who worked on this project.

Over time, the students were able to gain the trust of members of the homeless community and explore some of the major hurdles preventing them from obtaining stable housing. Topping the list was a need for affordable housing, combined with livable wages. As one community member cited in the AOCD report put it, “The wage around here is low, and then the rent’s high. If you get a job, it’s either pay your rent or buy food.” People also had a pressing need for resources such as telephones with voicemail so that potential employers could contact them, a public transportation system that would serve employees doing shift work, and job training.

Despite the formidable challenges to ending homelessness in Orange County, the students also reported major ongoing efforts to address this problem. “Getting to know some amazing people dealing with homelessness was probably the most rewarding aspect of working on this project,” says Rebecca Davis. “In fact, the number of services offered for the homeless in this area, and the time and effort the county has put into addressing this issue, are already impressive. Many service providers show true concern and want to reach out.”

The steering committee for the “Ending Homelessness” project has continued to rely on the AOCD report as it develops workgroups to address issues the students brought to light.

“I came away from this project with a deepened respect for the ways in which communities, when given the chance, will utilize their resources to lessen or eliminate disparities in a way that makes sense to them,” Davis says.

– by Elizabeth French

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Carolina Public Health is a publication of the University of North Carolina at Chapel Hill School of Public Health. To subscribe to Carolina Public Health or to view the entire Fall 2007 issue in PDF, visit www.sph.unc.edu/cph.