This article was downloaded by: [Universite Laval] On: 04 March 2015, At: 10:37 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Health Needs of a Suburban Community: A Nursing Assessment Approach Salley Peck Lundeen Published online: 07 Jun 2010.
To cite this article: Salley Peck Lundeen (1992) Health Needs of a Suburban Community: A Nursing Assessment Approach, Journal of Community Health Nursing, 9:4, 235-244, DOI: 10.1207/ s15327655jchn0904_5 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0904_5
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
JOURNAL OF COMMUNITY HEALTH NURSING, 1992, 9(4), 235-244 Copyright O 1992, Lawrence Erlbaum Associates, Inc.
Health Needs of a Suburban Community: A Nursing Assessment Approach Sally Peck Lundeen, RN, PhD, FAAN
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University of Wisconsin-Milwaukee
Community health nurses (CHNs) can play an important role in the implementation of studies related to the health needs of their communities of residence or service. Assessment of the health-related problems of the residents of a community as perceived by those residents should be collected periodically by all communitiesrural, urban, or suburban-regardless of the community's demographic profile. The focus of these assessments of community needs should conform to a public health mandate which focuses on broad issues related to health promotion and disease prevention. A community health nursing theoretical framework is ideal for the development of community assessment methodologies. Data reported here were collected as part of a comprehensive community health needs assessment survey conducted by the faculty and staff of an academic nursing center under contract to a Midwestern suburban community. This article presents: (a) rationale for the development of a health-needs assessment tool based on a community nursing perspective; (b) analysis of health needs survey data in the areas of environmental health, family health and well-being, and personal health and selfprotective behaviors; and (c) policy recommendations based on the findings. COMMUNITY ASSESSMENT METHOD The request for the community assessment was precipitated by a need for the community Board of Trustees to make some decisions as to the future of the community health department. Findings from the assessment were needed to review the mission, organizational structure, and funding for community health services in the next 10 years. It was determined, after discussions with the city manager and elected officials in the community, that a broadly focused assessment approach would be utilized. A contract was negotiated with the academic nursing center for faculty and staff to conduct the assessment using a community nursing framework. A number of community assessment frameworks were reviewed in the planning stages of this project (Chamberlin, 1988; Hanchett, 1988; Higgs & Gustafson, 1985; Institute of Medicine, 1988; Stanhope & Lancaster, 1988). A combination of Requests for reprints should be sent to Sally Peck Lundeen, RN, PhD, FAAN, Director, Nursing Center, University of Wisconsin-Milwaukee, P.O. Box 413, Milwaukee, WI 53201.
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the assessment techniques identified by these sources, including key informant interviews, epidemiological studies, analysis of existing community dataheports, and a survey of community residents, were all considered relevant to a comprehensive assessment of community needs. Most of these methods were used and incorporated into the final report to the Village Board of this community. The need to solicit specific data from a sample of community residents on perceived health problems, their current utilization patterns, and attitudes toward future community health services required the development of a new survey tool.
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Survey Instrument The complete Community Health Needs and Utilization Survey (CHNUS) instrument covers seven different areas including (a) respondent and respondent household demographics, (b) health and safety problem identification, (c) respondent health-related and self-protective behaviors, (d) awareness and utilization of current health department services, (e) respondents' household interest in selected healthpromotion programs and services, (f) respondents' insurance coverage for healthpromotion programs and services, and (g) respondents' evaluation of how health-promotion programs and services should be funded (Lundeen, Kreuser, & Mundt , 1992). The problem-identification section of the survey instrument is based on the Client Problem Classification Scheme developed by researchers at the Omaha Visiting Nurses Association (Martin, Scheet, Crews, & Simmons, 1986). Developed and tested by CHNs, this comprehensive assessment scheme is being used and further refined in community health settings across the country (Martin & Scheet, 1992). The problem-classification scheme was selected as a basis for this assessment because of its comprehensive conceptualization of community health issues which expands the scope of problem choices presented to respondents beyond many health assessment tools. Use of this existing taxonomy mitigated investigator bias based on any preconceptions about the nature of the health problems experienced by residents for any particular community. Problem areas are divided into three major categories corresponding to the Omaha System domains, including (a) environmental health, (b) psychosocial health, and (c) physiological health. These categories are renamed "Environmental Health and Safety," "Personal and Family Well-being," and "Physical Health" in the CHNUS. Questions from the fourth Omaha System domain, health-related behaviors, were also included in the CHNUS in two sections entitled "Health-Related Behaviors" and "Personal Prevention Measures." Although analysis of these latter sections provided direction for community health planning, results are outside the scope of this article. Sample The population of interest reside in a suburb of a Midwestern city. At the time of the study, the population was just under 15,000 and 99% of the residents were
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White. There was a growing population of residents 65 and older (15%) which already exceeded the national average (1 l %). Only 2% of the residents were below the poverty line as compared to a national figure of 12%. The survey respondents were mostly women (66.6%). Over 43% were 22 to 44 years of age, 28.5% were between 45 and 64 years of age, and 28.4% were 65 years or older; over 35% of respondent households had at least one member over 65 years of age. Over 60% of the respondents had lived in the village for over 10 years. Most (66.5%) of the respondents were married; 14.2% were widowed. A few (9.6%) reported that they were living in "blended family" households (parents with children from previous marriages). Forty-two percent of respondent households had children of school age; 7.1 % were single parents. This was largely an upper middle class respondent group with 41% reporting incomes over $60,000; 8.8% reported income under $20,000. Over 90% owned their own homes. Respondents were largely professionals (43%) or managers (17%). Nearly 25% were retired. Of the 22% of the sample who represented single-person households, 58% were women over 60 years of age. 'Ikrenty percent of the singleperson households reported income below $20,000 while only 8.7% had incomes over $60,000. This is a very different profile than the higher income distribution for the total sample. Procedure The survey tool was mailed to a systematic sample of community households generated from a computerized listing of the addresses of all community households. The survey was accompanied by a letter from the Community Board President encouraging participation in the study. The survey was initially mailed to a total of 1,381 (approximately 25%) of the households in the suburb. This was preceded by an article in the local newspaper discussing the survey and encouraging all residents to respond. A second follow-up mailing to the same households was sent 1 month later. This was again preceded by local newspaper coverage. A total of 642 usable surveys were returned for a response rate of 46.4%.
RESULTS
Rank Ordering of Identified Problem Areas by all Respondents Each of the potential problem areas identified by survey respondents were categorized by two sets of criteria for the purposes of analysis. First, all 2 to 5 responsesranging from no problem (1) to serious problem (5)-on each item were combined to provide aggregate data on the percentage of the entire sample who perceived the item as "a problem," regardless of the degree of concern. The second classification combines all 3 to 5 responses on each item in order to determine the percentage of respondents who indicated that each item presented a problem for themselves or
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Lundeen TABLE 1 Rank Order of Health Problems ldentified by at Least 15% of all Respondentsa
Health Problem Identifed by Household Members
Degree of Concern n
Any Degree of Concern (%)b
Moderate to High Degree of Concern (%p
Managing stress Insect/rodents Uncontrolled animals Noise Feelings of sadness/
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hopelessness/worthlessness Family member communication Vision Family discord Hearing Dental Leisure time activities Pain Pollution level Skin Social contact
62 1 62 1 597 62 1 596 595 62 1 593 624 597 624
30.2 29.2 25.1 23.1 21.0 19.5 19.4 18.4 16.8 16.6 15.0
14.2 11.9 10.2 9.4 9.0 9.5 8.4 10.5 6.2 7.2 8.9
"N = 642. b ~ u m of all 2, 3, 4, and 5 responses on a 5-point Likert scale. 'Sum of all 3, 4, and 5 responses on a 5-point Likert scale.
their household to a "moderate to high degree." The health problems identified by the respondents included concerns for environmental and psychosocial issues as well as those of a physical nature. A rank ordered list of all those potential problems identified as posing at least some degree of concern for at least 15% of all those surveyed is presented in Table 1. Demographic Variables Related to Identified Health Problems
Health program planning that is sensitive to the needs of specialized aggregate groups requires assessment data that can pinpoint identified community health needs to the subgroups that are experiencing the problem(s). The data of this community survey were analyzed to determine if relationships existed between the type of problems identified and the gender, age, or income level of the respondents. Respondents indicating a problem at any level and those indicating no problem were cross-tabulated with the demographic variables of gender, age (22- to 44-year-olds, 45- to 64-year-olds, and 65 years and older), and income level (less than $20,000/ year, $20,000 to $59,999/year, and $60,000 and over/year). Significant relationships determined by chi-square analysis for the problems identified by all respondents related to personal and family well-being are presented in Table 2. Personal and family well-being. Female respondents were more likely to indicate problems in the areas of managing stress and feelings of sadness, worthlessness, and hopelessness, than male respondents. Respondents under 45 years of age were more likely than older respondents to report problems for their households in the following areas: opportunities for social contact; leisure time activities; feelings of
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TABLE 2 Relationship Between Problems Related to Personal and Family Well-Being and Demographic Variables in All Respondent Householdss
Demogmphic Variables Households Indicating
Age
Gender -
Income
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Problem Limited social contact Limited leisure time Feeling of sadness/worthlessness hopelessness Little interest in daily activities Managing stress Thoughts of self-harm/suicide Communication among family members Family discord Lack of support systems Alcohol misuse Drug use among friends or children's friends
sadness, worthlessness, and hopelessness; interest in daily self-care activities; managing $tress; thoughts of suicide; communication among family members; family discord; support systems; alcohol misuse; and drug abuse of friends or childrens' friends. Communication among family members became a more frequently reported problem as income level increased. There was a slight tendency of households lteporting incomes over $60,000 to more frequently report a sexually active adolesaent and those under $20,000 to report sexual abuse. The low numbers of persons reporting these problems at all, however, precludes drawing any hard conclusions from this data. Analysis of Problem Areas by Selected Respondent Categories
In addition to an analysis of the problems identified by all survey respondents, data were also collected on three targeted subgroups of the total sample, including: (a) households with elderly or disabled members, (b) households with children up to age 20, and (c) single-parent households. The identification of the problems selected most frequently by each of these aggregates and an analysis of the relationship of gender, age, and income to each of the problem areas was done to assist with program planning in future years. Households with disabled or aged adults. Over one third of those surveyed indicated that they had an elderly or disabled adult living in the household (see Table 3). Respondents 45 to 64 years of age indicated significantly more problems in the areas of providing physical care, providing adequate supervision, providing respite care, providing health care, and protecting from accidental injury to older or disabled members. This may reflect the "sandwich generation" of individuals who are caught between providing care to their children and their parents at the same time. Both younger and middle aged re-
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Lundeen TABLE 3 Relationship of Health Problems Related to Demographic Variables in Households of Elderly or Disabled Membersa
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Demographic Variables Households Indicating
Age
Gender -
-
Problem
n
%
x2 (1)
x2(2)
~'(2)
Providing physical care/safety Providing emotional support Providing adequate supervision Respite care Providing prevention/therapeutic health Accidental injuries Verbal abuse Knowledge of medications Transportation Ability to provide personal care Ability to do housekeeping Personal safetylneed for assistance living in own home Knowledge of community resources Contact with friends of family
24 42 21 20 22 18 5 6 10 9 21 10 23 3
12.6 21.7 10.9 10.4 11.0 9.4 2.4 3.4 5.7 4.5 11.9 5.9 13.2 1.7
13.56** 34.07*** 12.78** 11.19** 21.24*** 10.76** 9.19* 8.67' 3.51 24.22*** 8.34* ,277 6.75* 3.74
.678 .081 1.78 2.05 ,789 3.87 1.96 .765 10.98** ,679 1.69 4.37* 1.69 .388
Income
1.71 4.54 1.65 1.40 .246 .60 .69 2.52 7.59 .47 .312 6.39 .64 6.23
"N = 196. *p < .05. **p < .01. ***p< .0001.
spondents indicated problems with providing emotional support for elderly or disabled household members. These problems are also likely to be issues for other community residents who have aging parents or loved ones living elsewhere in the immediate community or elsewhere in the metropolitan area. These individuals would not have responded to this subset of survey items due to the specific wording of the survey items which specifically sought a response only from those respondents who have an elderly or disabled member of the household. The findings therefore, probably represent an underestimate of the level of community need in this area. Older adult respondents were also asked to indicate concerns about issues related to aging. Not surprisingly, older individuals report more difficulties with knowledge about prescribed medications, ability to do their own housekeeping, and the ability to provide their own personal care. Women were more likely to report concerns about transportation and personal safety or need for assistance living in their own home. Persons with incomes under $20,000 reported more problems with transportation, personal safety, need for assistance in the home, and contact with friends or family. Households with children 0 to 19 years of age. Nearly 40% of the respondents indicated that they had children 19 years of age or younger in the household. Of these households, over half reported some difficulty in balancing home and work; 25% indicated that this is a problem to a moderate or high degree. Over half indicated that there were problems with discipline, while 29% had difficulties providing adequate daycare or supervision for their children, and found it difficult to provide emotional support to the children. A quarter of the respondents indicated that there was some degree of problem in the household with verbal abuse.
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TABLE 4 Relationship of Health Problems Related to Demographic Variables in Households With Children 0 to 19 Years of Age and Single-Parent Households
Demographic Variables Households Indicating
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Problem
n
%
Age
-
Gender
Income
xZ (1)
x2(2)
x2(2)
Households with children 0 to 19 years of age" ,591 26 10.6 Providing physical care .489 Providing emotional support 70 28.7 71 29.4 4.06 Locating child care 16 6.6 3.26 Providing preventivehherapeutic care Balancing work and home 13 54.3 9.88.. 327 50.9 4.77 Discipline 31 12.7 .68 Accidental injuries Verbal abuse 59 24.3 4.68 Violent domestic environment 12 4.9 11.24** Single-parent householdsb Locating child care 6.40* 12 25 Balancing work and home 16 34 9.84** Health care availability 9 19.1 1.86 Identifying support groups 9 18.1 1.26 Self-esteem 10 21.4 2.31 Adequate finances 17 36.2 8.48*
.024 .986 .819 .729 .628 .332 3.30 .577 1.12
2.21 .29 .25 .75 .66 .70 1.07 1.61 1.80
3.91* 1.93 5.22* 1.68 5.95 5.21
4.06 2.03 5.92* 4.44 5.07 6.56*
'N = 243. b~ = 48. * p < .05. * * p < .01.
Significant differences were noted by gender or age of the respondents for problems related to parenting of children 0 to 19 years of age in only two areas (Table 4). Households of younger respondents indicated more difficulty in the area of balancing work and home. Although middle-aged respondents (45 to 64 years of age) were statistically more likely to report a violent domestic environment, the limited number of those reporting this problem (n = 6) precludes drawing conclusions. Hou$eholds with single parents. Over a third of the single-parent households surveyed indicate problems with finance and balancing home and work (see Table 4). Problems with child care were reported by 25%. Low self-esteem was reported as a problem for 21% of this population and nearly a fifth had problems with health insurance coverage. Younger single-parent families reported more problems with child care, balancing home and work, and finances than older families. Women who were single parents report significantly higher problems providing child care, availability of health care/ insurance, self-esteem, and finances than their male counterparts. Households with incomas under $20,000 more frequently reported problems with finances and availability of health care/insurance.
DISCUSSION
Many of the personal health issues identified most frequently by the suburban community residents in this study were those related to the psychosocial aspects of per-
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Lundeen
sonal and family well-being. The families in this stable, upper middle class community are struggling to maintain a balance between provider and nurturing roles. Women and young families are particularly vulnerable. Although this is an issue which has received much concern in recent years in disadvantaged communities, it is important to note that it is not only low-income respondents who are affected. Financial problems are evident for a selected subset of the population in this affluent community with female-headed, single-parent families and older single women being most at risk. Single-parent families are particularly vulnerable to problems with inadequate daycare and feelings of low self-esteem. Evidence of the effect of these stressors in many homes is indicated by the incidence of verbal abuse reported by nearly one quarter of all households with children under 20. Some degree of domestic violence was reported by 5% of these households. Problems related to an aging population are an important health issue for this community. As it becomes increasingly difficult for older residents to manage their own care independently, additional assistance is needed for them to remain in their homes. This is particularly true for elderly, widowed women. The caretakers of these individuals tend to be middle-aged adults who reported difficulty in providing support and supervision. Over 20% of households with elderly or disabled members indicated concerns about providing emotional support to these members. The degree to which difficulty with managing stress, feelings associated with depression, problems with family communication, and difficulty in providing emotional support to family members were reported indicates that programs and services related to these areas must be considered by community health service planners. If community health services are to facilitate the early identification of health problems and facilitate or implement prevention and early intervention strategies to assist community residents to attain and maintain the highest possible levels of health, a heavy emphasis on the psychosocial aspects of wellness is indicated.
LIMITATIONS OF THE STUDY
The major limitation of this study reflects a sampling problem that may affect many studies conducted by mailed survey. The survey instrument covered many health-related areas and required at least 20 min to complete. Although there was an excellent return rate, it is important to note that this type of survey can present a sampling problem. This may be a particular concern when the focus of the study concerns issues related to health or health services. That is, the individuals most likely to be affected by health problems or most in need of services (i.e., the sick, those in crisis, the less educated, and those with limited resources) may be the individuals least likely to respond to any type of mailed survey. Therefore, the study may identify issues which have an effect on these subgroups but may not have elicited a representative response from them. This undersampling of the most vulnerable individuals in a population presents a dilemma for community health researchers and planners. Community health ser-
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vices must be planned with the needs of all segments of the community in mind. It was my recommendation that the findings relative to these subgroups be considered as potential underestimates of the true incidence of problems in the community until such time as additional, focused "oversampling" of these groups be conducted. Such additional data collection may be best accomplished through (a) solicitation of survey respondents through outreach to identified subgroups of the population, (b) focus group discussions, and (c) one-to-one interviews with community residents in the subgroups. This further assessment of needs affecting the most vulnerable residents of a community might frequently be accomplished by CHNs in conjunction with their multiple roles as educators, case finders, and care providers. SUMMARY
Community health nursing can play an important role in conducting community needs assessments that provide critical data upon which programming, planning, and evaluation should be based. The community health services developed for any given community should be planned with the specific needs of the community residents in mind. A community needs survey is one method that should be periodically employed to ascertain the specific needs and concerns of community residents. Nursing conceptual models developed by CHNs are very appropriate to the assessment of all aspects of community life related to health and well-being. Comprehensive community needs surveys should include assessment of environmental, psychosocial, and physiological aspects of health as well as indicators of health-related behaviors in the population. The Omaha classification system adapted for this study provides a broad conceptual framework that facilitates the development of comprehensive programs of assessment. Public health services are in a state of crisis in many states. Traditional program offerings may no longer be the key to providing the types of services most needed by some communities. Analysis of data on problems related to personal and family wellbeing in one upper middle class suburban community indicate a need for health promotion and services focused on many of the psychosocial aspects of health. The stress experienced by younger community residents appears to be related to issues of parenting and balancing the dual roles required at work and home. Families of elders are also confronted by issues concerning the decreasing independence of these individuals and the need to find additional support services for them. Community health services must be designed that take these factors into account. Professional nurses can provide the leadership necessary to assess health needs and current public health practices in these communities and to recommend and implement programs appropriate to the needs of the present and the goals of the future. REFERENCES Chamberlin, R. W. (1988). Rationale for a community wide approach to promote the health and development of families and children. In R. W. Chamberlin (Ed.), Beyond individual risk assessment: Community wide approaches to promoting the health and development of families and children:
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Conference proceedings (pp. 3-16). Hanover, NH: The National Center for Education in Maternal and Child Health. Hanchett, E. S. (1988). Nursing frameworks and community as client: Bridging the gap. Norwalk, C T Appleton & Lang. Higgs, Z. R., & Gustafson, D. D. (1985). Community as a client: Assessment and diagnosis. Philadelphia: Davis. Institute of Medicine. (1988). The future of public health. Washington, DC: National Academy Press. Lundeen, S. P., Kreuser, N. J., & Mundt, M. M. (1992). The community health needs and utilization survey. Manuscript submitted for publication. Martin, K. S., & Scheet, N. J. (1992). The Omaha system: Applications for community health nursing. Philadelphia: Saunders. Martin, K. S., Scheet, N. J., Crews, C., & Simmons, D. (1986). Client management information system for community health nursing agencies: An implementation manual (NTIS No. HRP0907023). Rockville, MD: U.S., Department of Health and Human Services, Public Health Service, Health Resources Services Administration. (DHHS, PHS, HRSA) Stanhope, M., & Lancaster, J. (1988). Community health nursing (2nd ed.). St. Louis: Mosby.
Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Health Needs of a Suburban Community: A Nursing Assessment Approach Salley Peck Lundeen Published online: 07 Jun 2010.
To cite this article: Salley Peck Lundeen (1992) Health Needs of a Suburban Community: A Nursing Assessment Approach, Journal of Community Health Nursing, 9:4, 235-244, DOI: 10.1207/ s15327655jchn0904_5 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0904_5
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
JOURNAL OF COMMUNITY HEALTH NURSING, 1992, 9(4), 235-244 Copyright O 1992, Lawrence Erlbaum Associates, Inc.
Health Needs of a Suburban Community: A Nursing Assessment Approach Sally Peck Lundeen, RN, PhD, FAAN
Downloaded by [Universite Laval] at 10:37 04 March 2015
University of Wisconsin-Milwaukee
Community health nurses (CHNs) can play an important role in the implementation of studies related to the health needs of their communities of residence or service. Assessment of the health-related problems of the residents of a community as perceived by those residents should be collected periodically by all communitiesrural, urban, or suburban-regardless of the community's demographic profile. The focus of these assessments of community needs should conform to a public health mandate which focuses on broad issues related to health promotion and disease prevention. A community health nursing theoretical framework is ideal for the development of community assessment methodologies. Data reported here were collected as part of a comprehensive community health needs assessment survey conducted by the faculty and staff of an academic nursing center under contract to a Midwestern suburban community. This article presents: (a) rationale for the development of a health-needs assessment tool based on a community nursing perspective; (b) analysis of health needs survey data in the areas of environmental health, family health and well-being, and personal health and selfprotective behaviors; and (c) policy recommendations based on the findings. COMMUNITY ASSESSMENT METHOD The request for the community assessment was precipitated by a need for the community Board of Trustees to make some decisions as to the future of the community health department. Findings from the assessment were needed to review the mission, organizational structure, and funding for community health services in the next 10 years. It was determined, after discussions with the city manager and elected officials in the community, that a broadly focused assessment approach would be utilized. A contract was negotiated with the academic nursing center for faculty and staff to conduct the assessment using a community nursing framework. A number of community assessment frameworks were reviewed in the planning stages of this project (Chamberlin, 1988; Hanchett, 1988; Higgs & Gustafson, 1985; Institute of Medicine, 1988; Stanhope & Lancaster, 1988). A combination of Requests for reprints should be sent to Sally Peck Lundeen, RN, PhD, FAAN, Director, Nursing Center, University of Wisconsin-Milwaukee, P.O. Box 413, Milwaukee, WI 53201.
236
Lundeen
the assessment techniques identified by these sources, including key informant interviews, epidemiological studies, analysis of existing community dataheports, and a survey of community residents, were all considered relevant to a comprehensive assessment of community needs. Most of these methods were used and incorporated into the final report to the Village Board of this community. The need to solicit specific data from a sample of community residents on perceived health problems, their current utilization patterns, and attitudes toward future community health services required the development of a new survey tool.
Downloaded by [Universite Laval] at 10:37 04 March 2015
Survey Instrument The complete Community Health Needs and Utilization Survey (CHNUS) instrument covers seven different areas including (a) respondent and respondent household demographics, (b) health and safety problem identification, (c) respondent health-related and self-protective behaviors, (d) awareness and utilization of current health department services, (e) respondents' household interest in selected healthpromotion programs and services, (f) respondents' insurance coverage for healthpromotion programs and services, and (g) respondents' evaluation of how health-promotion programs and services should be funded (Lundeen, Kreuser, & Mundt , 1992). The problem-identification section of the survey instrument is based on the Client Problem Classification Scheme developed by researchers at the Omaha Visiting Nurses Association (Martin, Scheet, Crews, & Simmons, 1986). Developed and tested by CHNs, this comprehensive assessment scheme is being used and further refined in community health settings across the country (Martin & Scheet, 1992). The problem-classification scheme was selected as a basis for this assessment because of its comprehensive conceptualization of community health issues which expands the scope of problem choices presented to respondents beyond many health assessment tools. Use of this existing taxonomy mitigated investigator bias based on any preconceptions about the nature of the health problems experienced by residents for any particular community. Problem areas are divided into three major categories corresponding to the Omaha System domains, including (a) environmental health, (b) psychosocial health, and (c) physiological health. These categories are renamed "Environmental Health and Safety," "Personal and Family Well-being," and "Physical Health" in the CHNUS. Questions from the fourth Omaha System domain, health-related behaviors, were also included in the CHNUS in two sections entitled "Health-Related Behaviors" and "Personal Prevention Measures." Although analysis of these latter sections provided direction for community health planning, results are outside the scope of this article. Sample The population of interest reside in a suburb of a Midwestern city. At the time of the study, the population was just under 15,000 and 99% of the residents were
Downloaded by [Universite Laval] at 10:37 04 March 2015
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White. There was a growing population of residents 65 and older (15%) which already exceeded the national average (1 l %). Only 2% of the residents were below the poverty line as compared to a national figure of 12%. The survey respondents were mostly women (66.6%). Over 43% were 22 to 44 years of age, 28.5% were between 45 and 64 years of age, and 28.4% were 65 years or older; over 35% of respondent households had at least one member over 65 years of age. Over 60% of the respondents had lived in the village for over 10 years. Most (66.5%) of the respondents were married; 14.2% were widowed. A few (9.6%) reported that they were living in "blended family" households (parents with children from previous marriages). Forty-two percent of respondent households had children of school age; 7.1 % were single parents. This was largely an upper middle class respondent group with 41% reporting incomes over $60,000; 8.8% reported income under $20,000. Over 90% owned their own homes. Respondents were largely professionals (43%) or managers (17%). Nearly 25% were retired. Of the 22% of the sample who represented single-person households, 58% were women over 60 years of age. 'Ikrenty percent of the singleperson households reported income below $20,000 while only 8.7% had incomes over $60,000. This is a very different profile than the higher income distribution for the total sample. Procedure The survey tool was mailed to a systematic sample of community households generated from a computerized listing of the addresses of all community households. The survey was accompanied by a letter from the Community Board President encouraging participation in the study. The survey was initially mailed to a total of 1,381 (approximately 25%) of the households in the suburb. This was preceded by an article in the local newspaper discussing the survey and encouraging all residents to respond. A second follow-up mailing to the same households was sent 1 month later. This was again preceded by local newspaper coverage. A total of 642 usable surveys were returned for a response rate of 46.4%.
RESULTS
Rank Ordering of Identified Problem Areas by all Respondents Each of the potential problem areas identified by survey respondents were categorized by two sets of criteria for the purposes of analysis. First, all 2 to 5 responsesranging from no problem (1) to serious problem (5)-on each item were combined to provide aggregate data on the percentage of the entire sample who perceived the item as "a problem," regardless of the degree of concern. The second classification combines all 3 to 5 responses on each item in order to determine the percentage of respondents who indicated that each item presented a problem for themselves or
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Lundeen TABLE 1 Rank Order of Health Problems ldentified by at Least 15% of all Respondentsa
Health Problem Identifed by Household Members
Degree of Concern n
Any Degree of Concern (%)b
Moderate to High Degree of Concern (%p
Managing stress Insect/rodents Uncontrolled animals Noise Feelings of sadness/
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hopelessness/worthlessness Family member communication Vision Family discord Hearing Dental Leisure time activities Pain Pollution level Skin Social contact
62 1 62 1 597 62 1 596 595 62 1 593 624 597 624
30.2 29.2 25.1 23.1 21.0 19.5 19.4 18.4 16.8 16.6 15.0
14.2 11.9 10.2 9.4 9.0 9.5 8.4 10.5 6.2 7.2 8.9
"N = 642. b ~ u m of all 2, 3, 4, and 5 responses on a 5-point Likert scale. 'Sum of all 3, 4, and 5 responses on a 5-point Likert scale.
their household to a "moderate to high degree." The health problems identified by the respondents included concerns for environmental and psychosocial issues as well as those of a physical nature. A rank ordered list of all those potential problems identified as posing at least some degree of concern for at least 15% of all those surveyed is presented in Table 1. Demographic Variables Related to Identified Health Problems
Health program planning that is sensitive to the needs of specialized aggregate groups requires assessment data that can pinpoint identified community health needs to the subgroups that are experiencing the problem(s). The data of this community survey were analyzed to determine if relationships existed between the type of problems identified and the gender, age, or income level of the respondents. Respondents indicating a problem at any level and those indicating no problem were cross-tabulated with the demographic variables of gender, age (22- to 44-year-olds, 45- to 64-year-olds, and 65 years and older), and income level (less than $20,000/ year, $20,000 to $59,999/year, and $60,000 and over/year). Significant relationships determined by chi-square analysis for the problems identified by all respondents related to personal and family well-being are presented in Table 2. Personal and family well-being. Female respondents were more likely to indicate problems in the areas of managing stress and feelings of sadness, worthlessness, and hopelessness, than male respondents. Respondents under 45 years of age were more likely than older respondents to report problems for their households in the following areas: opportunities for social contact; leisure time activities; feelings of
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TABLE 2 Relationship Between Problems Related to Personal and Family Well-Being and Demographic Variables in All Respondent Householdss
Demogmphic Variables Households Indicating
Age
Gender -
Income
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Problem Limited social contact Limited leisure time Feeling of sadness/worthlessness hopelessness Little interest in daily activities Managing stress Thoughts of self-harm/suicide Communication among family members Family discord Lack of support systems Alcohol misuse Drug use among friends or children's friends
sadness, worthlessness, and hopelessness; interest in daily self-care activities; managing $tress; thoughts of suicide; communication among family members; family discord; support systems; alcohol misuse; and drug abuse of friends or childrens' friends. Communication among family members became a more frequently reported problem as income level increased. There was a slight tendency of households lteporting incomes over $60,000 to more frequently report a sexually active adolesaent and those under $20,000 to report sexual abuse. The low numbers of persons reporting these problems at all, however, precludes drawing any hard conclusions from this data. Analysis of Problem Areas by Selected Respondent Categories
In addition to an analysis of the problems identified by all survey respondents, data were also collected on three targeted subgroups of the total sample, including: (a) households with elderly or disabled members, (b) households with children up to age 20, and (c) single-parent households. The identification of the problems selected most frequently by each of these aggregates and an analysis of the relationship of gender, age, and income to each of the problem areas was done to assist with program planning in future years. Households with disabled or aged adults. Over one third of those surveyed indicated that they had an elderly or disabled adult living in the household (see Table 3). Respondents 45 to 64 years of age indicated significantly more problems in the areas of providing physical care, providing adequate supervision, providing respite care, providing health care, and protecting from accidental injury to older or disabled members. This may reflect the "sandwich generation" of individuals who are caught between providing care to their children and their parents at the same time. Both younger and middle aged re-
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Lundeen TABLE 3 Relationship of Health Problems Related to Demographic Variables in Households of Elderly or Disabled Membersa
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Demographic Variables Households Indicating
Age
Gender -
-
Problem
n
%
x2 (1)
x2(2)
~'(2)
Providing physical care/safety Providing emotional support Providing adequate supervision Respite care Providing prevention/therapeutic health Accidental injuries Verbal abuse Knowledge of medications Transportation Ability to provide personal care Ability to do housekeeping Personal safetylneed for assistance living in own home Knowledge of community resources Contact with friends of family
24 42 21 20 22 18 5 6 10 9 21 10 23 3
12.6 21.7 10.9 10.4 11.0 9.4 2.4 3.4 5.7 4.5 11.9 5.9 13.2 1.7
13.56** 34.07*** 12.78** 11.19** 21.24*** 10.76** 9.19* 8.67' 3.51 24.22*** 8.34* ,277 6.75* 3.74
.678 .081 1.78 2.05 ,789 3.87 1.96 .765 10.98** ,679 1.69 4.37* 1.69 .388
Income
1.71 4.54 1.65 1.40 .246 .60 .69 2.52 7.59 .47 .312 6.39 .64 6.23
"N = 196. *p < .05. **p < .01. ***p< .0001.
spondents indicated problems with providing emotional support for elderly or disabled household members. These problems are also likely to be issues for other community residents who have aging parents or loved ones living elsewhere in the immediate community or elsewhere in the metropolitan area. These individuals would not have responded to this subset of survey items due to the specific wording of the survey items which specifically sought a response only from those respondents who have an elderly or disabled member of the household. The findings therefore, probably represent an underestimate of the level of community need in this area. Older adult respondents were also asked to indicate concerns about issues related to aging. Not surprisingly, older individuals report more difficulties with knowledge about prescribed medications, ability to do their own housekeeping, and the ability to provide their own personal care. Women were more likely to report concerns about transportation and personal safety or need for assistance living in their own home. Persons with incomes under $20,000 reported more problems with transportation, personal safety, need for assistance in the home, and contact with friends or family. Households with children 0 to 19 years of age. Nearly 40% of the respondents indicated that they had children 19 years of age or younger in the household. Of these households, over half reported some difficulty in balancing home and work; 25% indicated that this is a problem to a moderate or high degree. Over half indicated that there were problems with discipline, while 29% had difficulties providing adequate daycare or supervision for their children, and found it difficult to provide emotional support to the children. A quarter of the respondents indicated that there was some degree of problem in the household with verbal abuse.
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TABLE 4 Relationship of Health Problems Related to Demographic Variables in Households With Children 0 to 19 Years of Age and Single-Parent Households
Demographic Variables Households Indicating
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Problem
n
%
Age
-
Gender
Income
xZ (1)
x2(2)
x2(2)
Households with children 0 to 19 years of age" ,591 26 10.6 Providing physical care .489 Providing emotional support 70 28.7 71 29.4 4.06 Locating child care 16 6.6 3.26 Providing preventivehherapeutic care Balancing work and home 13 54.3 9.88.. 327 50.9 4.77 Discipline 31 12.7 .68 Accidental injuries Verbal abuse 59 24.3 4.68 Violent domestic environment 12 4.9 11.24** Single-parent householdsb Locating child care 6.40* 12 25 Balancing work and home 16 34 9.84** Health care availability 9 19.1 1.86 Identifying support groups 9 18.1 1.26 Self-esteem 10 21.4 2.31 Adequate finances 17 36.2 8.48*
.024 .986 .819 .729 .628 .332 3.30 .577 1.12
2.21 .29 .25 .75 .66 .70 1.07 1.61 1.80
3.91* 1.93 5.22* 1.68 5.95 5.21
4.06 2.03 5.92* 4.44 5.07 6.56*
'N = 243. b~ = 48. * p < .05. * * p < .01.
Significant differences were noted by gender or age of the respondents for problems related to parenting of children 0 to 19 years of age in only two areas (Table 4). Households of younger respondents indicated more difficulty in the area of balancing work and home. Although middle-aged respondents (45 to 64 years of age) were statistically more likely to report a violent domestic environment, the limited number of those reporting this problem (n = 6) precludes drawing conclusions. Hou$eholds with single parents. Over a third of the single-parent households surveyed indicate problems with finance and balancing home and work (see Table 4). Problems with child care were reported by 25%. Low self-esteem was reported as a problem for 21% of this population and nearly a fifth had problems with health insurance coverage. Younger single-parent families reported more problems with child care, balancing home and work, and finances than older families. Women who were single parents report significantly higher problems providing child care, availability of health care/ insurance, self-esteem, and finances than their male counterparts. Households with incomas under $20,000 more frequently reported problems with finances and availability of health care/insurance.
DISCUSSION
Many of the personal health issues identified most frequently by the suburban community residents in this study were those related to the psychosocial aspects of per-
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Lundeen
sonal and family well-being. The families in this stable, upper middle class community are struggling to maintain a balance between provider and nurturing roles. Women and young families are particularly vulnerable. Although this is an issue which has received much concern in recent years in disadvantaged communities, it is important to note that it is not only low-income respondents who are affected. Financial problems are evident for a selected subset of the population in this affluent community with female-headed, single-parent families and older single women being most at risk. Single-parent families are particularly vulnerable to problems with inadequate daycare and feelings of low self-esteem. Evidence of the effect of these stressors in many homes is indicated by the incidence of verbal abuse reported by nearly one quarter of all households with children under 20. Some degree of domestic violence was reported by 5% of these households. Problems related to an aging population are an important health issue for this community. As it becomes increasingly difficult for older residents to manage their own care independently, additional assistance is needed for them to remain in their homes. This is particularly true for elderly, widowed women. The caretakers of these individuals tend to be middle-aged adults who reported difficulty in providing support and supervision. Over 20% of households with elderly or disabled members indicated concerns about providing emotional support to these members. The degree to which difficulty with managing stress, feelings associated with depression, problems with family communication, and difficulty in providing emotional support to family members were reported indicates that programs and services related to these areas must be considered by community health service planners. If community health services are to facilitate the early identification of health problems and facilitate or implement prevention and early intervention strategies to assist community residents to attain and maintain the highest possible levels of health, a heavy emphasis on the psychosocial aspects of wellness is indicated.
LIMITATIONS OF THE STUDY
The major limitation of this study reflects a sampling problem that may affect many studies conducted by mailed survey. The survey instrument covered many health-related areas and required at least 20 min to complete. Although there was an excellent return rate, it is important to note that this type of survey can present a sampling problem. This may be a particular concern when the focus of the study concerns issues related to health or health services. That is, the individuals most likely to be affected by health problems or most in need of services (i.e., the sick, those in crisis, the less educated, and those with limited resources) may be the individuals least likely to respond to any type of mailed survey. Therefore, the study may identify issues which have an effect on these subgroups but may not have elicited a representative response from them. This undersampling of the most vulnerable individuals in a population presents a dilemma for community health researchers and planners. Community health ser-
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vices must be planned with the needs of all segments of the community in mind. It was my recommendation that the findings relative to these subgroups be considered as potential underestimates of the true incidence of problems in the community until such time as additional, focused "oversampling" of these groups be conducted. Such additional data collection may be best accomplished through (a) solicitation of survey respondents through outreach to identified subgroups of the population, (b) focus group discussions, and (c) one-to-one interviews with community residents in the subgroups. This further assessment of needs affecting the most vulnerable residents of a community might frequently be accomplished by CHNs in conjunction with their multiple roles as educators, case finders, and care providers. SUMMARY
Community health nursing can play an important role in conducting community needs assessments that provide critical data upon which programming, planning, and evaluation should be based. The community health services developed for any given community should be planned with the specific needs of the community residents in mind. A community needs survey is one method that should be periodically employed to ascertain the specific needs and concerns of community residents. Nursing conceptual models developed by CHNs are very appropriate to the assessment of all aspects of community life related to health and well-being. Comprehensive community needs surveys should include assessment of environmental, psychosocial, and physiological aspects of health as well as indicators of health-related behaviors in the population. The Omaha classification system adapted for this study provides a broad conceptual framework that facilitates the development of comprehensive programs of assessment. Public health services are in a state of crisis in many states. Traditional program offerings may no longer be the key to providing the types of services most needed by some communities. Analysis of data on problems related to personal and family wellbeing in one upper middle class suburban community indicate a need for health promotion and services focused on many of the psychosocial aspects of health. The stress experienced by younger community residents appears to be related to issues of parenting and balancing the dual roles required at work and home. Families of elders are also confronted by issues concerning the decreasing independence of these individuals and the need to find additional support services for them. Community health services must be designed that take these factors into account. Professional nurses can provide the leadership necessary to assess health needs and current public health practices in these communities and to recommend and implement programs appropriate to the needs of the present and the goals of the future. REFERENCES Chamberlin, R. W. (1988). Rationale for a community wide approach to promote the health and development of families and children. In R. W. Chamberlin (Ed.), Beyond individual risk assessment: Community wide approaches to promoting the health and development of families and children:
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Conference proceedings (pp. 3-16). Hanover, NH: The National Center for Education in Maternal and Child Health. Hanchett, E. S. (1988). Nursing frameworks and community as client: Bridging the gap. Norwalk, C T Appleton & Lang. Higgs, Z. R., & Gustafson, D. D. (1985). Community as a client: Assessment and diagnosis. Philadelphia: Davis. Institute of Medicine. (1988). The future of public health. Washington, DC: National Academy Press. Lundeen, S. P., Kreuser, N. J., & Mundt, M. M. (1992). The community health needs and utilization survey. Manuscript submitted for publication. Martin, K. S., & Scheet, N. J. (1992). The Omaha system: Applications for community health nursing. Philadelphia: Saunders. Martin, K. S., Scheet, N. J., Crews, C., & Simmons, D. (1986). Client management information system for community health nursing agencies: An implementation manual (NTIS No. HRP0907023). Rockville, MD: U.S., Department of Health and Human Services, Public Health Service, Health Resources Services Administration. (DHHS, PHS, HRSA) Stanhope, M., & Lancaster, J. (1988). Community health nursing (2nd ed.). St. Louis: Mosby.
