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RESEARCH AND PRACTICE |
Edith Parker is with the Department of Health Behavior and Health Education, University of Michigan, Ann Arbor. Lewis H. Margolis is with the Department of Maternal and Child Health, University of North Carolina at Chapel Hill. Eugenia Eng is with the Department of Health Behavior and Health Education, University of North Carolina at Chapel Hill. Carlos Henríquez-Roldán is with the Department of Statistics, University of Valparaíso, Chile, and the Department of Biostatistics, University of North Carolina at Chapel Hill.
Correspondence: Requests for reprints should be sent to Edith Parker, University of Michigan School of Public Health, 1420 Washington Heights, Ann Arbor, MI 48109-2029 (e-mail: edithp{at}umich.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. We created indicators of local public health agency capacity to engage in community-based participatory public health.
Methods. We sent a survey of 27 items reflecting aspects of community-based participatory public health to 429 employees in 4 local health departments. Two thirds (n = 282) responded. We performed a factor analysis to identify components of community-based participatory practice.
Results. We identified 4 factors: (1) the agency’s and (2) the individual employee’s skills in working with community groups and minority populations, (3) the extent and frequency of agency networking, and (4) community participation in health department planning.
Conclusions. Our findings suggest that it is possible to measure the competencies needed by health department staff to engage in community-based participatory public health.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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A crucial component of the public health infrastructure is workforce capacity and competency, defined by the Centers for Disease Control and Prevention as the expertise of the approximately 500 000 professionals who work in federal, state, and local public health agencies to protect public health.6(p6) Thus, any successful community-based participatory public health intervention must have the involvement of local public health department staff.7 Such involvement implies that health department staff need competencies that enable them to (1) enhance the capacity of community members to serve in partnership endeavors, (2) appreciate the role of participation by underrepresented or underserved populations, and (3) develop skills for mobilizing community resources to address community-defined priorities.8
Yet, little is known about the organizations and staff competencies of public health departments in community-based participatory public health. With regard to core functions outlined by the Institute of Medicine,7 public health researchers have given attention to the role of public health practice,9 the articulation of 10 essential public health services,6 and methods to assess the performance of health departments.10–13 For a local health department interested in attempting more of a community-based participatory approach, however, little guidance is available in terms of how to identify and monitor the acquisition of necessary skills and competencies. This article presents our attempt to operationalize such competencies and measure the performance of 4 health departments and their staff in community-based participatory public health practice.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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To achieve the latter 2 goals, the North Carolina consortium implemented 3 strategies to promote change in the 4 participating local health departments. One strategy created coalitions in each county, consisting of representatives from the 3 partners. The organization of these coalitions emphasized the importance of shared decisionmaking among community groups and agencies in identifying health problems and strategies to solve those problems; this prevents the health department, as the local health agency, from having to make these decisions alone. A second strategy developed a health department position in 1 of the counties in which a tenure-track university faculty member had a half-time appointment at the health agency and a half-time appointment at the School of Public Health. A third strategy established a series of retreats for health department staff to explore and discuss the definition of community-based participatory public health and ways to promote changes needed within their agencies to engage in such an approach.
The North Carolina consortium employed a multiple case study participatory evaluation design, with each county coalition, the overall consortium, and the academic partners all serving as single cases. Evaluation of the North Carolina consortium was done by staff of the University of North Carolina Center for Health Promotion and Disease Prevention. As part of the evaluation activities, a survey questionnaire was developed and administered to the 4 county health departments to examine the effects of the CBPH Initiative on each organization and its staff. The first draft of the instrument was developed by evaluation staff with prior experience in assessing community-oriented primary care programs in the United States. The initial draft was then shared with members of each coalition to elicit and incorporate their suggestions for additions or revisions to the instrument. The instrument’s primary focus was on measuring competencies in community-based participatory public health practice. This study describes the development and validation of this instrument.
Study Sample
The sample for this study consisted of employees in the health departments of the 4 participating counties. The survey was mailed to all employees whose positions required provision of public health services to community members; this included personnel in units such as maternal and child health, adult health, health education, dentistry, and sanitation. Excluded from the sample were personnel with clerical, security, or home health responsibilities. A total of 429 employees met the selection criteria. Of these, 282 completed and returned the survey, for a 66% response rate.
Measures
The survey contained 50 items. Of these, 7 elicited demographic characteristics of the respondents, including position with the agency (2 questions), major area of work, education level, number of years with the agency, ethnicity, and percentage of the respondent’s salary (if any) that was paid from CBPH Initiative project funds. The remaining 43 items focused on the respondents’ perceptions of the health department’s performance and their own performance in various aspects of public health. Among these 43 items, 27 items were specific to community-based participatory public health practice (Table 1
). These 27 items focused on 5 dimensions: (1) community-based skills of the health department as a whole, (2) community-based skills of the individual respondent, (3) the health department’s frequency and extent of networking with other community agencies and groups, (4) community participation in health department planning, and (5) community assessment by the health department.
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Community participation in health department planning. Five items measured the respondent’s perception of the extent to which community members were involved in planning and implementation of health department programs. Three of the items used a 5-point Likert scale, with "always," "often," "rarely," "never," and "don’t know" as possible responses. Two additional items included 2 response categories, "yes" and "no."
Health department’s networking with other community agencies and groups. Three items measured the respondent’s perception of his or her health department’s frequency and extent of networking with other community agencies and groups. These items used a 5-point Likert scale, with "always," "often," "rarely," "never," and "don’t know" as possible responses.
Assessment process. Five items focused on the health department’s community assessment process. Three of these items used a 5-point Likert scale, with "always," "often," "rarely," "never," and "don’t know" as possible responses. One additional item included "yes" and "no" as response categories. The final item, which asked how often an assessment was performed, used a 5-point Likert scale, with "annually," "every 2 years," "every 3 years," "never," and "don’t know" as possible responses.
Description of Data Analysis
In the first stage of data analysis, our objective was to determine whether the factor structure revealed in the data would justify the construction of scales to measure the hypothesized dimensions. Using SAS (SAS Institute Inc, Cary, NC), we conducted a factor analysis with an orthogonal rotation on responses to the 27 items intended to measure the 5 dimensions of community-based participatory public health skills and competencies. A response of "don’t know" was interpreted to signify a neutral level of involvement and knowledge of the respondent that nevertheless needed to be acknowledged; this response was therefore placed at a neutral point on the 5-point scales. Where appropriate, items were reverse-scaled to ensure consistency in the direction of responses. We excluded from the principal components analysis 102 respondents with missing responses on 1 or more items. Hence, 180 respondents were included in the principal components analysis. Their responses to all items were standardized with z scores for this analysis.
In the second stage of analysis, our objective was to determine which survey items to retain for the scales intended to measure the factors—i.e., the 5 dimensions of community-based participatory public health. The Cronbach 
was calculated for each of the factor scales identified in the factor analysis to assess the internal consistency of the scales. Finally, to examine the scale scores among the participating health department employees, we calculated descriptive statistics for the scales.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Twenty of the original 27 items loaded at .40 or above on these 4 factors and were thus retained for the next step in the analysis. Items 18, 19, 22, 24, 25, 26, and 27 were dropped from future analyses, because they did not contribute to explaining variation in the factors. The next step involved a second factor analysis in which the 4 factors were specified. Twenty of the 27 items loaded at .40 or above on at least 1 of the 4 factors (Table 2).
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The second factor had 7 items that loaded above .40. These items focused on the community-based and core function skills of the respondent. We named this factor "own skills." As with the first factor, and based on the results of the factor analysis, we retained all 7 of the items that were included to capture the respondent’s own community-based skills.
The third factor had 4 items reflecting what we called "community participation." Three of these items were intended to reflect actual participation, and 1 was intended to reflect assessment ("How often has your agency’s assessment tried to identify strengths as well as the weaknesses of the communities it serves?").
The fourth factor, defined as "networking," contained 2 items that focused on networking by the health department with other organizations and agencies in the community. The third item intended to reflect networking—"How often does your agency exchange resources with other agencies and organizations?"—did not load at .40 or above, so it was not retained.
The Cronbach ranged from .63 to .87 for the 4 factors, indicating moderate to high internal consistency for each scale.
The descriptive statistics for the 4 factors (Table 3) indicated a moderate level of participatory public health practice in this sample. The variation and range in the scales suggest that they may be useful measures of change in community-based capacity by health agencies.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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We identified 4 discrete dimensions of community-based participatory public health practice by health departments. Two scales measured public health staff skills fundamental to the practice of community-based participatory public health. Individuals’ assessments of the skills of others in their agency and of their own skills, such as community organizing and working with community groups, suggest that attention to staff skills is important. Individuals who seek employment at local health agencies may have developed these skills in their professional training, although the literature suggests that such is not likely to be the case.17 Continuing education strategies to enhance the skills needed for community-based work seem warranted.
The other 2 scales measure organizational practices or processes important to community-based participatory public health practice. The factor identified as "community participation" highlights organizational recognition of a community as possessing assets and deserving decisionmaking power. The key role of a community in decisionmaking is reflected in questions about "addressing problems identified by the community, when public health statistics point to different problems" or "[using] feedback from the communities . . . to make decisions on programs." An agency’s attention to the assets of communities, such as human resources available among groups of people, is essential to viewing the collective power of a community. Public health agencies are constrained by 2 components of the health systems to which they belong: the standardization of assessments and interventions inherent in health agencies and the perception of individuals as dependent clients with needs.18 Conversely, the alternative of community-based participatory practice would identify strengths as well as weaknesses and would address problems identified by the community when standardized statistics point elsewhere. Such an awareness of a community with collective contributions to make to public health decisions would move agencies away from the limited focus on deficiencies and need-based practices.
The other organizational practice or process, "networking," involves joint communication and planning among agencies serving the same communities. This scale measures a health department’s recognition of the need to combine and coordinate resources from multiple sectors to address the complex social and economic issues that contribute to the health of communities. Networking implies that an agency understands collaboration to be fundamental to community-based participatory public health practice.
One limitation of this study was the failure to capture a factor associated with the core public health function of assessment. This may reflect the fact that the items selected to measure that function portrayed a rather narrow view of assessment. For example, 3 of the 5 items asked how respondents used data, in contrast to asking how data were generated or obtained. One item asked about the frequency of community assessments, based on the unproven assumption that health departments that engage in more frequent community assessments may be more community based. It is noteworthy that the 1 item that clearly reflected a community-based principle—attention to the assets or strengths of communities—was retained by the factor analysis, but as part of the "community participation" factor.
A second limitation stems from our study’s reduced sample, which resulted from both the 66% response rate and the need to exclude respondents for whom data were missing. Although the direction of potential bias was not apparent, it is conceivable that responses from the more committed individuals—as indicated by their completion and return of the surveys—enhanced the validity of the factors. On the other hand, the scales may have overstated the level of community-based capacity in these departments if the nonrespondents are assumed to have been less committed to participatory research and practice.
A third limitation involves the use of differing response categories. Although the use of z scores diminished the possible effects of using different numbers of response codes (e.g., 3 codes vs 5 codes), the use of differently worded response categories within the same scale may have affected the psychometric capabilities of the method.
Through our analysis, we have identified and measured skills and competencies that may influence local health agencies’ commitment to community-based participatory public health. One important issue for the further development of these measures is how to refine the questions and scales that tap into the core function of assessment.
Our analysis has 2 implications for the practice of public health. First, our findings suggest that it is possible to operationalize community-based performance to guide health agencies as they determine their capacities to become more "community based." For example, departments can assess their employees’ skills and provide training, or they can examine how their policies enhance or impede community participation. The second implication is that efforts by policymakers and professionals to hold health agencies accountable can and should encompass indicators of "community basedness." Unless health agencies know that elected officials, community members, public and private funders, and others will evaluate their performance with regard to their community-based capacities and interventions, it is less likely that they will develop and implement such programs to enhance the health of communities.
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Acknowledgments |
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We would also like to acknowledge the contribution of Victoria Sanchez-Merki to the data collection process of this survey.
Human Participant Protection
This research project was reviewed by and received approval from the institutional review boards of the University of North Carolina at Chapel Hill and the University of Michigan.
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Footnotes |
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Accepted for publication April 16, 2002.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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2. Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-based research: assessing partnership approaches to improve public health. Annu Rev Public Health. 1998;19:173–202.[ISI][Medline]
3. Clay R. Let’s work together: connecting research and the community. Environ Health Perspect. 2000;108:A500.[Medline]
4. Green LW, Mercer SL. Can public health researchers and agencies reconcile the push from funding bodies and the pull from communities? Am J Public Health. 2001;91:1926–1929.
5. Centers for Disease Control and Prevention. Competing Renewal Request for Urban Research Centers Initiative; Special Interest Project 20—URC, Program Announcement #98047.
6. Centers for Disease Control and Prevention. Public Health’s Infrastructure: A Status Report. Atlanta, Ga: Centers for Disease Control and Prevention; 2000. Available at: http://www.phppo.cdc.gov/documents/phireport2_16.pdf. Accessed October 31, 2002.
7. Institute of Medicine. The Future of Public Health. Washington, DC: National Academy Press; 1988.
8. Margolis LH, Stevens R, Laraia B, et al. Educating students for community-based partnerships. J Community Pract. 2000;7:21–34.
9. Northridge ME. Putting diversity into practice. Am J Public Health. 2000;90:689.
10. Turnock BJ, Handler A, Hall W, Potsic S, Nalluri R, Vaughn EH. Local health department effectiveness in addressing the core functions of public health. Public Health Rep. 1994;109:653–658.[ISI][Medline]
11. Miller CA, Moore KS, Richards TB, Monk JD. A proposed method for assessing the performance of local public health functions and practices. Am J Public Health. 1994;84:1743–1749.
12. Mays GP, Halverson P, Miller CA. Assessing the performance of local public health systems: a survey of state health agency efforts. J Public Health Manag Pract. 1998;4(4):63–78.[Medline]
13. Turnock BJ, Handler AS, Miller CA. Core function-related local public health practice effectiveness. J Public Health Manag Pract. 1998;4(5):26–32.[Medline]
14. Brownson RC, Riley P, Bruce TA. Demonstration projects in community-based prevention. J Public Health Manag Pract. 1998;4(2):66–77.[Medline]
15. Parker EA, Eng E, Laraia B, et al. Coalition building for prevention: lessons learned from the North Carolina Community-Based Public Health Initiative. J Public Health Manag Pract. 1998;4(2):25–36.[Medline]
16. MacQueen KM, McLellan E, Metzger DS, et al. What is community? An evidence-based definition for participatory public health. Am J Public Health. 2001;91:1929–1938.
17. Bruce TA, McKane SU, eds. Community-Based Public Health: A Partnership Model. Washington, DC: American Public Health Association, W. K. Kellogg Foundation; 2000.
18. McKnight JL. Two tools for well-being: health systems and communities. Am J Prev Med. 1994;10(suppl 3):23–25.[ISI][Medline]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
