HEALTH EDUCATION RESEARCH
5 1999
Theory & Practice
Teaching community diagnosis: integrating community
experience with meeting graduate standards for health
educators
Sandra Crouse Quinn
Abstract
In 1996, the American Association for
Health Education and the Society for Public
Health Education developed new Standards
for the Preparation of Graduate Level Health
Educators. Learning to work effectively with
communities is an essential part of graduate
level health education. This article provides an
overview of the community diagnosis (CD) class,
a component of the Master’s in Public Health
program in the Department of Health Behavior
and Health Education, School of Public Health,
University of North Carolina. CD is a required
two-semester class in which student teams work
with preceptors to define a client community,
assess its needs and strengths, and establish a
foundation of quantitative and qualitative data
for future community action. This experience
provides a strong foundation for development
of graduate level competencies and fosters an
appreciation for the complexity of partnerships
with communities.
Introduction
Health education literature has long discussed
the importance of community participation in
health education programs and there is a growing
emphasis on enabling health education practitioners
to facilitate successful community involvement.
Department of Health Behavior and Health Education,
School of Public Health, Rosenau Hall, CB#7400,
University of North Carolina at Chapel Hill, Chapel Hill,
NC 27599-7400, USA
© Oxford University Press 1999
Vol.14 no.
Pages 685–696
Two recent government publications elucidate the
need for engaging the community effectively and
mobilizing community efforts in support of
prevention activities (CDC/ATSDR Committee on
Community Engagement, 1997; Substance Abuse
and Mental Health Services Administration, 1997).
Wallack et al. [(Wallack et al., 1993), p. 5] reinforce
this with their view that ‘contemporary public
health is as much about facilitating a process
whereby communities use their voice to define
and make their health concerns known as it is
about providing prevention and treatment’. In
this context, communities may be defined as
geographic- or locality-based entities or as
communities of identity that share a common
culture or characteristics.
Involving the community is not a new concept,
however. Guy Steuart (Steckler et al., 1993) called
for a partnership between community members
and health educators in program planning and
evaluation with community diagnosis (CD) as a
critical part of program planning. In contrast to
needs assessment, Steuart stated that:
Diagnosis is much broader and aims to under-
stand many facets of a community including
culture, values and norms, leadership and power
structure, means of communication, helping
patterns, important community institutions, and
history. A good diagnosis suggests what it is
like to live in a community, what the important
health problems are, what interventions are most
likely to be efficacious, and how the program
would be best evaluated [(Steckler et al., 1993)
pp. S9–10].
Steuart sought to incorporate the community’s
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S. Crouse Quinn
voice into field training because he felt that ‘the
ends of health education are achieved best where
they are harnessed to the felt needs and motivations
of the community itself’ [(Steckler et al., 1993),
p. S19]. Therefore, the CD process is a core
requirement of all Master’s in Public Health (MPH)
students in the Department of Health Behavior
and Health Education at the University of North
Carolina at Chapel Hill.
Developing health education programs with
communities requires a number of competencies,
many of which were elucidated in the new Graduate
Standards, developed by a Joint Committee of the
American Association for Health Education and
the Society for Public Health Education with
representatives from the National Commission for
Health Education Credentialing and the Council
on Education for Public Health (Dennison, 1997).
The CD process addresses many of these com-
petencies in a unique and integrated manner, and
provides a ready opportunity for experiential
learning in the complex environment of local
communities (see Table I for a selected, not
exhaustive list of competencies).
The purpose of this article is to discuss the
operationalization and implementation of the CD
process in the graduate curriculum. The article
will discuss choosing preceptors and communities,
course content, team process and development, the
steps of the CD process and specific competencies,
outcomes and challenges, and lessons learned.
Description
CD spans two semesters, bringing first year
graduate students together in the field in approxi-
mately nine teams of four or five. Four credit
hours are given per semester. Although the field
component of the MPH degree has evolved since
its inception in 1944, its philosophy has remained
constant: that an understanding of the multiple
levels that characterize a community’s ‘health’
comes through investigating primary and secondary
data sources. For a typical class of 35–45 first year
students, CD requires one full-time faculty member
(the field coordinator) and two teaching assistants.
686
The CD process consists of four distinct but related
parts: an examination of secondary data on social
and health indicators and the community’s history
and geography; an exploration of health and human
service organizations serving the community; an
identification of perceived needs, assets and com-
munity dynamics through qualitative interviews
with community members; and a community
forum.
CD incorporates characteristics of field place-
ments, such as being ‘intricately tied to depart-
mental curricula’, putting ‘classroom concepts and
learning into practice’ and ‘integrating the real
and academic worlds’ [(Center for Public Health
Practice, 1993), p. 3]. However, unlike traditional
field placements and internships, the CD student
works in communities during the first year in the
graduate program, not as a culminating or capstone
experience.
Choosing communities
Prior to the start of the fall semester, the field
coordinator recruits field team preceptors from
communities within approximately an hour’s
driving distance of the School. Some, but not all,
of the preceptors are graduates of the HBHE
program who are working in county health depart-
ments or agencies. Additionally, communities may
request that a team conduct a CD and health
educators frequently contact the field coordinator
with requests to consider specific communities.
The preceptors decide, in consultation with their
agencies and the field coordinator, where to place
field teams. The CD process allows local agencies
to learn about unfamiliar communities and foster
new relationships with community members.
Agencies may select communities because they
are interested in expanding their services or better
understanding communities that are changing
dramatically. For example, recently, North Carolina
has experienced tremendous growth in the Latino
population and several preceptors have requested
CDs to learn more about these new populations.
Similarly, the Triangle region of NC, the location
of the university, is experiencing a rapidly growing

Table I. Selected graduate level responsibilities and competencies addressed through community diagnosis
Selected competency
I. A. Obtain health related data about social and
cultural environments, growth and development
factors, needs and interests
I. B. 4. Analyze social, cultural, economic and
political factors that influence health
II. A. 5. Apply principles of community organization
in planning programs
VII. Communicating health and health education
needs, concerns and resources
VII. C. 3. Demonstrate both proficiency and accuracy
in oral and written presentations
VII. D. Foster communication between health care
providers and consumers
VIII. Apply appropriate research principles and
methods in health education
VIII. B. 1. Assess the merits and limitations of
qualitative and quantitative research methods
V. B. 2. Facilitate cooperation between and among
levels of program personnel
X. C. 1. Analyze the inter-relationships among ethics,
values and behavior
population of retirees and two preceptors have
requested that CD teams focus on the elderly
within a specific geographic area.
Course content
During the fall semester, students enroll in HBHE
240, Community Diagnosis and Needs Assessment.
The objectives of the course include:
d To provide an opportunity for students to apply
the concepts, principles and methods of a CD
in a field setting.
d To develop skills in gathering, understanding
and presenting secondary data.
d To develop skills in interviewing and other
Teaching community diagnosis
Selected CD experience
Teams gather qualitative and quantitative data from secondary
sources and interviews
Students analyze many factors that impact health within the
community
HBHE students work with community members to plan a
community forum where they facilitate issue selection and future
steps for community action
Students interview members of the community and service
providers to learn about the perceptions of each group and the
assets and needs identified
Students present their findings in a community forum and in a
comprehensive CD document
CD involves both providers and consumers, and can help inform
each about the other
Community diagnosis involves both quantitative and qualitative
research in a real community setting
Students must discern the merits and limitations of each type of
data, and communicate those effectively to community members
Teams must complete peer evaluations and manage communication
and conflict between members
Students grapple with difficult issues of controversial issues,
weigh potential unintended consequences that could impact the
community, and examine the relationship between their own values
and the community
forms of field observation in community
settings.
d To establish a conceptual foundation for the
understanding of community.
d To explore issues of culture, race and class as
they impact on health education practice in
community settings.
d To explore ethical issues involved in CD.
d To establish a conceptual foundation for health
education practice in a community setting.
Readings and class activities focus on the history
of public health, the evolution of health education,
definitions of health and its determinants, defini-
tions of community, philosophical issues related to
CD, ethics, cultural sensitivity, and community
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S. Crouse Quinn
competence. The required text, Community
Organizing and Community Building for Health
(Minkler, 1997), is supplemented by selected
journal articles (for a complete reading list, please
contact the author).
Although the major emphasis of the spring
semester course is the completion of the CD, course
content extends to different types of community
interventions. Course objectives for HBHE 241,
the spring course, include learning to: analyze
qualitative data; apply concepts from health
education to the data collection and analysis;
and critically examine the conceptual foundations
of community health, interventions and their
evaluation. Class sessions address qualitative data
analysis, preparation for community forums,
community-based health promotion, community
organizing and community building, community
coalitions, Healthy Cities, community assets and
mapping, and social capital. In both semesters,
lectures, small group discussion and activities,
role plays, and other learning activities provide
opportunities to integrate learning from CD with
broader concepts.
Steps in the CD process
Table II presents a timetable for the steps of the
CD process. To prepare for assignment to teams
and communities, students complete a background
questionnaire to assess their community experi-
ence, personal characteristics, language abilities,
computer capabilities and type of community in
which they would prefer to work. The field co-
ordinator uses this information to form teams and
to match student teams to specific communities.
She considers students’ strengths and areas of
expertise in team assignments as well as their
potential compatibility with the working style of
individual preceptors.
Preceptors provide entree into the communities,
help identify resources and meet with their field
teams regularly. Teams typically meet with their
preceptors twice a month; however, the frequency
of these meetings may depend somewhat upon
the preceptor’s availability and the team’s needs.
688
These meetings offer the preceptors opportunities
to discuss team process, tasks and significant
learning; to process critical incidents; and to
anticipate relevant issues. The field coordinator
meets with preceptors 4 times each semester to
discuss the process and monitor progress of the
teams.
Most field teams are assigned geographically
defined communities such as a neighborhood or
town. Sometimes, a field team’s assignment may
be a bit more unusual. For example, one team
worked in the Chapel Hill public housing com-
munity, a non-contiguous geographic community
with housing sites spread throughout town. Public
housing sites can be considered a community and
this perspective was illustrated during the teams’
interviews when the residents talked as much about
what it means to be living in public housing as
they did about living in Chapel Hill. Recently,
teams have focused on populations within specific
geographic locales, such as Latinos in three
different counties, the elderly in two different
towns and adolescents in one local community.
Windshield tour
A first task for students is to perform a ‘windshield
tour’: students drive around their selected com-
munities, looking through their car windshields, to
familiarize themselves with the area. Many teams
walk through their community, sometimes
informally chatting with residents and visiting
shops. The purposes of the windshield tour are
to observe conditions within the community, look-
ing for verification of secondary data; to identify
local resources and activities not captured through
more formal means; and to differentiate different
segments of the population in the community by
residential clustering. During the fall, the professor
encourages students to begin attending community
events (barbecues, festivals, town meetings, etc.).
Many students begin attending local churches, a
practice they continue throughout the two
semesters.
Collection of secondary data
The fall semester begins with secondary data
collection and analysis; later in the semester, inter-
 Teaching community diagnosis

Table II. Timeline for steps and products of CD in academic year 1998–1999

August September October November December January February March April

Assignment to Begin secondary Have Interviews Interviewing Analysis of Mock forums Forums Final and
communities data collection— completed at continue; continues interview in class completed complete
and meet with continues through least one other secondary through last data begins document
preceptor both semesters community data day of class due
activity collection
Peer continues
evaluations
due
Have completed Interviews During Last day Convene Late February
at least one begin in interviews, of class: forum through mid
windshield tour October after solicit synopsis of planning March—
IRB clearance volunteers all secondary committee community
and continue for forum data due forums
through planning Peer
January committee evaluations
due
Team contract due Pick date for
forum
Draft of interview
guide due
Complete IRB
package

viewing begins and continues concurrently with
collection of secondary data. Teams initially focus
their investigation on sources such as the US
Census, LINC (Log In to North Carolina, a database
of extensive demographic information for North
Carolinians), county data books prepared by the
North Carolina State Center for Health Statistics,
newspapers and local government documents.
Increasingly, students tap the resources of state,
local and federal agencies through the Internet.
During class time, expert librarians conduct
sessions on accessing data through the US Census
and LINC, and other readings and class sessions
focus on understanding and presenting secondary
data.
The goal of this research from secondary data
sources is to understand the community’s
history, geography, socio-demographics, educa-
tion, economy, political and governmental struc-
ture, transportation, and, of course, health. Classes
and activities facilitate the development of related
competencies from the Graduate Standards such
as obtaining health-related data about social and
cultural environments, growth, and development
factors, needs and interests; analyzing social,
cultural, economic and political factors as they
impact health behaviors; inferring needs for health
education on the basis of obtained data; assessing
the merits and limitations of qualitative and
quantitative research methods and apply those
methods; and employing electronic technology for
retrieving references.
Interviewing
In the fall, teams begin conducting interviews with
community members to discover the community’s
perceived needs, its pertinent issues, strengths,
units of identity, level of community competence
and readiness to take action on shared concerns.
To prepare, several class sessions focus on
interviewing techniques and skills, developing
interview guides, and analysis of qualitative data.

689
S. Crouse Quinn
Teams prepare semi-structured interview guides
with primarily open-ended questions, and work
jointly with other teams and faculty to critique the
questions prior to their first community interviews.
Typical areas of questions include daily community
life, relationships between groups within the
community, how the community has come together
to solve problems in the past, community assets
and current concerns.
Teams typically begin their interviews with con-
tacts provided by their preceptors. Teams make an
effort to interview a wide range of people in
order to capture diverse perspectives. During each
interview, the team solicits names of other inter-
viewees (using the snowball method of sampling);
many teams have found that their ongoing parti-
cipation in church services and community centers
has provided an excellent means of recruiting
community members for interviews. There is no
set number of required interviews as the number is
dependent upon the size and type of communities.
However, it is rare that teams conduct less than
30 interviews.
Each team also interviews service providers,
which are defined broadly to include not only
health care professionals, but also town officials,
librarians, police, educational system representa-
tives, local clergy, elected officials and others. A
pair of students conduct all interviews, enabling
one to take comprehensive field notes while the
other asks questions. The interviewers tape each
session to facilitate retrieval of salient quotations
to illustrate themes. Teams also gather primary data
through focus groups, participation in community
events and informal interviews on the street.
Additionally, teams will frequently supplement
their qualitative data collection with short surveys
they design to gather close-ended data on their
communities.
The process of interviewing and establishing rela-
tionships with community members and providers
is an opportunity to practice sub-competencies from
Responsibility VI, Competency B of the Graduate
Standards: to apply networking skills to develop and
maintain consultative relationships, and to foster
690
communication between health care providers and
consumers.
The complexity of entering communities neces-
sitates several classes on developing relationships
with communities and cultural sensitivity prior
to beginning interviewing. Classroom discussion
focuses on community etiquette which includes
issues related to appropriate dress, how to address
residents, adjustments to working according to
a community’s schedule and other concerns. A
session entitled ‘Entering the Community’ explores
the assumptions students make about their com-
munities and the impact that their own social
identity (race, class, sexual orientation, religion)
may have on their interactions with community
members.
Community forums
In late January and early February, as the
interview process winds down, the teams work
with community members to plan and conduct
community forums. During the forums, teams
present their findings, facilitate discussions about
priorities and future steps, and provide an oppor-
tunity for the community to begin to organize itself
around an issue. The process of planning and
conducting the forums provides ample opportuni-
ties to build a number of competencies: apply
principles of community organization in planning
programs; organize and facilitate groups, coalitions
and partnerships; facilitate collaborative efforts
among health agencies and organizations with
mutual interests; and demonstrate proficiency in
oral presentations.
CD documents
Throughout both semesters, teams work on the
development of a document that incorporates
observations of the windshield tour, secondary data
and primary data collected through interviews,
focus groups, and other strategies. After the forum,
each team compiles the final CD document from
drafts of sections written during the fall and spring
semesters. In the document, teams integrate the
qualitative data from interviews with secondary
data, and include an examination of whether the

community perceptions and secondary data are
congruent. This document contains the following
sections: history, geography and economic profile;
socio-demographic profile; community services,
resources and assets; health; chapters according to
the major themes emerging from primary data
collection; executive summary; and conclusions
including implications for health education. Each
team gives a copy of the entire document to
its preceptor and makes a copy accessible to
community members via the town hall, library or
other designated location.
Other competencies addressed through
CD
One of the new competencies added to the Graduate
Standards is the application of ethical principles
as they relate to the practice of health education.
During the fall semester, one class focuses on the
implications and application of the Belmont Report
(US National Commission for the Protection of
Human Subjects of Biomedical and Behavioral
Research, 1978), and the Codes of Ethics from
SOPHE (SOPHE, 1983) and AAHE (AAHE, 1994)
to the conduct of CD. In addition, each team must
submit a proposal to the Institutional Review Board
(IRB) of the School of Public Health prior to any
qualitative data collection. This proposal includes
the development of informed consent procedures
and provides another opportunity to relate ethical
principles to actual practice. Throughout both
semesters, ongoing discussions on CD in class
require students to meet one sub-competency,
analyzing the inter-relationships among ethics,
values and behavior, as they grapple with issues
emerging through their experience.
Through the overall experience of CD, students
gain experience in these additional competencies:
applying appropriate research principles and
methods in health education; identifying target
populations; and estimating future health education
needs based on changing demographics.
Teamwork
Throughout the first year, students will have to
grapple with work style and personality differences
Teaching community diagnosis
among team members. This ‘team process’ is a
critical component of CD and provides opportuni-
ties to practice sub-competencies of Responsibility
V, Competency B of the Graduate Standards which
focuses on facilitating cooperation between and
among program personnel: (1) promote cooperation
and feedback among personnel and (2) apply
various methods of conflict reduction as needed.
The field coordinator takes several additional
steps to facilitate effective team functioning. At
the start of the semester, all students complete a
Myers–Briggs Type Inventory (MBTI), and
through a class presentation and readings on the
MBTI, they examine implications of personality
traits for team functioning. Early in the fall
semester, one class meeting is extended to 3 h to
accommodate exercises in which team members
work on communication exercises, discuss effec-
tive team functioning and explore personal
dynamics that impact team interaction. Students
also receive readings and handouts on conducting
productive meetings and developing effective
teams. An outside expert on conflict resolution
conducts a 4-h session on conflict and communica-
tion in early October.
Students frequently struggle with what the CD
process means to them. How important is it? What
is their commitment to the process? What does it
mean to be working in communities? How do
they resolve differing expectations and standards
among team members? Team members wrestle
with process issues because of various levels of
commitment, understanding and expectations
during an intense, stressful period of learning.
Team members must develop a team contract to
help clarify each others’ goals and expectations,
and discuss this contract with their preceptor.
The field coordinator requires that each team
meet at least once, by early November, with her
or with a teaching assistant to assess team process,
respond to specific concerns about their experience
and address questions.
Evaluation
The field coordinator grades all CD documents and
other class requirements. Additionally, preceptors
691
S. Crouse Quinn
grade the final CD document. Besides the major
documents, evaluation of student performance in
the fall class is based on two peer evaluations
and class participation. In the spring semester,
requirements include a synthesis paper which
provides students an opportunity to reflect upon
their community and integrate concepts with
experience, two peer evaluations and the com-
munity forum.
Operational details and resources
Coordination of the CD requires a major com-
mitment of time and resources. Class preparation,
contact with students outside of class, review
of lengthy documents and coordinating with
preceptors demand a large time commitment
from the field coordinator. Having one professor
who oversees the whole field component provides
continuity for students between class and field
work. The field coordinator is able to foster
positive relationships with the surrounding com-
munities and their health and social service
agencies. Additionally, a portion of the time of
the department’s financial manager and other
administrative staff is necessary for administra-
tive tasks.
Costs associated with CD are covered through
a required student fee of $600 in 1997–1998.
Additionally, the Area Health Education Center
supports travel to local communities for CD.
Fees cover the cost of maintaining four state-
owned cars and to defray other expenses
associated with the CD process including: local
and long-distance telephone use, extensive copy-
ing costs, refreshments for community meetings,
publicity and other costs related to community
forums, reimbursement for personal car use,
cassette tapes, preceptors’ travel expenses and
refreshments for their meetings, and copying/
binding documents. The departmental financial
manager oversees the financial operations; she is
supervised by the field coordinator, who sets
policies for expenditures and monitors the budget.
692
Discussion
The outcomes associated with CD fall into
several categories: preparation of proposals and
new program development; formation of new
community action groups; informing other initia-
tives; new connections within communities; and,
finally, student growth and development.
Since 1995, CD documents have been donated
to the Health Sciences Library on University of
North Carolina’s campus, where students, faculty
and staff have access to them. In addition, the
Field coordinator provides copies of documents
upon request to agencies, the local media, and
local governments. In 1998, executive summaries
of CD documents were included in SERV-NC’s
web page. Within the next year, entire documents
will be available on the department’s web site for
downloading by interested individuals.
Grants and proposals
Communities, local government, agencies and
university faculty utilize documents from CD for
the preparation of funding proposals. For
example, in one community, they utilized the CD
process to come to consensus on the need for a
recreation facility and, with the document as its
foundation, successfully applied for funding to
build a park. Following completion of the park,
the same community this year requested another
CD to help them to assess directions for future
activities. In several local counties, CD documents
have provided justification for funding of resource
centers for local Latinos. Local agencies and other
universities frequently request documents for use
in proposal preparation, and UNC faculty have
readily used them to prepare proposals for a variety
of projects.
New programs
Some CD lay the foundation for new program
development and specific needs assessments.
Following the CD in one town, the health depart-
ment conducted specific needs assessments on the
issues identified in CD. In another community,
community members identified two concerns for

elderly citizens, lack of affordable medications and
lack of nursing care. The community, working
with the local health department and other agencies,
is moving forward to develop a community nurse
position and exploring options for access to low
cost medications. Contact between providers and
community members at forums also results in
improvement of service delivery and access to
care. In one forum in a Latino community, Latino
women requested that health department clinics
put bus route information in Spanish on program
brochures. While seemingly an easy request, the
providers had never thought of this and were
readily willing to make a simple adjustment that
could have significant impact on the ability of
women to access services.
Formation of community action groups
In a number of communities, the CD has
stimulated the development of a new community
action group that proceeds to address issues raised
during the CD process. In one African-American
community, ‘Us in Action’ formed as a result of
the CD process, achieved a number of its early
goals and is currently working on two projects that
grew out of a second CD they requested. In
another community, the forum, held in a local
church, provided a safe opportunity for com-
munity members to raise passionate concerns
about housing standards with the county health
director. An ongoing group is now working to
address the housing problem in that community.
In a recent community forum for senior citizens
in a local incorporated town, the student team
facilitated a lengthy discussion of specific needs
and next steps. In attendance was a Town Council
member who explained concrete strategies the
seniors could take to access a previously un-
disclosed town budget surplus.
In 1994–1995, one team worked with the Latino
population in a small city in Chatham County. The
team believed that the Latino community would
benefit from the translation of the CD document
into Spanish which was provided to a new task
force on Latino issues that had grown out of the
community forum. The task force was composed
Teaching community diagnosis
of ‘action groups’ to tackle a number of signi-
ficant issues, including the availability of bilingual
services at the Department of Motor Vehicles.
Informing other initiatives
Community diagnosis has long been a major com-
ponent of the Department of Health Behavior and
Health Education and the School of Public Health’s
service to local communities. Student teams are
often called upon to present their findings to boards
of health or the staff of local health departments.
For example, in Chatham County, the health depart-
ment has supported CD teams for a number of
years; at the end of the year, each team makes a
formal presentation to the board of health and the
health director; this assists the board in program
planning and allocation of resources.
In recent years, a local county agency utilized
CD to inform their development of Smart Start, a
state-funded initiative to improve early childhood
education. Local Healthy Carolinians task forces
and local health departments in surrounding coun-
ties utilize CD as a means to supplement their own
data collection efforts and to assist in priority
setting. In 1998, when a local member of the US
House of Representatives formed a task force on
Latino issues, the task force requested existing CD
documents on Latino communities.
Facilitating new connections within the
community
Anecdotal reports indicate the importance of CD
as the foundation for ‘small successes’. It might
bring different factions in communities together
for the first time to work on common concerns.
In one community, African-American and Latino
activists had never met to discuss mutual concerns
until the CD team brought them together at a
meeting to plan the community forum. In another
town, several groups had informally gathered to
discuss the potential for a residential facility for
senior citizens, yet they had not been aware of one
another until the forum. Not infrequently, providers
and community members come together for the
first time at forums in which community members
feel free to express their voices.
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S. Crouse Quinn
Ongoing student involvement
Finally, students may continue to be involved in
their communities through a variety of mechanisms.
In one community, students from the CD team
volunteered throughout the summer in a summer
day camp that community residents organized as a
result of the CD. In another community, two team
members continued throughout their second year to
work with youth at the neighborhood center. Other
students chose to complete their Individual Projects,
a 200 h requirement to work on a specific interven-
tion during the summer after their first year, on
projects that address issues from the CD they have
just completed. For example, after one community
had identified lack of recreation as a major concern,
one student worked with the recreation department
to develop programs in the community center.
Student growth and development
Community diagnosis has become a cornerstone
of the Department of Health Behavior and Health
Education. Although it is frequently stressful for
those students in the midst of the experience, it
fosters respect and a commitment to community-
based assessments among students. In 1996, the
Department’s Curricula and Competencies Com-
mittee surveyed alumni from 1990 to 1996 as part
of an evaluation of the field training component
of the MPH program. The survey found that for
many students, CD provides a strong orientation
toward community involvement, the opportunity
to develop a number of skills, and to thoroughly
examine and understand public health concerns
from the community’s perspective.
Graduates working in both practice and research
settings also report that CD has helped them in
their careers. One graduate wrote:
I think the CD approach is very relevant to
health educators today. Because CD offers
students first-hand experience with comprehen-
sive needs assessments in community settings,
HBHE graduates are equipped to work in com-
munity settings and, moreover, to advocate
for working with communities. Working in a
research setting as I do, the skills I acquired
694
through the field class have proven invaluable:
problem-solving, teamwork and collaboration,
community outreach, coalition building, and the
ability to work with diverse populations.
One former student commented, ‘CD will be
always my foundation for research and inter-
ventions in communities’. Other former students
commented on specific skills they had learned,
such as ‘CD has allowed me to put theory into
practice . . . incorporate new skills in quantitative
and qualitative assessment’ and from a second
student, ‘I became more confident in my abili-
ties, especially communicating with community
members’.
The intensity of working in communities from
which the students may differ by class, race or
religion frequently stimulates personal reflection
and growth. One student saw CD as an opportunity
for enhancing her cultural sensitivity, ‘Doing a CD
in an African-American community forced me to
critically examine what I knew about cultural
sensitivity’. The combination of classroom discus-
sion and experience in the field prompted one
student to remark, ‘Until we talked about race and
culture [in class], I never really thought about
separating the two but I did experience how they
differ during CD’.
Despite the challenges of the CD experience,
many alumni appreciate its value more once they
have entered the job market. One graduate com-
mented that:
. . . the more I think back on the CD experience,
the more I realize how valuable it was, despite
the frustration at the time in actually doing it!
. . . I have used a modified process of CD in
most of my jobs since I graduated. [(DHBHE,
1996), p. 15]
A 1991 graduate noted that ‘just having [CD]
on my resume impresses employers. Having ‘local’
experience seems very valuable in this field. The
skills learned were applicable in many settings in
addition to the field’ [(DHBHE, 1996), p. 13].

Obstacles and lessons learned
Maintaining the CD process as a part of the
curriculum requires grappling with numerous
challenges. For the Department of Health
Behavior and Health Education, faculty and staff
time required by CD represent a significant fiscal
commitment. The current field coordinator is an
assistant professor in a tenure track line, and the
time commitments of CD conflict with pressures
on her for more typical activities such as seeking
external funding and publication. Certainly, these
dual expectations emphasize the crucial importance
of full departmental support that recognizes the
field coordinator’s contribution to practice and
service. While the School of Public Health has
changed its promotion and tenure guidelines to
enable faculty promotion through practice, success-
fully balancing the CD process and other require-
ments for promotion will prove to be a significant
challenge.
Since communities must be located within a
reasonable driving distance, there is a risk of
overusing and exhausting nearby counties and
communities that may also be working with other
university programs (i.e. City and Regional Plan-
ning, Social Work, Medicine, Nursing, etc.). To
address this issue, the field coordinator tracks
which communities have had a prior CD and
teams only return to a community when there is a
specific request to do so. The field coordinator
works closely with potential preceptors to deter-
mine whether there has been or is ongoing student
involvement in a community prior to the final
decision to work in that community. Additionally,
the University of North Carolina is in the process of
developing a web page and database, SERV-NC,
that will specifically facilitate faculty awareness
and collaboration on placement of students in
community settings. The field coordinator has been
an active participant in shaping that initiative.
However, the concern about potential burdens on
the community is one that the entire university
will continue to discuss as more emphasis on
community-based education occurs in a variety of
academic programs.
Teaching community diagnosis
For the students, CD demands a significant time
commitment and work on a student team, and can
increase students’ general stress level. The field
coordinator utilizes formal and informal evaluation
strategies to assess student reactions, and to insti-
tute any changes that will make the process more
manageable. Within the Department of Health
Behavior and Health Education, an ongoing tension
has been the enormous amount of student time and
energy involved in CD. Since 1995, the field
coordinator and other faculty members have made
substantial efforts to better integrate core courses,
coordinate dates of examinations and papers, and
clearly distinguish course content to avoid duplica-
tion. Informal surveys of students that assess the
amount of time they spend on their core courses
indicates some success in the past 3 years in
reducing the average amount of time. Undertaking
a CD process as a component of any curricula
requires continual examination of the impact on
that curriculum.
A potential but rare challenge occurs when teams
encounter community organizations or members
that do not want to work with them. To avoid
this possibility, the field coordinator works with
preceptors in meeting with community members
and agencies, as appropriate, prior to the start of
the CD, and asks preceptors to actively work to
engage teams and key community members very
early in the process. However, the complexity
of who speaks for a community can sometimes
create difficult situations. Recently, one community
group requested a CD team without prior consulta-
tion with the local Community Advisory Com-
mittee. That Committee, angered by a previous
researcher’s mistreatment, slowed the team’s
access to many community members. Following
extensive discussions with the preceptor, the
Community Advisory Committee, the team and
the field coordinator, it was decided that the team
should persist in its work while respecting the
Committee’s wishes about which community
members to interview; the team worked closely
with their preceptor to develop an alternative
interviewing plan. In another community near
the university, students encountered some verbal
695
S. Crouse Quinn
hostility from a very active community member
about the frequency of student research in the
community without any demonstrable change. The
students were able to respectfully and successfully
hear this concern, and built a strong relationship
with the most vocal initial opponent to the CD.
This is the context in which the CD process offers
opportunities to gain an appreciation for local
politics and the complexity of interactions with
multiple community members. The challenge of
who speaks for a community and, therefore, who
has the right to invite a team presents a learning
opportunity for the teams as they deal with turf
issues and community autonomy. However, this
also demands some flexibility from the team and
the field coordinator who may need to modify the
process to accommodate community concerns.
Implications for professional
preparation
Minkler states:
As we approach the twenty-first century, health
educators...who work at the interface of health
systems and communities face unprecedented
new challenges and opportunities. [(Minkler,
1997), p. 3]
To face these formidable responsibilities, students
must be skillful in working with communities
while fully prepared with academic skills. The
newly adopted Graduate Standards address a
breadth of competencies, propelling the profession
of health education to a new level of professional
recognition. While CD is only one component of
the department’s curricula that aims at building
competencies, the faculty of the Department of
Health Behavior and Health Education believes it
constitutes a strong experiential foundation for
development of a variety of competencies. While
teaching CD as a core of a graduate program
requires a significant commitment of resources, its
value in the preparation of health educators ready
to work in complex interactions with communities
is worthy of exploration by other professional
preparation programs.
696
Acknowledgements
I would like to acknowledge Amy Vincus, MPH,
who worked with me on the preparation of a case
study from which portions of this article have been
drawn. In addition, I wish to thank Catherine
Harbour, Allan Steckler and the reviewers for their
helpful suggestions.
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Received on February 23, 1998; accepted on September 11, 1998