Conducting a community health needs assessment in a rural Arizona town with an extremely diverse population has been, unsurprisingly, a challenge. It has also been an incredible experience and one in which I have learned about not only health issues but also the process of doing fieldwork and the importance of adapting to circumstances. Living in Winslow, Arizona, observing the place and the people in it, finding respondents willing to discuss health care, and conducting interviews have all had their challenges. They have been both academically and personally difficult and have pushed me to see different points of view, to communicate more effectively, to understand people in circumstances very unlike my own, and occasionally to accept things that are out of my control. After listening to professors lecture about how messy work in the field can be, I feel like I finally have an understanding of what that means.

After ten weeks of data collection, the picture that I have of health care in Winslow is a complex and multifaceted one. There are huge challenges faced by a rural hospital in administering quality care. The  community lacks resources to support health beyond the hospital. The service population is spread out. Many of the people in it are of low socioeconomic status and have difficulty affording care or even finding the necessary transportation to make a hospital visit. The population is highly diverse with many cultural aspects that affect how care can and should be administered.  It is difficult to find health care professionals willing to live and work in such a remote place. This is not an exhaustive list, but one that I hope demonstrates the hardships faced by both the community and the hospital.

This bigger picture of the difficulties of providing and receiving care is made up of individual stories that took great effort to collect. Obviously it is important to draw conclusions based on the interview data. Hopefully these conclusions can then be useful to the hospital and community in making goals and allocating resources. But I also think it is important to remember that there are individuals behind these generalizations. I spoke to people who had lost limbs due to complications of diabetes. I spoke to people who had lost loved ones, sometimes to highly preventable conditions. Individuals had a great impact on me in the course of this project, and I left Winslow with the very acute sense that I was leaving behind people who still have to deal with extremely serious health and health care issues everyday. My study may be over, but the hardships of an underserved community and an overworked hospital are not. This perspective is one of the most significant things I took away from this experience. I am very grateful to be back home where the places are familiar, where the people are known to me, and where I know what to expect. After my experiences over the summer, however, things don’t look precisely the same because, at the risk of sounding very cliche, I’m different than I was when I left.

The last part of my project was undoubtedly the most difficult. Interviewing members of the community about health and health services presented a number of challenges. The first of these was recruitment. It was extremely hard to find people willing to talk to me. Initially, my project called for application of a block sampling method, which would require that I delineate neighborhoods, pick houses with a random frame, and go door to door. It did not take me long to realize that there were definitely some areas of Winslow in which it was unwise for me to go door to door by myself. When I attempted block sampling in other areas of town, it proved largely fruitless. People were not at all receptive to answering my questions. I found that the community was very tight-knit and suspicious of strangers, which was not entirely surprising in a town so small. In order to gain information despite this, I used organizations such as local churches and clubs to help find people to interview. This introduced a selection bias as the sample was no longer random, but I judged that it was better to collect data with an acknowledged bias than to collect no data at all.

Unfortunately there were additional impediments to attaining a truly representative sample. Winslow has an extremely diverse population which was not as well represented in the research as I would have liked. One issue was a language barrier. There is a non-English speaking population which I lacked the skills to communicate with. I considered trying to find an interpreter, but I felt that I had not spent enough time in the community to sufficiently understand the relationships among people and, therefore, to understand the potential impact of asking one person to help me collect private information from others. I also had particular difficulty in penetrating the Native American community. Although a significant percentage of the population is Navajo, I only managed to recruit a handful of respondents from among them. Ultimately, the majority of respondents that I was able to recruit were white females. While I still gained valuable insight from them, there were definitely perspectives on community health that I missed in my sampling.

Another difficulty in undertaking the community interview process was in getting informed consent from people. Most were already suspicious of me and my project, and asking them to sign an informed consent form, even after explaining its content and purpose, was challenging. Also because there are issues of illiteracy in the population giving people a form to sign does not always help put them at ease or guarantee that you are effectively communicating your intentions.

Even with respondents recruited and consent obtained, I had more difficulty in the actual administration of the interviews to community members than in the previous interviews with medical personnel. The reason for this was at least somewhat related to education. I was admittedly more comfortable around hospital staff and found it easier to communicate with them in part because of our similarities in regards to education. When I went out into the community, I found it a lot more difficult to talk to people and to make myself understood. This also made our interaction less comfortable despite my efforts. My questions sounded like something written by a college student, which was not an issue when interviewing doctors but became more problematic in the community at large. I do not want these remarks to be interpreted as disparaging as that is certainly not my intention. I only want to communicate honestly that I had difficulty in relating to the people of Winslow because our life experiences were so different.

Despite these complications, I did manage to collect valuable data about community health needs. By this point I felt that I had learned a huge amount about health care and gained many perspectives, although it also seemed to me that the more I discovered from talking to people the more I realized how much there was to discover. Ten weeks gave me insight, but I got the sense that I could stay for ten more and still be finding out new and interesting things. However, with the end of summer rapidly approaching, I set out for Virginia while working at the mental task of absorbing and appreciating everything I had learned.

After gaining some degree of general understanding about the community and health care providers in Winslow, I spent the next few weeks scheduling and performing face to face, structured interviews with employees of the local medical service providers. Ultimately, the goal of a health needs assessment is to develop a clear picture of how health care addresses or fails to address the needs of the community in order to make suggestions for positive change. To do this, it is necessary to explore the experiences and perceptions of those working to administer health care. I quickly realized that this is often easier said than done, however.

In all the time I spent planning and, to be honest, obsessively worrying about this project before I started, it actually never occurred to me to worry about some of the more basic logistical issues like scheduling. I had assumed that that would be one of the easier parts. I found out quickly that my assumption was very incorrect. In order to eliminate selection bias, I picked respondents based on a random sample. This left me with a list of names and contact information and a few weeks to do interviews. It took me almost a week just to make contact with most of the people on the list and find times to meet with them. It was not only difficult because so many medical personnel are so busy but also because they often work unusual shifts. I ended up conducting several interviews at around three o’clock in the morning during the night shift. An additional difficulty that I faced was one of willingness. I had to be persuasive in some cases to convince people to talk to me, and despite my best efforts at describing the goals of the project some people still refused.

Once I lined up willing participants, I began interviewing in earnest. I gained a lot of interesting insight from the process itself. Although I put considerable thought into wording and order when drafting my questions, I still found myself having to constantly refine and clarify them. People had a huge range of responses both to the questions and to the interview itself. While I tried to deliver each interview in the same way, I found that some respondents were simply more helpful than others. Some said the bare minimum and some had a lot of information to share. I tried to do my best to make each interview a quality experience, but it also struck me that sometimes it was at least somewhat out of my control and dependent upon the other person. This aspect of field work, that it is to some degree out of the researcher’s control, made for an experience that was both interesting and nerve-wracking.

The weeks spent conducting medical personnel interviews yielded a lot of information on how the providers of health care perceive the community and its needs. Integrating the information was a challenge because respondents had so many different answers and opinions, all of which I then attempted to fit into the framework of my own observations. This framework would again develop and change during the following weeks when I undertook the great challenge of interviewing respondents from the larger community.