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Population Health for Nurses

17.1 Assessment Tools and Application to Practice

Population Health for Nurses17.1 Assessment Tools and Application to Practice

Learning Outcomes

By the end of this section, you should be able to:

  • 17.1.1 Differentiate among assessment tools and data sources (primary and secondary) used to evaluate the health status of populations, communities, and systems.
  • 17.1.2 Use a wide variety of sources and methods to access public health information.
  • 17.1.3 Conduct a community needs assessment considering self-resilient capabilities of a target population to identify and prioritize problems and health concerns.

Nurses gain a broad understanding of health issues during assessment and analysis. During assessment of an individual, the nurse gathers information about a client’s health condition and includes data from primary sources (head-to-toe assessment, client interview) and secondary sources (previous medical records, health professionals, family, or friends). Comparably, assessment of populations is termed community health assessment (CHA), or community health needs assessment (CHNA). In this instance, the client is the defined population or community. Nurses and other health care professionals use a comprehensive, systematic approach to gather community health data with the primary goal of implementing programs to benefit people in an area as a whole.

A CHA provides a comprehensive picture of a community’s current health status, identifying factors contributing to higher health risks or poorer health outcomes and available community resources to improve health (Public Health Accreditation Board [PHAB], 2022). The purpose of community health assessment and a subsequent community health improvement plan is to identify a community’s key health needs and address them through strategic intervention. Systematic processes are utilized to collect data, identify and analyze community health needs and assets, prioritize those needs, and provide a foundation for decision-making to implement a plan to address unmet needs (Centers for Disease Control and Prevention [CDC], 2023).

A CHA’s timing varies depending on the community’s needs. For example, public health departments seeking or maintaining PHAB accreditation must complete a community health assessment every 5 years. Some communities choose to conduct a CHA more often due to policy mandates. For example, the Affordable Care Act (ACA) requires nonprofit hospitals to conduct a CHA every 3 years. Communities may also conduct a partial or full CHA as needed. As noted in the chapter introduction, Tia wonders how the opioid crisis impacts the local community. To understand this issue clearly, Tia can conduct a partial CHA focusing on the opioid crisis. If a larger CHA is in process or was completed recently, such as within the past year, Tia can extract the data regarding drug use and overdose.

Community Health Assessment Models, Frameworks, and Tools

CHA models, frameworks, and tools guide community assessment and community health improvement. They provide a systematic, evidence-based process for organizing the assessment team; collecting and analyzing data; and planning, implementing, and evaluating community health improvement strategies. Most assessment and planning frameworks contain common actions. According to the CDC (2023), common elements of assessment and planning frameworks include the following:

  • Organize and plan
  • Engage the community
  • Develop a goal or vision
  • Conduct community health assessment(s)
  • Prioritize health issues
  • Develop a community health improvement plan
  • Implement and monitor the community health improvement plan
  • Evaluation process and outcomes

These common actions are evident within the frequently used CHA models, frameworks, and tools described in this chapter. This section reviews the Community Health Assessment toolkit, the Mobilizing for Action through Planning and Partnerships (MAPP) framework, the Community Health Assessment aNd Group Evaluation (CHANGE) tool, the PRECEDE-PROCEED model, and the Agency for Toxic Substances and Disease Registry (ATSDR) action model.

Community Health Assessment Toolkit

The American Hospital Association (AHA) developed the Association for Community Health Improvement Community Health Assessment toolkit to help nonprofit hospitals comply with Internal Revenue Service regulations for CHAs. The toolkit consists of nine steps for conducting a CHA and developing intervention strategies (AHA, 2017).

The Community Health Assessment Toolkit identifies community engagement as a central component of the CHA process. Community engagement is the process of working collaboratively with and through groups of people to identify the health needs of community residents and strategies to address them. To engage the community, the nurse must invite community partners to participate. Community partners, also called stakeholders, are all persons, agencies, and organizations that have an investment in the community’s health and in the local public health system (National Association of County and City Health Officials [NACCHO], 2016). This includes community members who benefit from health services and those that provide health services, such as informal or formal leaders from schools, faith-based organizations, businesses, social clubs, health care, transportation, and government. Community members may decide to establish a partnership, a relationship characterized by mutual cooperation and responsibilities among individuals and groups (Figure 17.2) (NACCHO, 2016). Partnerships may expand into coalition building. A coalition is a group of people and organizations that work to address community needs and solve community problems (PHAB, 2022). Planning Health Promotion and Disease Prevention Interventions further describes partnerships and coalitions.

A large group of people sit in chairs and stand against the wall in a conference room. Three people wearing suits sit at a table at the front of the room, and a fourth person wearing a suit  stands beside them, addressing the crowd.
Figure 17.2 Community partnerships include community members who benefit from health services and those that provide health services, such as seen in this town meeting at a health center in Maryland. (credit: “Zeta Center for Health and Active Aging Town Meeting” by James W. Brown/Flickr, CC BY 2.0)

Community engagement strengthens the CHA by including diverse perspectives; increasing collaboration and stronger partnerships; sharing a sense of ownership and resources; and improving communication among individuals from the community, community partner organizations, and hospitals. The Community Health Assessment toolkit enhances community engagement by establishing committees that collaborate at each step. Users of this toolkit sequentially follow the nine steps described in Table 17.1.

Community Health Assessment
Toolkit Steps
Actions
Step 1: Reflect and Strategize
  • Review the previous CHA.
  • Identify leadership.
  • Create the assessment team.
  • Identify and procure resources, including budget planning.
Step 2: Identify and Engage Community Partners
  • Connect with community partners from various sectors to ensure diverse perspectives.
  • Identify community members from populations that have increased risk for health disparities.
Step 3: Define the Community
  • Describe the geographic community.
  • Identify community groups, including populations of interest, such as underserved populations.
Step 4: Collect and Analyze Data
  • Collect quantitative and qualitative data to comprehensively describe community indicators and factors that impact health.
  • Attain an overall picture of community health status and highlight the needs of populations within the community, such as populations that experience health inequities.
  • Analyze data.
Step 5: Prioritize Community Health Issues
  • Prioritize community health needs based on severity and magnitude, the community’s capacity to act, the availability of resources, and the needs of vulnerable populations.
Step 6: Document and Communicate Results
  • Communicate results of the CHA and convey priorities to community members and identified partners.
Step 7: Plan Implementation Strategies
  • Develop evidence-based, far-reaching strategies that utilize strategic partnerships and available resources to target identified health priorities and populations.
  • Set goals and objectives of the community health improvement plan.
Step 8: Implement Strategies
  • Develop an action plan that details specific activities, accountability, and timelines to guide implementation.
  • Put planned strategies into action.
  • Modify programs and activities, if needed, to address logistical, community partner, and budgetary concerns.
Step 9: Evaluate Progress
  • Evaluate goals, objectives, and strategies.
  • Begin the CHA process again.
  • Compare current data to previous data and determine whether the implemented strategies worked to improve community health outcomes.
Table 17.1 Steps in the Community Health Assessment Toolkit

Theory in Action

Community Health Needs Assessment

Conducting community health assessment through collaborative partnerships can positively impact the overall process. This video features key team members from two competing health systems and Penn State Hershey, an academic medical center, who participated in a Community Health Needs Assessment in Pennsylvania.

Watch the video, and then respond to the following questions.

  1. Why is it important to conduct a CHNA?
  2. What are the benefits of establishing collaborative partnerships to conduct a CHNA?
  3. What are the goals of a CHNA according to the speakers in the video?

Mobilizing for Action through Planning and Partnerships

Public health leaders can use the Mobilizing for Action through Planning and Partnerships (MAPP) framework for local-level community health improvement planning. The MAPP framework is community-driven and facilitates prioritizing public health issues and identifying resources to address them (NACCHO, 2023). MAPP emphasizes community engagement and collaboration for system-level planning. Originally consisting of six steps, the framework is undergoing redesign (NACCHO, 2020). The redesign includes the foundational principles of equity, inclusion, trusted relationships, community power, strategic collaborations, data-informed action, flexibility, and continuous improvement. The revised MAPP, shown in Table 17.2, provides a streamlined approach to community health assessment and community improvement and directs the nurse and program team through three phases consisting of multiple activities (NACCHO, 2023).

Phases Activities Completed
1 Build the Community Health
Improvement (CHI) Infrastructure
  • Establish CHI leadership and administrative structures.
  • Strengthen community and partnership engagement.
  • Assess and improve CHI infrastructure, processes, and outcomes.
2 Tell the Community Story
  • Perform Community Status Assessment.
  • Perform Community Context Assessment.
  • Perform Community Partners Assessment.
3 Continuously Improve the Community
  • Identify CHIP priorities, strategies, and actions.
  • Complete power analyses and partner profiles.
  • Conduct joint implementation of CHIP.
  • Engage in continuous quality improvement.
Table 17.2 The Revised MAPP Phases

Community Health Assessment aNd Group Evaluation

The CDC developed the Community Health Assessment and Group Evaluation (CHANGE) tool for community members who desire to improve their community’s health (CDC, 2010). CHANGE focuses on gathering and organizing data on community assets and potential areas for improvement to prioritize needs for multilevel changes in policies, systems, and the environment. An Action Guide with worksheets and templates assists community members through the eight action steps within the CHANGE tool (see Table 17.3).

The CHANGE tool divides the community into five sectors: community-at-large, community institution/organization, health care, school, and work site. The community-at-large sector includes the social and built community environments, such as safety, food access, and policies that affect health. The community institution/organization sector includes human services and facility access, such as the YMCA, senior centers, faith-based organizations, childcare, and colleges and universities. The health care sector includes emergency services, clinics, hospitals, and provider offices. The school sector includes primary and secondary learning institutions. The work site sector includes places of employment.

CHANGE Tool Action Step Actions Taken
1: Assemble the Community Team
  • Recruit team members from diverse sectors of the community.
  • Include key community decision makers.
  • Ideally, have no more than 10 to 12 total members.
2: Develop Team Strategy
  • Determine how the team will collect data and complete the CHANGE tool; for example, the team may decide to divide into subgroups.
  • Determine decision-making strategies, such as by majority vote or unanimous vote.
3: Review All Five Change Sectors
  • Develop an understanding of the big picture.
  • Review the five sectors (by subgroups if that was decided in Action Step 2).
4: Gather Data
  • Gather data from each sector using multiple data collection methods (the CHANGE tool describes suggested methods).
  • Gather data from multiple sites (ideally 13 or more) within each sector.
5: Review Data Gathered
  • Review data collected as a team.
  • Rate data following the CHANGE tool parameters, which includes the team coming to a consensus rating that will be used to evaluate improvement.
6: Enter Data
  • Designate one team member to input data, including data collected, ratings, and team member comments.
7: Review Consolidated Data
  • Summarize findings.
  • Determine areas for improvement.
  • Develop a Community Action Plan.
8: Build the Community Action Plan
  • Create project and annual objectives.
  • Plan for activities to meet those objectives.
  • Evaluate the Community Action Plan annually and upon project completion.
Table 17.3 CHANGE Tool Action Steps

PRECEDE-PROCEED Model

The Green and Kreuter PRECEDE-PROCEED model uses a social-ecological, population-level approach to guide health promotion strategies. This model considers the impact of the social determinants of health (SDOH) and the community environment on the target population’s quality of life and needs (Porter, 2016). Members of the target population participate throughout each phase of the model.

PRECEDE stands for Predisposing, Reinforcing, Enabling Constructs in Educational/Environmental Diagnoses and Evaluations. The PRECEDE process occurs before implementation of an intervention and includes the following four phases:

  1. Define the outcome: Social and situational assessment of what the community wants and needs. Includes data collection and assessment.
  2. Identify the issue: Select the most important issue that can be influenced by an intervention. Includes analysis and prioritization.
  3. Examine factors that influence behavior, lifestyle, and responses to environment: This includes analysis of predisposing, enabling, and reinforcing factors that influence health promotion. See Health Promotion and Disease Prevention Strategies for further explanation of each factor.
  4. Identify best practices for intervention and organizational issues that could have an impact: Design an action plan.

PROCEED stands for Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development. The four phases of PROCEED guide the implementation of the intervention itself. PROCEED is discussed further in Planning Health Promotion and Disease Prevention Interventions as a model used for programming planning, implementation, and evaluation.

Agency for Toxic Substances and Disease Registry Action Model

The Agency for Toxic Substances and Disease Registry (ATSDR) (2023) developed an Action Model for community members to identify community problems and create a plan to improve the community through redevelopment (see Figure 17.3). Redevelopment consists of making changes to an area to impact health outcomes, such as repairing sidewalks and buildings, removing harmful environmental exposures, or building a playground. For example, a community with increased adolescent obesity rates decides to redevelop a park to provide areas for exercise. They add basketball and tennis courts, walking trails, and outdoor exercise equipment to the park.

The four steps of the ATSDR are: Step 1: What are the issues in the community?; Step 2: How can development address these issues?: Step 3: What are the corresponding community health benefits?; Step 4: What data are needed to measure change?
Figure 17.3 Community members can work through the four steps of the ATSDR Action Model to identify community problems and create a plan to improve the community through redevelopment. (credit: modification of work “The Action Model is built around four steps or questions” by Agency for Toxic Substances and Disease Registry/U.S. Department of Health and Human Services, Public Domain; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Before working through the Action Model, a team of community members who are interested in the identified issue or are impacted by the issue will play a role in redevelopment plans. A toolkit is available to walk community members through building a team and Action Model steps.

Primary and Secondary Data Sources

A CHA consists of data and information from multiple sources. Required data includes information about the community’s demographics, health status, morbidity and mortality rates, socioeconomic characteristics, quality of life, community resources, behavioral factors, environment, and other social and structural determinants of health (PHAB, 2022). A comprehensive CHA needs a variety of primary and secondary data sources to gather information. In fact, PHAB requires public health departments to use primary and secondary data sources and include both quantitative and qualitative measures. Quantitative data are expressed by amounts in numerical terms. Qualitative data are expressed in word form, cannot be quantified, and describe perspectives of individuals and populations. CHA data and indicators should be valid, reliable, feasible, meaningful, and collected over time.

An assessor collects primary data directly from community members. PHAB considers primary data to be data for which collection is conducted, contracted, or overseen by the health department (PHAB, 2022). Collecting primary data can be time- and resource-intensive. Table 17.4 describes common primary data sources.

Primary Data Source Description
Participant observation
  • Purposeful sharing of life in a community, noting details about the people and environment
  • Includes attendance at local events
  • This type of data is qualitative.
Interview key informants
  • Interview people viewed as local leaders in the community.
  • Leaders may not have a formal title or position and may include individuals from businesses, organizations, social clubs, religious congregations, civic clubs, or government.
  • This type of data is qualitative.
Forum or town hall meeting
  • Community members congregate to discuss a particular issue or proposal that influences all community members.
  • This may include discussions regarding health policy or infrastructure.
  • This type of data is qualitative.
Focus group
  • Small groups of individuals (8 to 10 per group) are interviewed using mostly open-ended questions.
  • Interactions between participants may prompt discussion or generate ideas.
  • This is most often used to reach community members who may not be heard from in other ways.
  • This type of data is qualitative.
Photovoice
  • Community members take photos to represent a topic or theme about the community. The photos convey visual messages about community strengths and concerns, adding depth to the CHA.
  • This is useful when working with groups that may be marginalized or have little power.
  • This type of data is qualitative.
Survey
  • Standardized questionnaire via mail, telephone, face-to-face, or electronic
  • Usually developed through collaboration among multiple community partners
  • This type of data is quantitative and qualitative depending upon survey questions.
Windshield survey
  • Simple observation while driving or walking through a community
  • Notes common characteristics of people, housing quality, services, and geographic boundaries
  • This type of data is qualitative.
Table 17.4 Primary Data Sources Used in Community Health Assessment

Secondary data are obtained through an existing report on the community originally collected by another entity or for a purpose other than CHA. Secondary data are usually readily available and may be inexpensive for the assessor. Secondary sources include census data, vital statistics, health indicators, health profiles, and spatial data. Vital statistics are population data about births, deaths, marriages, and divorces. Health indicators are numerical measures of health outcomes, such as morbidity and mortality, that have been analyzed and are used to compare rates or trends of priority community health outcomes and determinants of health. They are usually attained through secondary data sources. Health indicators provide a snapshot of community health outcomes and allow for benchmarking. A benchmark is a standard or point of reference against which measurements can be compared.

Sources and Methods to Access Public Health Information

A comprehensive CHA contains public health data from various sources displayed in ways to identify trends and patterns. Public health information is also used to compare local data to state and national data, which can be used for benchmarking and to trend data to evaluate progress.

Spatial Data

One method to identify trends and patterns is using spatial data, which identifies the geographic location of phenomena. Spatial data provide an overview of the whole community in map form and facilitate comparing one part of the community to another. This is an important tool to use when conducting a CHA because geographic location can affect access to resources and exposure to health threats. Major differences in health outcomes, especially in mortality rates, have been found even between locations within 5 to 10 miles of each other (Couillard et al., 2021; Hollar, 2016; Pedigo et al., 2011).

The Roots of Health Inequities

Where You Live Matters!

A person’s geographical location influences their access to healthy foods, education, jobs, safe housing and neighborhoods, facilities that promote health, and health care resources. Individuals living in neighborhoods with greater economic resources have healthier lifestyles. By identifying locations where health disparities exist, even in the same community, nurses can recognize populations at risk for negative health outcomes. Additionally, spatial data helps identify the SDOH within a location that contribute to negative health outcomes. For example, a nurse finds that higher rates of tuberculosis occur in one community area. The nurse uses spatial data to locate the geographical area of tuberculosis diagnoses and assesses potential environmental factors that influence TB’s spread, such as housing and living conditions. The nurse prioritizes interventions by focusing on improving living conditions in the area.

This American Heart Association video explains why a person’s zip code may be more important than their genetic code.

Watch the video, and then respond to the following questions.

  1. Consider your community. What areas or locations might you compare using spatial data to clarify whether inequities exist?
  2. How does location relate to social determinants of health and other environmental factors that impact health?

Geographic information systems (GIS) are software and technology that can store, visualize, analyze, and interpret spatial data (CDC, 2019a). The software creates maps electronically using primary or secondary data to determine how location impacts disease and disability. Any data that can be mapped can be used and compared by location. This helps locate areas of communities where high rates of health problems occur.

Nurses and other health care professionals can use GIS maps to identify areas within a community—such as those with higher rates of opioid overdoses, for example—to target them for intervention. Additionally, it is possible to analyze the environment in that location for potential determinants of health that lead to increased opioid use and overdose. GIS tools and examples can be found on the CDC’s website.

Using GIS to Predict Outbreaks

This Queens University video describes how researchers are using GIS to create interactive maps to track information about a range of topics, such as population movement and infection rates of emerging diseases.

Watch the video, and then respond to the following questions.

  1. How can maps be used in community health assessment to determine health patterns?
  2. How were GIS and other assessment data used to predict the spread of COVID-19?
  3. How can GIS data be used to plan for intervention within a community?

Secondary Data Sources

Public health information sources provide data on local, state, and federal health indicators. During the CHA, the team can use these secondary sources to compare local health data to other municipalities, state, and federal health data for benchmarking. All are quantitative data sources. Table 17.5 describes frequently used secondary data sources and methods to access public health information.

Secondary Data Source Description
Behavioral Risk Factor Surveillance Survey (BRFSS)
https://www.cdc.gov/brfss/data_tools.htm
  • Survey data are collected by telephone in 50 states, the District of Columbia, and three U.S. territories.
  • Data include demographic characteristics, health conditions, and current health behaviors.
  • Tools on the site allow users to attain state or national prevalence and trend data by health topic and compare two or more geographic areas by health indicator.
Population-Level Analysis and Community Estimates (PLACES)
https://www.cdc.gov/places/
  • This site reports U.S. data at multiple local area levels (county, place, census tract, and zip code) on health risk behaviors, health outcomes, health status, and prevention practices.
  • Tools on the site allow users to attain data by location and health measures and compare up to three geographic areas by health measures. Interactive maps are also available.
CDC Wide-Ranging Online Data for Epidemiologic Research (WONDER)
https://wonder.cdc.gov/
  • This site integrates public health information data sets and any statistical research data published by the CDC.
  • Tools on the site allow users to retrieve information on mortality, common disease and disability, communicable disease, vaccinations, births, environmental and occupational health, injury prevention, and health practices. Information can be viewed at national, state, and sometimes county levels.
National Center for Health Statistics: FastStats
https://www.cdc.gov/nchs/fastats/default.htm
  • This site provides national statistics on multiple health topics in the United States.
  • Topics include several diseases and conditions, infectious disease, family life, health care and insurance, disability and risk factors, injuries, life stages and populations, and reproductive health.
U.S. Census
https://www.census.gov/ https://data.census.gov/
  • These sites report U.S. data by different geographies (national, states, counties, places, tribal areas, zip codes, and congressional districts) on topics such as population, education, housing, employment, health, business and economy, families and living arrangements, poverty, and emergency management.
  • Data can be produced in table or map format. Detailed instructions are available to assist with data retrieval.
Healthy People 2030
https://health.gov/healthypeople
  • Provides national data on 359 national objectives to improve health and well-being
  • Can be used to compare local data to national data and objectives
County Health Rankings
https://www.countyhealthrankings.org/
  • Ranks (using the County Health Rankings Model) are provided at the county level using health outcomes and health factors attained from other entities. State and national values are provided for comparison.
  • Length of life, quality of life, health behaviors, clinical care, social and economic factors, and physical environment data are available.
State Cancer Profile
https://statecancerprofiles.cancer.gov/
  • This site reports cancer data at the state level. Data include demographics, screening and risk factors, incidence, and mortality on 20+ cancer sites.
  • National data are provided for comparison.
  • Data are provided in statistic, chart, and map formats.
State Health Access Data Assistance Center
https://www.shadac.org/
  • Provides state-level data on health insurance, cost of care, health care access and utilization, health behaviors and outcomes, and affordability of care
  • Includes national data for comparison
State Health Assessment
See state public health department websites for state health assessments.
  • Provides CHA data gathered at the state level
  • Can be used to compare local data to state data or to compare state to state
Tribal Health Assessment
See tribal health department websites for tribal health assessments.
  • Provides CHA data gathered at the tribal level
  • Can be used to compare local tribal data to previous local data, other tribal health data, or state or national data
Local Health Assessment
See local health department websites for local community health assessments.
  • Provides CHA data gathered at the local level
  • Can be used to compare local data to previous local data, similar counties/communities, state, or national data
Table 17.5 Secondary Data Sources to Enhance a Community Health Assessment

Healthy People 2030

Reduce Drug Overdose Deaths

Drug overdose deaths are one common health indicator measured within a CHA and are considered a national emergency. As such, a leading health indicator of Healthy People 2030 within Drug and Alcohol Use objectives is reducing drug overdose deaths. The target goal for this health indicator is 20.7 drug overdose deaths per 100,000 people, which was the baseline measure in 2018. In 2020, 28.3 drug overdose deaths per 100,000 individuals occurred; in 2021, 32.4 drug overdose deaths per 100,000 individuals occurred.

At this time, the 2020 and 2021 data signify that drug overdose deaths have increased in the United States. This aligns with the public health emergency declaration for the opioid crisis.

Conducting a Community Health Needs Assessment

The first steps of conducting a CHA, no matter the framework, model, or tool chosen as a guide, are planning, engaging the community, and recruiting the assistance of key community partners. After creating the team and determining team roles, the next step is defining the community and the data collection process.

A community may be defined by geography or place of residence, shared characteristics or demographics, or common interests. PHAB (2022) defines a community as a group of people with common characteristics; this can be defined by location, race, ethnicity, age, occupation, interest in particular problems or outcomes, or other common bonds. The definition of the community may change depending upon the context. For a CHA, the community should be defined by people, place or environment, and community systems. Table 17.6 clarifies data that fall under each category.

Category Data Included
People:
  • Who are the people within the community?
  • Demographics and vital statistics (size and density of population, age, gender, race, ethnicity, income, education level, household makeup)
  • Health indicators and health behaviors
  • Morbidity and mortality patterns (leading causes of death and disability)
  • Values and beliefs
Place:
  • Where is the community?
  • What is the physical environment?
  • Geographical boundaries
  • Distance and relation to other communities
  • Community size
  • Historical information
  • Physical environment (water quality, indoor and outdoor air quality, climate, pollution)
Community systems:
  • What services and resources are available?
  • Safety (crime, police, fire, EMS, sanitation, laws)
  • Transportation
  • Politics and government (government buy-in and focus on health)
  • Educational opportunities (all levels)
  • Recreation (safe indoor and outdoor areas)
  • Economics (existing jobs, unemployment, types of industry)
  • Businesses and services
  • Communication (phone, radio, internet, TV, media)
  • Religious or spiritual organizations
  • Social clubs (civic clubs, neighborhood associations)
  • Availability of healthy foods
  • Built environment (housing, sidewalks, roads)
  • Emergency disaster planning
  • Aesthetics (art, music, culture)
  • Health and social services (health care providers, hospitals, hospice, emergency care, mental health care, specialty services)
Table 17.6 People, Place, and Community Systems Used to Define Community Within a CHA

Data gathering is required to assist with defining the community. A rich CHA and definition of the community contain both quantitative and qualitative data, and PHAB requires a CHA to show evidence of both (PHAB, 2022). To provide a comprehensive picture of the community, the CHA should include several primary and secondary data collection methods to define the community. Refer to Table 17.4 for potential primary data sources and Table 17.5 for potential secondary data sources. Primary data sources may include qualitative data, quantitative data, or both. Secondary data sources are quantitative in nature.

The community health nurse focuses on data regarding areas of need. This includes mortality, morbidity, and other health outcome data, such as SDOH. A comprehensive review of access to education, healthy nutrition, transportation, healthy spaces, resources for exercise, health care services, economic opportunities, a healthy environment, and employment provides perspective on potential causes of negative health outcomes and areas for improvement.

The community health nurse should not focus only on data regarding areas of need, but on areas of strength and potential resources as well. The values and beliefs of the community, available resources, and current and potential funding are considered. Community values and beliefs are important to ensure community buy-in when programs are implemented to target an identified area of concern. Although statistical health data may indicate poor outcomes in one area, other health-related areas may be of greater concern and importance to community members. Evaluation of the adequacy of community systems should also occur. One method to assess the extent to which community agencies successfully provide support is the seven As (Truglio-Londrigan & Gallager, 2003):

  • Awareness: Community members are aware that a service is needed and know where to attain that service.
  • Access: Community members can contact the agency, can navigate the agency’s technology, and have no limitations in getting to the service.
  • Availability: Service is offered at a time, location, and place that is convenient for community members.
  • Affordability: Community members are able to pay for the service.
  • Acceptability: Community members perceive that the service is meeting their needs.
  • Appropriateness: Community members believe the service is suitable.
  • Adequacy: Service is provided in sufficient quantity or degree.

Assigned individuals or groups within the CHA team carry out the work of data collection. Most often, the local public health department or health care system provides team leadership. Some CHA teams may decide to hire outside professionals to conduct the work of data collection and subsequent work writing in collaboration with the CHA team.

Most CHAs include surveys mailed to randomly selected community members. The team creates surveys in collaboration with various community partners and organizations that provide care to community members. Most often, these individuals and organizations have information that they need to determine if the care and programs they provide are still needed and effective. For example, a representative from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) may be a part of the CHA team and ask that data regarding breastfeeding is collected. This ensures that the data collected is not only useful to the public health department, but to community partners as well.

Key interviews or focus groups add important qualitative information regarding the values and beliefs of the community. Examples of questions that may be asked to determine the values, beliefs, and concerns of community members include the following:

  • What do you consider to be the major health concerns of the community?
  • What do you consider to be the least important health issues of the community?
  • What are some of the current efforts to address health concerns of the community?
  • What do you consider to be strengths of the community?
  • What do you consider to be challenges of the community?
  • What do you consider to be needs of community members that are not being addressed?
  • In your opinion, why are those needs not being addressed?

Youth data may be difficult to collect. School-age children complete multiple required assessments per year, which takes away from instruction. Additionally, parents must provide permission for assessment, which is not always granted. Often youth data are derived from either data collected by other agencies or organizations or by surveys completed by school-age youth enrolled in local schools. For example, the Ohio Healthy Youth Environment Survey (OHYES!) is a free survey schools can use to collect data from students in grades 7 to 12 (Ohio Department of Health, 2023). It includes questions about health, safety, and behavior health factors.

Data collection ends when all planned assessment tasks are conducted and the data represent a comprehensive view of the community. The data are collated into a final written report and presented by topic. Most often, the CHA report contains topic areas such as health care access, adult health behaviors, chronic disease, social conditions, youth health, and demographics. The data are presented in written format, tables, graphs, and images to highlight areas of strength and concern. Examples of current CHA reports can be found on most public health department or health care system websites.

Unfolding Case Study

Part A: Conducting a CHA

Read the scenario, and then answer the questions that follow.

After contacting community members, Tia joined an assessment team with the goal of implementing interventions to combat the opioid crisis. The team chose the PRECEDE-PROCEED model to guide its assessment and planning for intervention. During the first phase, social assessment, data regarding community needs and desires are collected. The team found that community members are concerned about the current opioid crisis and would like to reduce substance misuse and overdose death rates. During the second phase, epidemiological assessment, the team gathers data from primary and secondary sources and considers behavioral and environmental factors contributing to the opioid crisis. During the third phase, educational and ecological diagnosis, the team identifies predisposing, enabling, and reinforcing factors of the opioid crisis.

1.
The team plans to gather qualitative information from key community partners regarding the opioid crisis during the first step. Which of the following data collection strategies would be appropriate?
  1. Collecting survey responses from community members
  2. Using GIS to map incidences of opioid overdose deaths
  3. Gathering local overdose statistics to compare to national data
  4. Conducting a focus group with local emergency responders
2.
Which of the following would be categorized as an enabling factor for addressing opioid misuse?
  1. A drug rehabilitation center is located within the community.
  2. Local media promotes community naloxone training.
  3. High school students gain knowledge of the consequences of opioid misuse.
  4. A cycle of drug misuse is linked to specific families in the community.
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