17.1 Assessment Tools and Application to Practice

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.

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

Access multimedia content

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?

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.

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.

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.

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.

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.