17.1: Assessment Tools and Application to Practice
By the end of this section, you should be able to:
- Differentiate among assessment tools and data sources (primary and secondary) used to evaluate the health status of populations, communities, and systems.
- Use a wide variety of sources and methods to access public health information.
- 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.
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.
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Community Health Assessment
Toolkit Steps |
Actions |
|---|---|
| Step 1: Reflect and Strategize |
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| Step 2: Identify and Engage Community Partners |
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| Step 3: Define the Community |
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| Step 4: Collect and Analyze Data |
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| Step 5: Prioritize Community Health Issues |
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| Step 6: Document and Communicate Results |
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| Step 7: Plan Implementation Strategies |
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| Step 8: Implement Strategies |
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| Step 9: Evaluate Progress |
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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.
- Why is it important to conduct a CHNA?
- What are the benefits of establishing collaborative partnerships to conduct a CHNA?
- 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 |
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| 2 | Tell the Community Story |
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| 3 | Continuously Improve the Community |
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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 |
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| 2: Develop Team Strategy |
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| 3: Review All Five Change Sectors |
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| 4: Gather Data |
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| 5: Review Data Gathered |
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| 6: Enter Data |
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| 7: Review Consolidated Data |
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| 8: Build the Community Action Plan |
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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:
- Define the outcome: Social and situational assessment of what the community wants and needs. Includes data collection and assessment.
- Identify the issue: Select the most important issue that can be influenced by an intervention. Includes analysis and prioritization.
- 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.
- 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.
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 |
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| Interview key informants |
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| Forum or town hall meeting |
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| Focus group |
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| Photovoice |
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| Survey |
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| Windshield survey |
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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).
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.
- Consider your community. What areas or locations might you compare using spatial data to clarify whether inequities exist?
- 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.
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.
- How can maps be used in community health assessment to determine health patterns?
- How were GIS and other assessment data used to predict the spread of COVID-19?
- 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 |
|
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Population-Level Analysis and Community Estimates
(PLACES)
https://www.cdc.gov/places/ |
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CDC Wide-Ranging Online Data for Epidemiologic Research
(WONDER)
https://wonder.cdc.gov/ |
|
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National Center for Health Statistics: FastStats
https://www.cdc.gov/nchs/fastats/default.htm |
|
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U.S. Census
https://www.census.gov/ https://data.census.gov/ |
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Healthy People 2030
https://health.gov/healthypeople |
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County Health Rankings
https://www.countyhealthrankings.org/ |
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State Cancer Profile
https://statecancerprofiles.cancer.gov/ |
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State Health Access Data Assistance Center
https://www.shadac.org/ |
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State Health Assessment
See state public health department websites for state health assessments. |
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Tribal Health Assessment
See tribal health department websites for tribal health assessments. |
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Local Health Assessment
See local health department websites for local community health assessments. |
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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:
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Place:
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Community systems:
|
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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.
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?
- Collecting survey responses from community members
- Using GIS to map incidences of opioid overdose deaths
- Gathering local overdose statistics to compare to national data
- Conducting a focus group with local emergency responders
2. Which of the following would be categorized as an enabling factor for addressing opioid misuse?
- A drug rehabilitation center is located within the community.
- Local media promotes community naloxone training.
- High school students gain knowledge of the consequences of opioid misuse.
- A cycle of drug misuse is linked to specific families in the community.