Chapter 2: Community Assessment
This chapter will cover:
- What is a Community Assessment?
- Primary versus Secondary Data
- Primary Data
- Secondary Data
- Conducting a Health Needs Assessment
- First Step – Assessment
- Second Step – Analysis
- Analyze Data to Identify Health Patterns and Factors That Influence Health
- Synthesize Assessment Findings to Prioritize Needs
- Priorities Health Concerns
- Develop the Community Nursing Diagnosis
- Third Step – Planning
2.1 What is Community Assessment
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.
2.2 Primary Versus Secondary Data Sources
A CHA (Community Health Assessment) 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 (Public Health Accreditation Board) 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.
Primary Data
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 2.1 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 |
|
Secondary Data
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.
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 2.2 describes frequently used secondary data sources and methods to access public health information.
| Secondary Data Source | Description |
|---|---|
| Behavioral Risk Factor Surveillance Survey (BRFSS) |
|
| Population-Level Analysis and Community Estimates (PLACES) |
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| CDC Wide-Ranging Online Data for Epidemiologic Research (WONDER) |
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| National Center for Health Statistics: FastStats |
|
| U.S. Census |
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| Healthy People 2030 |
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| County Health Rankings |
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| State Cancer Profile |
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| State Health Access Data Assistance Center |
|
| 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. |
|
2.3 Conducting a Community Health Needs Assessment
The First Step
The first steps of conducting a CHA (Community Health Assessment), 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 2.3 clarifies data that fall under each category.
| Category | Data Included |
|---|---|
People:
|
|
Place:
|
|
Community systems:
|
|
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 2.1 for potential primary data sources and Table 2.2 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 (Social Determinants of Health). 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 A’s (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?
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.
The Second Step
The second stage of the nursing process for individual clients, diagnosis, is similar to community diagnosis. Members of the CHA team organize, explore, and synthesize data gathered in the assessment phase. They compare CHA data to previous health assessments and to data from adjacent counties and communities as well as state and national data to determine if benchmarks have been met or if efforts have fallen short. The CHA team reviews the data for specific community health problems and other factors influencing health, areas where the community is doing well, and identified resources. The steps of data analysis of community health data are as follows:
- Gather collected data into one place.
- Assess collected data for completeness.
- Identify and generate missing data.
- Synthesize data and identify themes.
- Identify community needs and problems.
- Identify community strengths and resources.
Steps 1 to 3 involve organization and analysis of data to identify health patterns and factors that influence health. The team compares local data to benchmarks at local, regional, tribal, and national levels. Steps 4 to 6 synthesize assessment findings to prioritize education, health promotion, and disease prevention needs, resources, and capacity.
Analyze Data to Identify Health Patterns and Factors That Influence Health
First, the CHA team completes a statistical analysis of survey data and other quantitative information. Most often, the data are presented in frequencies, percentages, and/or central tendencies. Primary and secondary data are organized by topic or health pattern to assess completeness and determine if data are missing. If data appear to be missing, the team collects additional information. For example, if input from an at-risk population is missing, the team may hold a focus group to gather the missing data.
Morbidity and mortality data collected in the current assessment are presented along with previous assessment, state, and U.S. data, usually in table format. The team may also include other local municipality or county data. If data are available, the specific population at risk is noted. Specific populations at risk may be designated according to age, income level, gender, race/ethnicity, and/or geographical location.
Next, the team reports on factors influencing health in written or table format. Factors include health care access, health behaviors, and environmental and social conditions such as economic stability, education, neighborhood and built environment, and social and community context.
By this point, the CHA team should have a comprehensive picture of the occurrence and distribution of health patterns and health factors and be able to answer the following questions:
- What is the health concern (or health factor), and to what extent is it occurring?
- Who is impacted by the health concern (or health factor)? Is one aggregate affected more than others?
- Where is the health concern (or health factor) most prevalent?
- When, if applicable, is the health concern (or health factor) occurring?
Synthesize Assessment Findings to Prioritize Needs
Synthesis aims to critically analyze each health concern to identify why and how the problem is occurring. This step moves past identifying and organizing the data and links factors influencing health to each health concern.
Common health needs and themes emerge, and the team creates a problem list of no more than 12 issues based on a synthesis of primary and secondary community assessment data (NACCHO [National Association of County and City Health Officials], 2023). This can be managed by merging similar topics into one theme. Each problem should include the aggregate most impacted, community needs or gaps, available community resources, and capacity for change. The problem list is prioritized as part of the next phase of the community nursing process.
Formulating a nursing community diagnosis and plan of care is similar to individual nursing community diagnosis and care planning. First, the CHA team identifies and prioritizes community health concerns. Next, the team develops community nursing diagnoses. Finally, the team tailors a community health improvement plan to community culture.
Prioritize Health Concerns
The CHA team uses the identified problem list created during analysis to prioritize community problems based on:
- Extent of the problem (percent of the population affected by the problem and perception of health needs)
- Relevance of the problem (degree of risk and economic loss)
- Estimated effect of the intervention (impact, improvement of health outcomes, and potential adverse effects)
Health priorities should be those for which intervention would make the most impact on the community as a whole or for a specific at-risk population. Health priorities are those that have the
- highest community perception of need,
- largest reach,
- highest degree of risk if unaddressed,
- greatest economic impact,
- greatest opportunity for improvement in health outcomes,
- opportunity to promote health equity and reduce health disparities, and
- least adverse effect on the population.
The team should base priorities on community strengths and available resources to increase the possibility of successful implementation of programs targeting those priorities. Resources include current and potential partnerships and collaborations, human resources or capacity, and funding. Health concerns may also be prioritized because they align with state and federal priorities, allowing for benchmarking and comparison to state and local data. Additionally, monies are usually available to fund programs that align with state or federal priorities.
The method the CHA uses to prioritize health concerns is determined by the CHA model, framework, or tool it chose at the beginning of the process. Choosing health priorities also includes picking at least one health outcome indicator to measure health problem changes and identify the priority population of focus. For example, a team may choose mental health and addiction as a health priority. The priority outcome of this focus should then align with data collected during the CHA. Examples of mental health and addiction topic priority outcomes are “decrease the percentage of the community with depression,” “decrease suicide deaths,” and “decrease drug overdose deaths.”
Develop the Community Nursing Diagnosis
The community nursing diagnosis includes only one identified priority and the aggregate (population) affected, and it provides a rationale. A community nursing diagnosis should be written for each selected priority and include these three parts:
- Risk of: Identifies a specific problem or health risk faced by the community
- Among: Identifies the specific community aggregate with whom the nurse will be working in relation to the identified problem or risk
- Related to: Describes characteristics of the community
The community problem must be observable and measurable at the aggregate level. It considers which aggregate the risk affects most and which intervention will have the biggest impact. The community’s characteristics may contribute to the identified problem and/or be strengths of the community that can be built upon.
Examples of appropriately written community nursing diagnoses are as follows:
- Risk of drug overdose among Hardin County adults related to increased opioid usage, presence of fentanyl, lack of available naloxone, ineffective drug misuse prevention programs, and decreased access to drug rehabilitation programs
- Risk of infant and child malnutrition among families in Richmond County related to lack of regular developmental screenings, knowledge deficit about infant-related and child-related nutrition, knowledge deficit about available community resources, and lack of access to healthy foods
- Risk for cardiovascular disease among Bailey County adults related to sedentary lifestyles, lack of walking trails, lack of safe sidewalks, and lack of affordable exercise facilities
The Third Step
The third step of the community nursing process is planning. The CHA team uses the identified priorities and community nursing diagnoses to develop the community health improvement plan (CHIP), the care plan for the entire community. The community nursing diagnosis provides an explanation of the health need, aggregate, and factors that influence the health need. The plan outlines goals and strategies community organizations, coalitions, and members will use to address priority health problems. The chosen health priorities are ones in which intervention would make the most impact, utilize community resources, and meet the community’s needs.
References
National Association of County and City Health Officials (NACCHO). (2023). Mobilizing for Action through Planning and Partnerships (MAPP). https://www.naccho.org/programs/public-health-infrastructure/performance-improvement/community-health-assessment/mapp
Public Health Accreditation Board. (PHAB). (2022). Acronyms & glossary of terms. https://phaboard.org/wp-content/uploads/2019/01/Acronyms-and-Glossary-of-Terms.pdf
Truglio-Londrigan, M., & Gallagher, L. P. (2003). Using the seven A’s to determine older adults’ community resource needs. Home healthcare nurse, 21(12), 827–831. https://doi.org/10.1097/00004045-200312000-00010
Content in this chapter is an adaptation of chapter sections 17.1, 17.3, 17.4, and Ch 17 Chapter Summary, Population Health Nursing by Jessica Ochs, Sherry L. Roper, and Susan M. Schwartz in OpenStax, licensed CC BY.
