Chapter Six: Community Health Assessment and Evaluation
Overview
The purpose of this chapter is to review two community health assessment tools that can be used to perform a community assessment. Community assessments can help nurses identify community needs, examine elements of the environment where their patients live and work, and provide the data necessary to develop an effective plan for intervention or health promotion.
Learning Objectives
- Understand the purpose of performing a community assessment
- Identify two commonly used frameworks for conducting a community assessment
- Apply different approaches to conduct an assessment (community, population, setting-specific, problem-focused)
- Evaluate quantitative and qualitative data that can be used in the community assessment
Key Terms
- community health assessment
- windshield survey
- walking survey
- quantitative data
- qualitative data
Introduction
Community assessment is a fundamental skill for community and public health nurses. Assessment frameworks are used to identify problems. Nurses and communities work collaboratively to design and implement strategies to alleviate problems as seen and experienced by the community members. Community health frameworks include the evaluation of programs.
Community Health Assessment
A community health assessment, also known as community health needs assessment, refers to a state, tribal, local, or territorial health assessment that identifies key health needs and issues through systematic, comprehensive data collection and analysis. In many ways, community health assessments are similar to patient assessments. As with the nursing process, the first step is assessment. The community health assessment identifies critical health needs and issues through systematic, comprehensive data collection and analysis. This assessment provides organizations with comprehensive information about the community’s current health status, needs, and issues. This information can help health professionals to develop a community health improvement plan by justifying how and where resources should be allocated to best meet community needs (Centers for Disease Control and Prevention [CDC], 2018).
Frameworks
Content in this section was adapted from the “Community Planning for Health Assessment: Frameworks & Tools” from the Centers for Disease Control and Prevention (2024).
Most community health assessment and planning frameworks include steps or phases similar to those of the nursing process, commonly referred to as ADPIE: assessment, diagnosis, planning, implementation, and evaluation. The first four steps of community health assessment and planning frameworks—organize and plan, engage, develop, and conduct—align with the assessment itself: prioritizing the health issues is the diagnosis, developing the community health plan is the planning aspect of the process, and then implementing and evaluating (Table 6.1).
|
Community Health Assessment Framework |
The Nursing Process |
|---|---|
|
Organize and plan |
Assess |
|
Engage the community |
|
|
Develop a goal or vision |
|
|
Conduct community health assessment |
|
|
Prioritize health issues |
Diagnose |
|
Develop Community Health Improvement Plan (CHIP) |
Plan |
|
Implement and monitor CHIP |
Implement |
|
Evaluate process and outcomes |
Evaluate |
CHANGE Framework
One commonly used framework for the community health assessment is the CHANGE framework (community health assessment and group evaluation). It is a data collection tool and planning resource developed by the CDC for community members who want to make their community healthier. The CDC’s Healthy Communities Program designed the CHANGE tool for all communities interested in creating social and built environments that support healthy living. The purpose of CHANGE is to gather data about the community to determine potential areas for improvement (National Center for Chronic Disease Prevention and Health Promotion, 2010).
The Social-Ecological Model
The social-ecological model (Figure 6.1) provides a valuable framework for showing the multiple influences on community health and barriers to health improvement. Understanding these factors and barriers is essential for developing strong, actionable strategies for the community.
Long Description for Figure 6.1
Individual: knowledge, attitude, and skills. Interpersonal: family, friends, and social networks. Organizational: organizations, and social institutions. Community: the relationships among organizations. Public policy: national, state, and local laws and regulations.
The Mobilizing for Action Through Planning and Partnerships (MAPP) Model
Content in this section was adapted from the Public Health Professionals Gateway: Assessment & Planning Models, Frameworks & Tools from the Centers for Disease Control and Prevention (2015).
The mobilizing for action through planning and partnerships (MAPP) model provides a framework for community health improvement planning at the local level. The focus of this framework emphasizes community engagement and collaboration for system-level planning after identifying assets and needs. The MAPP process has six phases: (1) organizing for success and partnership development, (2) visioning, (3) performing the four assessments, (4) identifying strategic issues, (5) formulating goals and strategies, and (6) moving into the action cycle. Figure 6.2 provides a visualization of the process for this community health assessment plan.
Long Description for Figure 6.2
The road begins with organizing for success or partnership development and our values at the community level. The road leads to the next step, which includes the 4 M A P P assessments, such as local public health system assessment, community health status assessment, forces of change assessment, and community themes and strength assessment. The road continues through identifying strategic issues and formulating goals and strategies which lead to action plan and evaluating the implemented plan.
Approaches to Community Health Assessment
There are six types of community health assessments. These include comprehensive assessments, rapid needs assessments, problem or health issue assessments, health impact assessments, population-focused assessments, and setting-specific assessments.
A comprehensive assessment is an assessment that includes the assets within a community, such as local health department capacity and identification of problems and issues within the community. It also identifies opportunities for action within the community. As the name implies, the rapid needs assessment is a tool that addresses potential emerging public health concerns and the capacity for emergency response. The problem or health issue–based assessment focuses on addressing a specific problem or concern within a community, such as an outbreak of HIV. A population-focused assessment concerns a specific population of people, such as children with elevated lead levels. A setting-specific health assessment is completed in a specific environment such as a work site with increased injuries or the school setting. According to the World Health Organization (WHO), a health impact assessment is used to evaluate the potential effects of policies (WHO, 2022; Savage, 2019).
What Is a Community Assessment?
Content in this section was adapted from the Public Health Professionals Gateway: Assessment & Planning Models, Frameworks & Tools from the Centers for Disease Control and Prevention (2015).
As noted, a community health assessment is sometimes called a community health needs assessment. Regardless, the fundamental purpose of the assessment is to identify the health needs and issues of the population being evaluated. These are carried out to assess various populations ranging from an entire state or territory to being focused on smaller groups at the local or tribal level. To identify these key needs or issues, systematic, comprehensive methods collect and analyze data. Community health assessments use such principles as:
- Multisector collaborations that support shared ownership of all phases of community health improvement, including assessment, planning, investment, implementation, and evaluation
- Proactive, broad, and diverse community engagement to improve results
- A definition of community that encompasses both a significant enough area to allow for population-wide interventions and measurable results and that includes a targeted focus to address disparities among subpopulations
- Maximum transparency to improve community engagement and accountability
- Use of evidence-based interventions and encouragement of innovative practices with thorough evaluation
- Evaluation to inform a continuous improvement process
- Use of the highest quality data pooled from, and shared among, diverse public and private sources
Comprehensive community statements should be collaborative and involve all stakeholders, including community members.
Community Health Assessment Tools
Content in this section was adapted from “Chapter 3. Assessing Community Needs and Resources, Section 21. Windshield and Walking Surveys,” from the University of Kansas Community Toolbox (Rabinowitz, 2022).
One way to get a sense of a community is to drive or walk around it, observing and taking note of its characteristics. Windshield and walking surveys can be an important part of a community assessment. In this section, they are described in more detail, and how to conduct one successfully is discussed.
What Are Windshield and Walking Surveys?
Windshield surveys are systematic observations made from a moving vehicle. Walking surveys are systematic observations made on foot. Either or both can help the observer gain a better understanding of the community in general or its specific condition or aspect.
Windshield surveys are handy when the area to be observed is large and the aspects of interest can be seen from the road. A walking survey might be a better choice when there is a need to understand things that are harder to see from a moving vehicle.
Windshield and walking surveys can be used to assess general community needs—to estimate the poverty level, for example—or to examine more specific facets of the community’s physical, social, or economic character. Some possibilities:
- Age, nature, and condition of the community’s available housing
- Infrastructure needs (roads, bridges, streetlights, etc.)
- Presence or absence of functioning businesses and industrial facilities
- Location, condition, and use of public spaces
- Amount of activity on the streets at various times of the day, week, or year
- Noise level in various parts of the community
- Amount and movement of traffic at various times of day
- Location and condition of public buildings (the city or town hall, courthouse, etc.)
Why Conduct Windshield and Walking Surveys?
Windshield or walking surveys can be structured to provide an objective view of the community. These are especially adaptable to community-based participatory initiatives. These collaborative interventions can include scientific researchers, health care workers, stakeholders, and members of the community to address diseases and conditions disproportionately affecting populations experiencing health disparities (National Institute on Minority Health and Health Disparities, 2024).
- They can be the easiest and quickest way to get an overview of the entire community.
- They allow clear comparisons among different parts of the community and help determine where to focus.
- They can be beneficial in understanding specific aspects of a community.
Some aspects of the community where one of these surveys could reveal valuable information could be:
- The community’s relationship to the environment
- The nature of street life
- Traffic
- Access to food
When Should Windshield and Walking Surveys Be Conducted?
Often in the Community Toolbox the answer to the “When …?” question is determined by what is most appropriate or beneficial based on the political or social climate and the logistics of acting. A windshield or walking survey can be conducted whenever it is needed. However, to understand how people use the community, conduct the survey at a time—perhaps several different times—when the community is likely to be engaged in an observable activity. To get the best picture of a community, do surveys at different times of the day, week, and/or year.
Who Should Conduct Windshield and Walking Surveys?
The answer to who should conduct the survey depends on several factors. How large is the area to be surveyed? How many times will surveys be conducted? Is this a participatory research project? Will the survey be conducted in teams or as individuals? A small neighborhood or rural village might be adequately surveyed in a day by a single person, whereas a large city might require several days with several teams of observers. If the survey includes participatory research, organize observers in teams, each of which has representatives of different ages, cultures, ethnicities, income levels, community sectors (business, government, health, and community services, etc.).
One important issue is safety. If there is hostility between races or ethnic groups, it may not be safe for some people to survey particular neighborhoods. Even if there is no real danger but only a perception of danger, the resulting anxiety can affect a survey’s accuracy and completeness.
Another difficulty with conducting a windshield or walking survey as a participatory research project is that community members might already have set ideas about many of the questions need to be asked. However, a windshield or walking survey can also serve to open community members’ eyes to the realities of their environment.
How Are Windshield and Walking Surveys Conducted?
Windshield and walking surveys are similar in many ways, but some important differences exist. Here we offer guidelines that relate to both and then look at each in turn.
Designing the Survey
- Determine who will conduct the survey.
- The best results are likely if those who will be conducting the survey are involved in its planning. Their observations will be sharper if they understand what they are looking for, which is most likely if they help to develop the survey.
- Whether the survey is conducted driving or walking, the ideal is to use a team or teams for which resources are available. The variety of perspectives will enrich the survey, and each team member can focus on a particular task (observation, recording, etc.), making for a more efficient survey.
- Decide on the questions the survey will answer.
- The questions will determine the scope and structure of the survey. Basic research questions (e.g., “What is the nature of the community?”) may require follow-up with secondary questions. Questions with a narrow focus (e.g., “Do most streets in the community have sidewalks?”) may not require follow-up. Some questions will have more than one part (e.g., “How, by whom, and how much are public playgrounds used?).
Training the People Who Will Conduct the Survey
- Get well acquainted with the questions, the purpose of the survey, and what it is looking for.
- Make and use a checklist to ensure that all questions have been addressed and observe all the necessary areas.
- Try to be unobtrusive. People not only act differently when they know they are being observed but also may become suspicious or hostile.
- Carry identification.
- Take notes. Take photos or videos with a camera or cell phone to remember and illustrate what has been observed.
- Work in teams and assign roles. A team should have at least one observer and at least one recorder.
- Discuss findings as the survey is conducted.
- Pay attention to safety. Be aware of the neighborhood and situation, especially while walking. If the situation does not feel safe, leave.
What to Examine in a General Community Assessment Survey
- Housing. What is the age and condition of housing in the neighborhoods being surveyed? Are houses and apartment buildings kept up, or are they run-down and in need of repair? Are yards neat or overgrown?
- Other buildings. Are the buildings mostly or fully occupied? Do public and commercial buildings seem accessible to people with disabilities (ramped, street-level entries, etc.)?
- Public spaces. Are there public spaces where people can gather? Are they well kept up? Do they have seating areas, trees, and plants, attractive design, cafes or food vendors, or other features that encourage people to use the space? Who uses these spaces? Is there diversity?
- Parks. Are parks used by a variety of people? Are they well kept up? Are there sports facilities (basketball courts, soccer pitches, baseball fields, cricket pitches, etc.)? Are they used at night?
- Culture and entertainment. Are there museums, theaters, restaurants, clubs, sports stadiums, historic sites, etc.? Are they accessible to all parts of the community (centrally located, reachable by public transportation)? Do they reflect the cultures of community members?
- Streetscape. The streetscape is the environment created by streets and the sidewalks, buildings, trees, etc., that line them. Are there trees and/or plants? Are there sidewalks? Are building facades and storefronts attractive and welcoming? Are the streets and sidewalks relatively clean? Are there trash cans? Is there outdoor seating?
- Pedestrian and bicycle safety. What is the road design, traffic speed, and road/sidewalk quality? How safe is it to walk or ride? What condition are the sidewalks in? What is the physical activity level? Are there pedestrian or bicycle collisions occurring?
- Street use. Are there people on the streets at most times of the day? In the evening? How late? Do they interact with each other? Are streets and sidewalks well lit at night?
- Commercial activity. What kinds of businesses are there? Are there boarded-up or vacant storefronts? Is there a mix of large and small businesses? Are there grocery stores and supermarkets, pharmacies, and other stores that provide necessities in all parts of the community?
- Signs. What languages are business, road, and traffic signs in? Are traffic signs informative? Are there signs directing people to various parts of the community (downtown, museums, highways, etc.)?
- Industry. What kinds of industries exist in the community? Does they seem to be causing pollution?
- Land use. How much open space is there? How are residential, commercial, and industrial areas distributed? Do major roads or railroad tracks divide neighborhoods, or are they on the edges of the community?
- Infrastructure. What is the condition of roads, bridges, sidewalks, etc.? Do these conditions differ from one area of the community to another? Do all parts of the community seem to be equally served by electricity, water, phone, fiber optic, wastewater treatment, waste disposal, and other infrastructure services?
- Public transportation. Is there a functioning public transportation system? Is it well used? By whom? Does it allow relatively easy access to all parts of the community? How easy is it to navigate and use? How much does it cost? Are its vehicles energy-efficient?
- Traffic. How heavy is traffic in the community? Is it mostly commercial and industrial (vans, trucks, etc.) or mostly private cars? Is there ever gridlock? Is there much bicycle traffic? Are there bike lanes? Are there bike racks in many places?
- Environmental quality. How much usable green space is there, and is it scattered throughout the community? Is there smog or haze? Does the air smell of smoke, garbage, car exhaust, chemicals, industrial waste, etc.? Does the water in streams, ponds, lakes, etc. seem reasonably clear?
- Race/ethnicity. Who lives in the community? Are there identifiable racial and ethnic groups? Do particular groups seem to live in particular areas?
- Faith communities. What kinds of religious institutions are there? Do the institutions of one particular religion or sect dominate? Are there separate houses of worship for people of different ethnicities or races, even if they share the same faith?
- Health services. How many hospitals and clinics are there in the community? Where are they located? How big are they? How easy are they to get to?
- Community and public services. Are there identifiable community service providers and organizations in the community (mental health centers, food banks, homeless shelters, welfare offices, etc.)? Are they concentrated in a particular area? Are they easy to reach by public transportation?
- Community safety. Where are police and fire stations located? Are they in good repair? Is the community well lit at night?
- Public schools. Are schools in different neighborhoods in noticeably different states of repair? Are schools well maintained? Or in some developing countries, are there schools in the community?
- Higher education. Are there two- and four-year colleges and/or universities in the community? Where are they located? Do they seem open to the community, or do they seem self-contained and isolated?
- Political activity. Are there signs or other indications of political activity? Is it clear that political activity is allowed and/or encouraged? Are there protests or demonstrations?
- Community organizations. What evidence is there of organizations in the community? Are there service clubs (Lions, Elks, Masons, etc.)? Are there other organizations (groups centered around community issues, the environment, sports or leisure pursuits, socialization, etc.)?
- Media. Are there local media outlets such as radio and TV stations, newspapers, and internet sites devoted to local issues? Are they independent, or are they sponsored or run by governments or corporations? Where are their facilities?
- Food access. Are there markets? Fast-food restaurants? Community gardens?
- Differences among neighborhoods or areas of the community. What are the differences among different parts of the community? Are schools, stores, public and other buildings, streets, etc., in different areas in different conditions? Do some areas seem neglected whereas others are maintained?
- The “feel” of the community. What is the overall impression of the community?
Conducting a Windshield Survey
- Use a map. Google Maps or similar services are an excellent resource.
- Try to use a team of at least two. That way, one person can concentrate on driving while the other navigates and records observations. It is difficult to observe closely and drive safely at the same time.
- Drive at a moderate speed and avoid unexpected actions.
- Drive on both major and minor streets, particularly in residential neighborhoods. Get a sense of different parts of neighborhoods and different streets.
- Pull over at regular intervals to make and compare notes.
- Try to be inconspicuous.
Conducting a Walking Survey
Study a map beforehand or do a drive-through to plan. Try to work in teams of two to three.
- Two or three people walking together is a normal group, but five or six is a crowd and stands out.
- To experience the community, participate in everyday activities. Take public transportation; eat in a local restaurant; or buy something in a drugstore, supermarket, or discount store. Listen to people’s conversations and get a sense of how they interact.
- Go inside public buildings and cultural institutions.
- Sit down in a quiet place to take notes.
In Summary
Sometimes, the best survey can be a combination of walking and driving. Consider some general questions:
- What are the community’s outstanding assets?
- What seem to be the community’s biggest challenges?
- What is the most striking thing about the community?
- What is the most unexpected?
- Does the community have an aesthetic quality, either positive or negative (i.e., is it particularly beautiful or particularly ugly)?
Whether you are starting an all-encompassing campaign to eliminate poverty in the community or simply looking for good places to paint murals to stimulate community pride, a windshield or walking survey can be an excellent way to begin.
Analyzing Data as Part of the Community Health Assessment
Content in this section was adapted from Public Health Professionals Gateway: Data & Benchmarks resource from the Centers for Disease Control and Prevention (2021).
Community health assessments typically use primary and secondary data to characterize the community’s health. Primary data are collected firsthand through surveys, listening sessions, interviews, and observations. Sometimes the initial observations are done informally via a windshield or walking survey. This entails driving or walking through a community and making observations about the community, such as noting the population makeup, the type of housing, or the number of health care facilities or schools. Note the type and state of buildings and housing in the community. This type of data is qualitative data. Qualitative data cannot be measured or expressed in terms of numbers; rather, such data are descriptive and give a feel of the community.
Secondary data are collected from other sources such as census records or state or county records. This information is quantitative, meaning that it can be expressed in terms of numbers. This information allows nurses to learn more about the community’s demographic makeup, median income, housing, and rental costs. Also, look at the prevalence and incidence of diseases. It is important to obtain and review both primary and secondary data when performing a community health assessment. Community health assessment is a valuable tool in understanding and improving the health of communities at both the local and national levels.
The Nurse’s Role in Community Health Assessment and Evaluation
Conducting a community health assessment provides the nurse with comprehensive information about the community’s current health status, needs, and issues. This information can help develop a community health improvement plan by justifying how and where resources should be allocated to best meet community needs.
Community health assessments provide a number of important benefits:
- Improved organizational and community coordination and collaboration
- Increased knowledge about public health and the interconnectedness of activities
- Strengthened partnerships within state and local public health systems
- Identified strengths and weaknesses to address in quality improvement efforts
- Baselines on performance to use in preparing for accreditation
- Benchmarks for public health practice improvements (CDC, 2022a)
Identifying key health needs and issues through systematic, comprehensive data collection and analysis enables nurses to deliver care that meets the individual needs of the community.
Practice Application
➔ Setting the Scene
Local health departments help provide a safe and healthy environment for their communities. They provide these services, among others:
- Planning for emergencies
- Securing resources for disasters, such as first aid equipment and vaccines
- Administering vaccinations
- Managing local disease outbreaks
- Inspecting restaurants, grocery schools, and other community resources for food safety
- Implementing and supporting interventions for drug overdoses
They often work with community partners to ensure a base level of health for the communities they serve (National Association of County and City Health Officials, 2017).
➔ Think About It
Imagine that you are a new member of your local health department. Before you meet with community members, you decide to gather some additional data to help you draw a mental picture of the community. You will need to understand the range of social determinants of health, built environment, and the community’s perception of their health and well-being.
- Describe the benefits, disadvantages, and considerations for each of the following types of assessments.
- Census data for the community
- Health impact assessment
- Windshield survey
- MAPP survey
- Hospital needs assessment (published every 3 years by nonprofit hospitals)
- Which assessment type (or combination of assessments) would you pick to help you become quickly familiar with your new community and why?
- What information will you need to complete a windshield survey?
Additional Resources
CDC, National Healthy Worksite Program – Community Partnerships Issue Brief Number 3
CDC, Public Health Professionals Gateway – Community Health Assessment & Health Improvement Planning
Community Health Nursing [Article]
Healthy Communities Foundation
Northeastern State University – The Nurse’s Role in Community Health
Robert Wood Johnson Foundation – Focus Areas: Healthy Communities
References
Centers for Disease Control and Prevention. (2015). Assessment & planning models, frameworks & tools. Public Health Professionals Gateway. www.cdc.gov/publichealthgateway/cha/assessment.html
Centers for Disease Control and Prevention. (2018). Community planning for health assessment: Index. Public Health Professionals Gateway. https://www.cdc.gov/public-health-gateway/php/public-health-strategy/?CDC_AAref_Val=https://www.cdc.gov/publichealthgateway/cha/index.html
Centers for Disease Control and Prevention (2021). Data & benchmarks. Public Health Professionals Gateway. www.cdc.gov/publichealthgateway/cha/data.html
Centers for Disease Control and Prevention. (2022a). Community health assessments & health improvement plans. Public Health Professionals Gateway. https://www.cdc.gov/public-health-gateway/php/public-health-strategy/public-health-strategies-for-community-health-assessment-health-improvement-planning.html?CDC_AAref_Val=https://www.cdc.gov/publichealthgateway/cha/plan.html
Centers for Disease Control and Prevention. (2022b). The social-ecological model: A framework for prevention. https://www.cdc.gov/violence-prevention/about/?CDC_AAref_Val=https://www.cdc.gov/violenceprevention/about/social-ecologicalmodel.html
Centers for Disease Control and Prevention. (2024). Community planning for health assessment: Frameworks & tools. Public Health Professional Gateway.
Marion County. (2015). Mobilizing for Action through Planning and Partnerships (MAPP). https://www.co.marion.or.us/HLT/communityassessments/Pages/MAPP.aspx
National Association of County and City Health Officials. (2017). Local health departments Impact our lives every day. www.naccho.org/uploads/downloadable-resources/transition-appendix-A-Infographic.pdf
National Center for Chronic Disease Prevention and Health Promotion (U.S.). Division of Adult and Community Health. (2010). Community Health Assessment aNd Group Evaluation (CHANGE) action guide; building a foundation of knowledge to prioritize community needs: an action guide.
National Institute on Minority Health and Health Disparities. (2024). Community-based participatory research program. Retrieved March 9, 2024, from https://www.nimhd.nih.gov/programs/extramural/community-based-participatory.html
Rabinowtiz, P. (2022). Chapter 3: Assessing community needs and resources, Section 21. Windshield and walking surveys. Community Tool Box (University of Kansas). https://ctb.ku.edu/en/table-of-contents/assessment/assessing-community-needs-and-resources/windshield-walking-surveys/main
Savage, C. (2019). Public/community health and nursing practice: Caring for populations (2nd ed.). F. A. Davis Company. https://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=5985007
World Health Organization. (2022). Health impact assessment. www.who.int/health-topics/health-impact-assessment