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Conducting a Community Assessment
The uncreative mind can spot wrong answers. It takes a creative mind to spot wrong questions.
A. Jay
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ecoming aware of current conditions through a community assessment is one of the first steps in an evidence- based process. The path to the desti- nation depends very much on the starting point. As noted earlier, evidence- based processes include conducting assessments to identify issues within a community, prioritizing these issues, developing interventions to address these issues based on a review of what has worked effectively in other places, and evaluating the process, impact, and outcome of intervention efforts.Because the determinants of chronic diseases and common risk factors are multilevel (including individual, social, organizational, community, and sys- tem level factors), each of these steps will require some engagement of non- health partners across a wide variety of sectors of the community. Their level of engagement in each step may vary.
Community assessments may include efforts to identify morbidity and mortality, environmental and organizational conditions, existing policies, and relationships among key organizations and agencies. In conducting these assessments it is important to attend to not only the needs in the community and problems but also community strengths and assets (similar to the strate- gic planning considerations outlined in chapter 6).
Although it is ideal to do a complete and thorough assessment, this may not be possible in all instances. Choices about what to assess should be based on what it is that you want to know and who will be using the information.
Ideally, assessments should be made with partners who will use the informa- tion for decision making about future programs and policies and those who
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are affected by these decisions. In reality, some of these partners may join at a later stage in the evidence- based process, bringing new perspectives or ques- tions that warrant additional assessments.
This chapter is divided into several sections. The first provides a back- ground on community assessments. The next section describes why a community assessment is critical. The third section discusses a range of partnership models that might be useful in conducting community assess- ments. The next sections outline who, what, and how to conduct assess- ments. The final section describes how to disseminate the community assessment findings.
BACKGROUND
Community assessments identify the health concerns in a community, the factors in the community that influence health (i.e., determinants of health), and the assets, resources and challenges that influence these fac- tors.1,2 Ideally, assessment is a process in which community members and a broad array of medical/ health, business, community, faith- based, and gov- ernmental organizations become partners in assessing the community and use this information as part of a process to prioritize and develop inter- ventions (programs, policies, or environmental changes) for community improvement.3 The types of data reviewed are determined within this part- nership based on the questions the partnership is interested in answering.
After the data are synthesized and provided back to the partnership, they are often then shared with the broader community to inform others’ plan- ning efforts.1
WHY CONDUCT COMMUNITY ASSESSMENT?
Community assessments are essential to ensure that the right interventions are implemented. This is in part because they can provide insight into the community context so that interventions are designed, planned, and car- ried out in ways that are acceptable and maximize the benefit to the com- munity. In addition, the assessments can identify (and in some cases build) support for a particular intervention approach. This support is critical for garnering resources and ensuring a successful intervention. Assessments can also provide a baseline measure of a variety of conditions. This baseline, or starting point, is helpful in determining the impact of intervention efforts.
In chapter 11, more information will be provided on how to compare baseline measures with measures collected during and after the intervention to iden- tify differences.
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Community assessments may be encouraged by local, state or provincial, and national entities as a way to better focus intervention efforts and utilize resources, or they may be conducted as part of a mandatory process for public health agency accreditation or assessment processes for hospitals and health care systems.
ROLE OF PARTNERS IN COMMUNITY ASSESSMENT
The roles of partners, including community members, community- based organizations, governmental or public agencies, private agencies, local busi- nesses, and health practitioners in conducting a community assessment may vary. Although some involvement of each of these groups is important, the assessment may be started by one group, with others joining in at a later time.
Alternately, the assessment may be conducted with a small group, with other partners being asked to join only after a specific intervention has been cho- sen. Some have argued that engagement of community members and these multiple sectors from the beginning and throughout the process is likely to enhance the relevance and accuracy of the overall assessment and increase the effectiveness of the chosen interventions (Box 5.1).4– 7
Recognizing that solving complex health issues requires that agencies and community leaders work together, public health professionals have worked with existing or created new coalitions. A coalition is defined as a group of community members or organizations that join together for a common pur- pose.8,9 Some coalitions are focused on categorical issues, such as diabetes pre- vention or the reduction of infant mortality rates. Other coalitions form to address broader public health issues (e.g., a partnership for prevention).
Coalitions may differ considerably in the roles and responsibilities of each partner and the types of activities in which they wish to engage.10 This can be thought of as a continuum of integration.8,9,11,12 At one end of the continuum is the desire of agencies and individuals to work together to identify gaps in services, avoid duplication of services, and exchange information to allow for appropriate client referral. This level is characterized by networking and coor- dination. The next level of integration involves a higher level of cooperation.
Agencies maintain their autonomy, agendas, and resources but begin to share these resources to work on an issue that is identified as common to all. The highest level of integration involves collaboration among the agencies as they work together to develop joint agendas, common goals, and shared resources.
Before starting a community assessment it is important for partners to be clear about the level of integration they desire because each requires progres- sively higher levels of commitment and resources.
Although community coalitions are growing in popularity, their ability to assess their community and create healthful changes depends in part on the
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coalition’s ability to move through various stages of development. There are many recent efforts to define and describe these various stages.8,13,14 Most often, for these groups to be effective, it is essential that they begin by devel- oping a common vision of what they want to accomplish and a common set of skills to engage in the change process together. In addition, it is important that the individuals involved in the coalition build relationships as individuals and as representatives of their respective community organizations. As with other types of community- based health promotion programs, to be effective, coalitions may need to focus on a variety of issues, such as developing a com- mon set of skills and building trust, at different stages. Wolff summarized the unique characteristics that contribute to the development of effective coali- tions (Table 5.1).15 When coalitions have established these processes they are ready to determine what to assess and how to conduct the assessment.
WHO AND WHAT TO ASSESS
What to assess depends very much on the knowledge to be gained and from whom it will be collected. In terms of the “who” question, it is important to
Box 5.1
REDUCING DISPARITIES IN DIABETES AMONG AFRICAN- AMERICAN AND LATINO RESIDENTS OF DETROIT: THE
ESSENTIAL ROLE OF COMMUNITY PLANNING FOCUS GROUPS
A strong community- academic- health system partnership was created to address long- standing health disparities.7 The REACH (Racial/ Ethnic Approaches to Community Health) Detroit Partnership included commu- nity residents, community- based organizations, the health department, a medical care system, and academicians, who worked together to assess the factors influencing diabetes and related risk factors. Partners were involved in all aspects of the development, implementation, and analysis of the data. Community members, including those who were bilingual in Spanish and English, were recruited and trained to moderate the focus groups. Focus groups were held at community sites. All partners worked together to establish a focus group discussion guide and analyze the results. Focus group participants were asked to discuss the challenges as well as the assets in their community, and were provided specific sugges- tions for strategies to reduce diabetes and related risk factors. The broad- based partnership was able to take these suggested strategies and obtain funding for a wide range of individual, family, health system, social sup- port, and community level interventions.
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clearly identify the “community” of interest. The community may be defined as individuals who live within a specified geographic region or as individuals who have a common experience or share a particular social or cultural sense of identity.16,17 For example, a community might involve members of a particular church, residents of a neighborhood, or individuals connected through social media who share a common bond (e.g., ethnic heritage). In conducting the assessment, it is also important to identify any subgroups within the commu- nity of interest (e.g., youth, lower income adults) so that the assessments can adequately reflect the range of community members.
The decision regarding what to assess should be guided by the goal of the assessment. For instance, an assessment focusing on youth would include dif- ferent elements than an assessment focusing on elderly people. Alternately, some governmental or funding agencies will require that certain things be assessed, and a group will need to decide if it wishes to expand on those requirements. With that in mind, there are some general guidelines that are helpful to consider in planning an assessment. In particular, it is important to assess factors along the full range of the ecological factors that influence
Table 5.1. CHARACTERISTICS OF EFFECTIVE COMMUNITY COALITIONS
Characteristic Description
1. Holistic and comprehensive Allows the coalition to address issues that it deems as priorities; well illustrated in the Ottawa Charter for Health Promotion
2. Flexible and responsive Coalitions address emerging issues and modify their strategies to fit new community needs
3. Build a sense of community Members frequently report that they value and receive professional and personal support for their participation in the social network of the coalition
4. Build and enhance resident engagement in community life
Provides a structure for renewed civic engagement; coalition becomes a forum where multiple sectors can engage with each other
5. Provide a vehicle for community empowerment
As community coalitions solve local problems, they develop social capital, allowing residents to have an impact on multiple issues
6. Allow diversity to be valued and celebrated
As communities become increasingly diverse, coalitions provide a vehicle for bringing together diverse group to solve common problems
7. Incubators for innovative solutions to large problems
Problem solving occurs not only at local levels but also at regional and national levels; local leaders can become national leaders
Source: Adapted from Wolff.15
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population health and well- being, and in doing so include the assets in the community— not just the problems (Figure 5.1).16, 18– 20
Ecological frameworks (also discussed in chapter 10) suggest that individ- ual, social, and contextual factors influence health.21 Several variations of an ecological framework have been proposed.22– 25 Based on work conducted by McLeroy and colleagues22 and Dahlgren and Whitehead,26 it is useful to con- sider assessment of factors at five levels:
1. Individual— characteristics of the individual, including biological; knowl- edge, attitudes, skills, and a person’s developmental history; and individual lifestyle behaviors
2. Interpersonal— formal and informal social networks and social support systems, including family and friends
Broad sociaal, economic, cultural, health, and environm ental cond
itionsb
and p olicie
s at the glo
l, n ba nal, atio st an ate, cal d lo vel le s
Living and working conditi on
s Social family and community
netw ork Individual beh s
avior
Living and working conditions may include:
• Psychosocial factors
• Employment status and occupational factors (income, education, occupation)
• The natural and builtC environments
• Public health services
• Health care services Innate
individual traits:
age, sex, race, and biological
factors The biology of—
disease
Over the life span
Figure 5.1: Ecological influences on health.
aSocial conditions include, but are not limited to: economic inequality, urbanization, mobility, cultural val- ues, attitudes and policies related to discrimination and intolerance on the basis of race, gender, and other differences.
bOther conditions at the national level might include major sociopolitical shifts, such as recession, war, and governmental collapse.
cThe built environment includes transportation, water and sanitation, housing, and other dimensions of urban planning.
Source: From the Institute of Medicine.19
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3. Organizational— living and working conditions, including social institu- tions, organizational characteristics, and rules or regulations for operation.
Assessments of organizational factors may include not only the existence of these institutions but also their organizational capacity and readi- ness for change (e.g., organizational support, communication within and between organizations, decision- making structures, leadership, resources available16, 27– 29)
4. Community, social, cultural, and environmental conditions— relationships between organizations, economic forces, the physical environment, and cultural factors that shape behavior
5. Governmental and policy— local, state, national, and international laws, rules, and regulations
Using an ecological framework to guide an assessment leads to assessing people in the community (their health and wellness and their behaviors), the organizations and agencies that serve the community, and the environment within which the community members reside.30 In fact, the most effective interventions act at multiple levels because communities are made up of indi- viduals who interact in a variety of social networks and within a particular context; therefore an assessment needs to provide insight along this wide range of factors. Table 5.2 provides a list of a number of possible indicators for each of these levels of the ecological framework. In addition, the list of resources at the end of the chapter includes a variety of expected indicators for various agencies.
COLLECTING DATA
There are a number of different ways to collect data on each of the indicators listed previously. Too often, community assessment data are collected based on the skills of the individuals collecting the data. If someone knows how to collect survey data, those are the data collected. As noted earlier, for any com- munity assessment process to be effective, it is essential to determine the questions that need answering and from whom data will be collected. Methods should be used that are best suited to answer the questions— obtaining assis- tance as needed. Some information may be found using existing data, whereas other types of information require new data collection. Data are often clas- sified as either quantitative or qualitative. Quantitative data are expressed in numbers or statistics— they answer the “what” question. Qualitative data are expressed in words or pictures and help to explain quantitative data by answering the “why” question. There are different types and different methods of collecting each. More often than not, it is useful to collect multiple types of
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Table 5.2. INDICATORS BY LEVEL OF AN ECOLOGICAL FRAMEWORK
Level Indicators
Individual:
characteristics of the individual such as knowledge, attitudes, skills, and a person’s developmental history
• Leading causes of death
• Leading causes of hospitalization
• Behavioral risk and protective factors
• Community member skills and talents
Interpersonal:
formal and informal social networks and social support systems, including family and friends
• Social connectedness
• Group affiliation (clubs, associations)
• Faith communities, churches, and religious organizations
• Cultural and community pride
Organizational:
social institutions, organizational characteristics, and rules or regulations for operation
• Number of newspaper, local radio or TV, and media
• Number of public art projects or access to art exhibits and museums
• Presence of food pantries
• Number and variety of businesses
• Number of faith- based organizations
• Number of civic organizations
• Supportive services resource list
• Public transportation systems
• Number of social services (e.g., food assistance, child care providers, senior centers, housing and shelter assistance)
• Chamber of Commerce— list of businesses
• Number and variety of medical care services: clinics, programs
• Number of law enforcement services
• Number of nonprofit organizations and types of services performed (e.g., the United Way, Planned Parenthood)
• Number of vocational and higher education institutions and fields of study available to students: community college and university
• Library Community and social:
relationships between
organizations, economic forces, the physical environment, and cultural variables that shape behavior
• Public School System Enrollment numbers
• Graduation and drop- out rates
• Test scores
• Community history
• Community values
• Opportunities for structured and unstructured involvement in local decision making
• Recreational opportunities: green spaces, parks, waterways, gyms, and biking and walking trails
• Crosswalks, curb cuts, traffic calming devices
• Housing cost, availability
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Level Indicators
• Environmental issues— trash, animals, pollution
• Existence of local and city- wide strategic planning processes
• Employment and unemployment rates
• Area economic data
• Crime incidence: arrests and convictions, incidence of domestic violence
• Motor vehicle crashes
• Informal educational opportunities for children and adults
• Number and types of existing collaborations among organizations
Governmental and policy:
local, state, and national laws, rules, and regulations
• Zoning regulations
• Housing standards
• Environmental policies (e.g., air or water standards)
• Economic policies (e.g., minimum wage, taxes) Table 5.2. CONTINUED
data because each has certain advantages and disadvantages. Bringing differ- ent types of data together is often called triangulation.31
Quantitative Data
National, State, and Local Data From Surveillance Systems
These sources of quantitative data are collected through national or statewide initiatives and may include information on morbidity and mortality (cancer registry, death certificates), behavior (Behavioral Risk Factor Surveillance System), or social indicators (European Health for All Database, US Census).
The advantage of these data is that they are comparable across geographic regions, allowing comparisons between one community and other communi- ties. The disadvantage of these data is that they may not be a good reflection of a community because of geographic coverage, sampling frames, or method of data collection (e.g., phone interviews). In addition, these data sets may not include data relevant for answering questions related to a particular assess- ment or the development of a specific intervention.
Surveys or Quantitative Interviews
These data are collected specifically for a particular community and may include information on demographics, social indicators, knowledge, behavior, attitudes, morbidity, and so forth. These data may be collected through phone,