CHAPS HomePhase III: Community Health Assessment
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CDPHE Office of Planning and Partnerships
4300 Cherry Creek Drive S.
Denver, CO 80246
Phone: 303-692-2359
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Objective
 
The objective of this phase is to conduct a community health assessment by collecting, interpreting and reporting information relative to the community’s health status. The results will ultimately inform the local public health improvement plan and drive the community’s work over the next five years.





 
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Why is this phase important?
 
During this phase, you will determine the health status of your community by considering health and environmental data, demographic trends, and information gathered from experts and other stakeholders. Ultimately, you will be able to describe your community’s top health issues in the context of population characteristics, economics, culture, and the environment in which people live. The information collected during this phase will be the foundation for educating and mobilizing stakeholders, developing priorities, creating a local public health improvement plan, and garnering resources to support plan implementation.

Considered a necessary foundation for quality public health work, the preparation of a comprehensive assessment of the community’s health and environmental status is a requirement for local public health agencies in Colorado as well as a prerequisite for agencies choosing to become accredited under the national voluntary Public Health Accreditation Board standards (PHAB). CHAPS Phase III follows PHAB Domain 1, Standard 1.1. “Participate in or conduct a collaborative process resulting in a comprehensive community health assessment.” Non-profit hospitals are also required to conduct community health assessments under the Affordable Care Act, which provides an opportunity to coordinate plans, processes, and share resources locally.
 

Who should be involved?
 
The project management team and steering committee (if applicable) will guide the process and provide input throughout. Hospitals and healthcare providers, schools, other governmental departments, community non-profits, and CDPHE programs can help to:

  • Contribute qualitative input such as perceptions of health and environmental issues
  • Indentify the types of data to consider in the process including local data sources
  • Provide feedback on data and interpretation of findings
Key informants and subject matter experts can add insight about particular health and environmental issues. These stakeholders may include the general public, leaders in the field, community members and representatives of hard-to-reach populations who bring a unique and valuable perspective to an issue. Phase II provides detailed information on the process of identifying and engaging stakeholders.
 

What requirements are related to this phase?
 
According to the 2008 Public Health Act, every local health plan shall “examine data about health status and risk factors within the local community.” The Act does not require a specific process, content, or reporting format for the community health assessment. Therefore, each community will determine the best method for sharing this information based on local need. For agencies planning to seek accreditation, PHAB Standard 1.1 has specific requirements and suggestions for documentation.
 

What technical assistance is available?
 
Technical assistance is available from CDPHE’s Office of Planning and Partnerships and Health Statistics Section to assist with:
  • Accessing data and submitting special data requests
  • Interpreting and summarizing data
  • Planning for the collection of qualitative data and other types of community information
  • Presenting data using tables and graphs
  • Using data to make a case for new resources, services and policy change
  • Developing a community health assessment report

The Office of Planning and Partnerships can also link you to additional technical assistance providers, including academic and non-profit resources.
 

What type of data and information should be considered?
 
In general, using both quantitative and qualitative techniques to gather data and information will result in a more in-depth and reliable assessment than using only one approach. Using multiple or “mixed” methods of data collection will allow you to answer questions on a variety of levels, make comparisons, and use one form of data to validate the other.

Quantitative data are data based on counts, rates, percentages and other quantifiable measures. Such data are often calculated for a defined geographic area (e.g., county or state) and time period (e.g., one year). Interview and survey data that are based on closed questions (e.g., number or percent of participants responding “yes”) are also considered quantitative data.


Qualitative data are based on information such as the perceptions, observations or opinions of individuals. Such data are often synthesized into themes and presented in narrative form. Examples of qualitative data include findings from focus groups, results from open-ended interview questions, feedback derived from a community meeting, and descriptions of a program or service based on the experience of individual participants. Qualitative data can provide important contextual information and a deeper understanding of an issue.

Qualitative data often reveal important information that is not found in quantitative data and vice-versa. Using both qualitative and quantitative methods whenever possible and practical can help validate your findings. For example, if quantitative data shows that there has been an increase in the number of teen pregnancies in your county during the past five years, and qualitative data from a focus group with teens finds they do not know how to access contraception, then your results demonstrate an opportunity for action. Details and resources related to the collection of quantitative and qualitative data are discussed in steps 4 and 5 of this phase. Qualitative data often reveal important information that is not found in quantitative data and vice-versa. Using both qualitative and quantitative methods whenever possible and practical can help validate your findings. For example, if quantitative data shows that there has been an increase in the number of teen pregnancies in your county during the past five years, and qualitative data from a focus group with teens finds they do not know how to access contraception, then your results demonstrate an opportunity for action. Details and resources related to the collection of quantitative and qualitative data are discussed in steps 4 and 5 of this phase.
 

What are the steps for Phase III: Conduct a Community Health Assessment?
 
During this phase you will review background materials, gather data, interpret and summarize the data, and then report the results to the community. These results will be used to inform the prioritization process in Phase V, in preparation of the local public health improvement plan in Phase VI. Steps for this phase are outlined below. A Phase III Work Plan is provided to help organize and track progress.

Step 1: Review background materials
To begin, review any health assessments conducted by your agency in the recent past in order to be informed by significant findings from previous years and allow you to investigate significant changes or trends. Review needs assessments conducted by other organizations in your community that can supplement your health assessment, prevent duplication of effort, and help determine what additional community-specific data or information you may need. Consider reviewing community health assessment reports from other jurisdictions, which are available on the CHAPS website, to build an awareness of how similar communities have documented their assessment findings. Become familiar with the state health priorities known as Colorado’s Winnable Battles and the latest Statewide Public Health Improvement Plan to assure alignment between your assessment and statewide areas of focus.

Step 2: Determine the scope of your community health assessment
After considering the information that already exists within your community and your agency’s capacity for conducting this process, determine the scope of your community health assessment. Useful questions to consider include:

  • What is the timeline of our process? Are there any deadlines driving it and if so, what can be accomplished in the allotted time frame?
  • What human resources are available or obtainable to dedicate to this project? Will we use a consultant to support any activities?
  • How will any pre-existing community assessments influence the scope of this new process?
  • Are we going to engage a community-based steering committee for ongoing participation?
  • How large will our stakeholder engagement process be?
  • Do we need to conduct additional community surveying or will we use the quantitative data that is readily available?
  • Will our qualitative data gathering include interviews, focus groups, and/or community meetings, and if so, approximately how many?

Step 3: Develop a community health assessment data gathering outline
An important step in creating your community health assessment is to develop or adopt a data gathering outline or table. The purpose of this step is to identify and document the data you wish to collect. Review community health assessments from other jurisdictions to inform your data collection outline. A Health Indicator Collection Table is provided as an example. This tool lists readily available health indicators organized in alignment with the CDPHE Health Equity Framework, featuring categories such as community description, physical environment, population health outcomes, and health behaviors and conditions. Note that the outline or table you use to guide your initial data collection efforts may differ from how you ultimately choose to organize and present or publish your community health assessment findings.

Step 4: Gather Quantitative Data
During this step you will systematically collect quantifiable information that describes your community’s health status. The CHAPS Health Indicators Collection Table is provided to assist in this process. The table can be used to identify and track the majority of health and environmental indicators you will explore in this step. A hyperlink is provided to take you directly to the data, which is featured on the Colorado Health and Environmental Data website. A Data Interpretation Guide is available there to assist with data analysis and interpretation. Finally, information is available from additional data sources such as the U.S. Census Bureau, the U.S. Bureau of Labor Statistics, and the Colorado Health Foundation by visiting the Quantitative Data Resource List provided.

The bulk of your quantitative data collection will focus on exploring health indicators. These, when looked at collectively, can comprehensively illustrate the health status of a community. These indicators include health behaviors (e.g., smoking rates), health conditions (e.g., percentage of overweight or obesity), and health outcomes (e.g., leading causes of disease, injury and death). Fortunately, much data exits on health indicators; the Colorado Department of Public Health and Environment collects many types of health data, including birth and death data; maternal and child health data; data on health behaviors, injuries, and communicable disease; and others. Referencing the Health Indicators Collection Table can be particularly helpful in making this part of the process manageable and efficient. The story that these data tell may then inform which categories to supplement with additional data collection.

A closer look at health indicator data sources:

Colorado’s Health Indicators site provides county and regional data (depending on population size), and the ability to compare your jurisdiction to other counties, regions, the state, and national Healthy People 2020 objectives. Note that if using data to describe health conditions in an area of low population, it may be necessary to combine years of data, site a regional rate, or consider number of events.

Colorado Health Information Dataset (CoHID) provides the ability to query local, regional and state-level indicator data on health behaviors, conditions and outcomes. The user is able to combine years of data and look at the data by demographics such as age, gender and race/ethnicity.

Colorado Environmental Public Health Tracking Network provides searchable, county level data for indicators of environmental factors that affect health (e.g., air and drinking water quality) as well as health outcomes that are affected by environmental factors (e.g., asthma and heart attack rates). You can compare data between counties and the state as a whole, and view data trends over time.



The following examples provide suggestions for approaching Step 4 within specific categories of data.

Example 1: Community Description
When collecting data to craft your community description, consider including information such as the number of square miles, elevation, and geographic boarders. Maps provide a strong visual method for displaying geographic information. The US Census Bureau, and particularly its State and County Quick Facts website, (www.quickfacts.census.gov) provides this information, as does your local county government.

Example 2: Demographics
Demographics are the statistical characteristics of the people that live in your community, such as number, gender, race/ethnicity, age of residents, persons per square mile, home ownership, educational level and employment status. Demographic trends can help describe changes over time. For example, has the overall population increased or decreased? Is the overall age of the population changing? Is the population of specific racial and ethnic groups or those who speak a language other than English increasing or decreasing?

Example 3: Leading Causes of Disease, Injury and Death
These indicators are quantified by number of events, that is, the number of residents who were sick, became injured or died during a certain time period. Knowing the number of persons impacted by a given type of event illustrates the magnitude of an issue in relationship to other issues. Begin by collecting the data points listed below using the state’s Colorado Health and Environmental Data website, Colorado Health Indicator Dataset (CoHID) and Communicable Disease Data webpage. Note: If collecting data for a geographical area of low population, a special data request may be submitted to CDPHE to explore possibilities such as combining multiple years of data to generate a rate.

  • Leading causes of death (number of events)
  • Leading cause of injury hospitalizations (number of events)
  • Leading causes of reported communicable disease, including sexually transmitted infections and HIV (number of events)
  • Leading sites of cancer (number of events)
  • Leading cancer deaths by site (number of events)

Example 4: Health Behaviors and Conditions
Health outcomes are heavily influenced by health behaviors and conditions. Both positive and negative health behaviors play a role in the leading causes of death, injury, and disability. Data from the Colorado Behavioral Risk Factor Surveillance System (BRFSS) provide an important look at the health-impacting behaviors reported by residents of your community. Gathered via a random digit dial telephone survey, the data provide self-reported information such as:

  • Percentage of residents who are overweight or obese
  • Percentage of residents without health insurance
  • Percentage of residents who engage in leisure time activity
  • Percentage of residents who have had a colonoscopy, mammogram or pap smear
  • Percentage of residents reporting diabetes
BRFSS data are featured on the Colorado Health Indicators website and are available on CoHID.

Example 5: Environmental Health
Monitoring and assessing environmental health-related data can provide important information about how the community impacts the environment, and how the environment impacts a community’s health.

Local sources of information, such as locally-tracked levels of E. coli in recreational water sources or the presence or absence of a local energy conservation ordinance, provide a window into a community’s environmental health status. Consider augmenting your assessment efforts with information on environmental health-related citizen complaints received on an annual basis in categories such as housing, air and water quality, food safety, septic systems, and zoonosis. Additionally, the Environmental Health Tracking Network provides data for answering questions such as: How does the air we breathe compare to other areas in the state? How many people are hospitalized for asthma in my county? Has this changed over time? Examples of environmental health data to consider:
  • Air quality as compared to state and over time
  • Asthma hospitalization rates compared with air quality data
  • Childhood lead poisoning as compared to state and over time
  • Food-borne illness rates and number of food safety violations
  • Hospital admission rates for carbon monoxide poisoning
  • Household radon test results
  • Percentage of population with private wells
  • Rates of vector borne and zoonotic disease compared to state and over time
  • Water quality compared to state and over time

Example 6: Maternal and Child Health Indicators
Health status is influenced to a great degree by what occurs during the periods of preconception, pregnancy, and early childhood. Assessing and seeking to impact issues such as prenatal care, breastfeeding, and unintended pregnancy rates can provide a strong foundation for a healthy community. Examining the health indicators listed below will provide a foundational snapshot of maternal and child health in your county. This information can be found on Colorado Health and Environmental Data website under Maternal and Child Health Data.

  • Birth rate of county compared to state and over time
  • Birth rate of teens in county, compared to state and over time
  • Indicators such as unintended pregnancy, weight gain, breastfeeding, and smoking during pregnancy
  • Low birth weights—overall rates compared with the state and by population (teens/race/ethnicity)
  • Proportion (percentage) of births by race/ethnicity (teens and adults)
  • Rates of prenatal care—first, second, third trimester, no care, compared to state, and by population (teens/race/ethnicity)

Example 7: Social Determinants of Health
Determinants of health are the circumstances in which people are born, grow up, live, work, and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by wider set of forces: economics, social policies, and politics (WHO). Health status, for example, tends to correlate highly with socio-economic status. Population groups with lower income levels frequently experience higher rates of disease, injury and death than the general population. The reasons are a complex combination of everyday life experiences. For example, an individual living in an area with higher crime rates is more likely to experience a higher degree of overall daily stress, which can contribute to poorer health outcomes. Income is therefore a determinant of health. Other determinants of health include the physical environment, educational level, health care access, and social factors such as racism/discrimination, which can be a chronic stressor. The CDPHE Health Equity Model, a conceptual framework for the determinants of health, is provided on the Colorado Health Indicators website. Understanding the determinants of your community’s health will be useful when planning how best to impact health outcomes for population groups over the long term. Additional tools and information related to health equity can be found on the CHAPS website under the resources tab.

The Colorado Health Indicators website provides county-level health determinants data organized according to CDPHE’s Health Equity Model. A web-based mapping tool is available to illustrate disparities in health determinants at sub-county, county, and regional geographies across Colorado. This tool allows users to view the median household income, percent of families living below poverty threshold, and percent of adults (25+) without a high school degree from the American Community Survey and Census 2010 estimates. Population density, sex, age, and race/ethnicity can be viewed by census geography, and maps created of socio-demographic indicators within communities as well as comparisons of population characteristics between counties or regions. Visit the Quantitative Data Resource List for additional sources of social determinants of health data, such as the Annie E. Casey Foundation’s Kids Count website, which provides county-level indicators on education, economics and family structure and Headwaters Economics’ Economic Profile System-Human Dimensions Toolkit, which allows users to produce free, detailed socio-economic profiles at a variety of geographic scales.



To conclude Step 4, consider where areas exist that might require data collection from additional sources. For example, law enforcement can provide data on DUI or drug possession arrests. The Colorado Department of Transportation can provide the causes of local motor vehicle crashes and demographics of the drivers involved. Your local hospital may be able to provide the top 10 emergency department visits to help you assess whether primary care services are being accessed in more expensive, emergent care settings.

Step 5: Gather Qualitative Data
Incorporating qualitative data into your community health assessment will broaden your overall findings and enrich the story you are able to tell. This type of information may uncover health issues that the quantitative data do not illustrate. Qualitative data can help describe factors unique to your community; capture the perceptions of its citizens; provide a context for the quantitative data; and delve into a specific issue more thoroughly. There are a variety of qualitative data gathering techniques from which to choose, such as:

  • Community meetings
  • Focus groups/listening sessions
  • Key informant interviews
  • Community meetings

The following scenarios are examples of how qualitative data collection might be incorporated into your community health assessment process.

Example 1: Identify factors impacting the public health system and community health improvement process.
Examining your community in a broader context can determine factors that may assist or hinder the public health system in general, and also your community health improvement process. New legislation, rapid technological advances, changes in funding, differing philosophies of elected officials, shifts in economic forces, changing family structures and demographics are all examples. These factors are important because they either directly or indirectly impact the health and quality of life in the community, and the effectiveness of the local public health system. Identifying these factors early in your process can help determine their impact and provide the opportunity to either take advantage of or compensate for them.

Example 2: Identify community perceptions of the leading health and environmental issues.
Gathering this type of information may uncover issues that you did not know existed. You may also learn that issues residents perceive as problems, and to which the community may be allocating resources, are not supported by quantitative data. You can gather community perceptions through interviews, surveys and/or stakeholder meetings with local organizations, staff, advisory committees and others.

Example 3: Identify community perceptions of the causes of and/or solutions to the leading physical health and environmental health issues.
Consider conducting one-on-one interviews with subject matter experts to learn more about these issues. Conversations of this nature may help uncover the root causes of an issue. For example, a subject matter expert may work closely with a hard-to-reach population and have valuable insight regarding what keeps them from engaging with the community or accessing services. Another qualitative method is the focus group. For example, to determine barriers to service you may decide to facilitate a group discussion with clients.

To facilitate the process of comparing and contrasting your qualitative findings, data may be translated into quantitative values by assigning numeric codes to the responses, which can then be summed and analyzed to identify outliers and trends. This type of analysis can help tease out findings such as: What percent of the issues identified by our SWOT analysis participants fell into the category of mental health? How many key informant interview participants identified obesity as a leading community concern? Among those, how frequently did each respondent refer to lack of healthy food access as a major contributor to the problem? What percent of community meeting participants highlighted on an issue that fell into the category of injury prevention?

In summary, gathering community input regarding the leading health issues, their causes and solutions, plus obstacles to and opportunities for your public health improvement process can provide richness to your assessment that would not be obtainable from quantitative data alone. In addition, the process can both educate and mobilize your community. Helpful resources to determine and design your process are provided in the Qualitative Data Resource List, which points you to specific guidance in the following techniques: focus groups, key informant interviews, nominal group process, and SWOT (strengths, weaknesses, opportunities, and threats) analyses.

Step 6: Interpret the Data and Information
In this step you will review the data collected to identify key findings and correlations.

Use quantitative health indicator data to generate an overview of your community’s health status, such as the leading causes of disease, disability and death as well as health conditions and behaviors. Spot the top health issues that emerge by considering the current rate of each health issue or indicator, the movement of that rate over time, and the rate as it compares with those of neighboring or comparable counties, the state as a whole, and Healthy People 2020 targets. If the population is large enough, you may compare health indicators by age, gender and race/ethnicity to identify disparities.

Cluster your quantitative and qualitative data into categories, isolating themes and natural connections. Use data on residents’ perceptions to see whether it supports the quantitative data. Note health issues that are not captured in the quantitative data, but that emerged as a significant community concern. Draw conclusions to decide where to go next. If the number of events for a particular health issue is high or your county has a disparate rate from the state, consider looking further into this issue by gathering related health indicators, demographics, determinants of health and qualitative data. The Interpretation Guide on the Health Indicators website will help make sense of that data and develop a picture of the community’s health status.


Below are sample questions your data interpretation process could answer:

  • What are the most prominent conditions and recent trends in the community’s health?
  • What are the leading causes of disease, injury and death? What health behaviors and other factors are influencing these? Who is impacted the most?
  • What concerns do community members have? Are these validated by quantitative data?
  • Were emerging issues uncovered that we did not expect to find?


The following examples provide suggestions for approaching Step 6 within specific categories of data.

Example 1: Social Determinants of Health
What groups in your community are the most vulnerable to health problems? Information that describes the determinants of health will provide a context for community health given the specific economic, environmental and social dynamics that influence human behaviors and health outcomes throughout the life course. CDPHE’s Health Equity Model identifies a number of topic areas to consider. Sample questions your data interpretation process may answer include:

  • How have economic indicators changed over time, such as median income, median home price, unemployment and number of home foreclosures?
  • Who are the invisible or hard-to-reach populations in your community and why?
  • What groups are most impacted by recent changes and how might this influence health?
  • Are there groups that report experiencing chronic stress or social isolation that results in a lack of access to services or a lower rate of positive health behaviors? If so, why (e.g., language or financial barriers, lack of information, etc.).
  • What other factors might be influencing access to services and health behaviors?
  • Did any local promising practices emerge through the qualitative data that could be expanded upon during plan development (Phase VI)?
Example 2: Obesity
  • The percentage of residents impacted is high and is trending upward.
  • Our county’s rate is significantly higher than the rate of Colorado as a whole. (Disparities exist between the local and state or neighboring county rate.)
  • Young adults have the highest rate of obesity in our community. (Disparities exist between groups.)
  • Twenty-five percent of residents reported no physical activity during the prior 30 days. (Behavioral data contributes to these outcomes)
  • Residents participating in focus groups reported a lack of access to recreational opportunities due to: 1) weather, 2) crime and a lack of sense of safety, 3) the expense of indoor recreation, and 4) childcare-related concerns. Corresponding to these findings, our community’s unemployment rate has doubled and our poverty rate and crime rates have significantly increased since the start of the economic downturn in 2008.

To complete your data interpretation, synthesize the information gathered into major findings. You might consider an issue a key finding due to a high prevalence (or unexpected low prevalence), a disparity between groups, or the discovery of an emerging health issue, threat or opportunity. Questions that may help determine key findings include:

  • What has changed since our last assessment and did new issues emerge?
  • Considering the demographic make-up of the county, its history, its culture and health determinants, what conclusions can be drawn about 1) health indicators and 2) community perceptions related to health and the environment?
  • How does the health of the community differ from the health of neighboring counties, the state, or Healthy People 2020 targets? What are the factors that influence this? (Consider differences in demographics and health determinants.)
  • When comparing you community to other counties or the state, are there obvious areas of disparity? Is this true for the entire population or certain sub groups (e.g., racial/ethnic populations, adolescents or seniors, etc.)?
  • Given the data, are there health or environmental areas that have turned out to be non-issues (e.g., perception of the problem is high but actual prevalence is low)?


Step 7: Report the results
Now that you have reviewed, collected, and interpreted the data, it is time to summarize and report the information.

When preparing to present the community health assessment findings, many communities begin by selecting a specific framework within which to organize the information. Examples include the Colorado Department of Public Health and Environment’s Health Equity Framework, Colorado’s 10 Winnable Battles, and the National Prevention Strategies. Use your results to create a unique picture of public and environmental health that is specific to your community. Highlight surprising or not-so-surprising data trends, paying special attention to anomalies that exist between your area and similar communities; health outcomes impacting a large proportion of residents; and those impacting certain segments of the population disproportionately. Assist the audience by drawing direct links between the major health outcomes reported for your jurisdiction and the environmental and behavioral factors that precede them. The CDPHE Health Equity Framework can be a useful tool in connecting these key relationships. In addition to the assessment findings, it is important to also communicate the methods used to conduct the assessment, sources of information, limitations of the data, and the stakeholders involved.

How a community chooses to communicate their health assessment results will be based on both the purpose and the target audience. The results will be used to educate and mobilize stakeholders, identify priorities, create a local public health improvement plan, and garner resources to support plan implementation. Common reporting formats include hard copy and web-based community health profiles, community health status reports, or online data dashboard systems. To accommodate a variety of communication needs, communities often develop multiple presentation formats, including PowerPoint slides, fact sheets, and executive summaries of their key findings. While the publication of a formal document to present your findings is not required, two sample community health assessment outlines (Sample A and Sample B), are provided as examples.

 

Colorado Community Health Assessments

Community Health Assessment Examples

Locally Developed Tools

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Colorado Department of Public Health and Environment
Office of Planning and Partnerships
4300 Cherry Creek Dr. S
Denver,CO 80246
303-691-2359
Email Us : cdphe.edplanningandpartnerships@state.co.us
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