Wetta, Ruth E. PhD, MPH, MSN, RN; Pezzino, Gianfranco MD, MPH; LaClair, Barbara MHA; Orr, Shirley MHS, APRN, NEA-BC; Brown, Molly B. BA
Department of Preventive Medicine and Public Health, University of Kansas School of Medicine–Wichita (Dr Wetta and Ms Brown); Kansas Health Institute, Topeka (Dr Pezzino and Ms LaClair); SOCO Consulting, Wichita, Kansas (Ms Orr).
Correspondence: Ruth E. Wetta, PhD, MPH, MSN, RN, Department of Preventive Medicine and Public Health, University of Kansas School of Medicine–Wichita, 1010 N Kansas Ave, Wichita, KS 67212 (firstname.lastname@example.org).
This work was supported by a grant from the Robert Wood Johnson Foundation, Public Health Services and Systems Research program (grant no. 69682).
The authors declare no conflicts of interest.
Context: Community health assessment (CHA) and community health improvement planning (CHIP) is central to public health accreditation and essential functions and therefore important to local health departments (LHDs). However, rural states face significant challenges to pursue public health accreditation.
Objective: The purpose of this statewide study was to identify factors that impede or promote the timeliness of CHA and CHIP completion.
Design: Fifteen focus groups, representing 11 of 15 public health regions, were conducted via telephone, using a structured interview script between April and September 2012.
Setting: The sampling frame for the project was represented by counties in Kansas that planned to conduct a CHA-CHIP activity during 2012.
Participants: Participants (N = 76) were LHD administrators, hospital representatives, and key community stakeholders from frontier, rural, and urban settings who were involved in CHA-CHIP activities. They were predominantly female (86.0%) and 51 years or older (66.7%).
Main Outcome Measures: The study assessed perceptions and opinions about the inputs, process, outputs, and outcomes of CHA-CHIP activities within the community.
Results: Overall, CHA-CHIP implementation in Kansas was in its early stages. Rural counties reported a lack of capacity and confidence to perform many CHA-CHIP activities. Early CHA-CHIP adopters were located in more populous, metropolitan areas and had progressed further into the CHA-CHIP process. Regardless of rural/urban status, a history of collaborative activity among community stakeholder groups appeared to promote progress in CHA-CHIP completion. Participants reported that additional funding, time, trained staff, technical assistance, and community leadership were needed to conduct CHA-CHIP activities. Barriers included maintaining required LHD services while conducting assessment and planning activities and differences in public health and federal cycles for performing CHA.
Conclusions: Study findings have implications for strengthening rural workforce development and technical assistance for CHA-CHIP activities.
Since 1983, the US public health system has explored the implementation of community health assessment (CHA) to facilitate community health improvement planning (CHIP).1 The Public Health Accreditation Board standards2 require public health agencies to complete a CHA-CHIP process when applying for national accreditation; therefore, successful completion of this core public health function is increasingly important to local health departments (LHDs). However, rural states face significant challenges to pursue public health accreditation.3 Of the 100 decentralized LHDs in Kansas, 90 serve predominantly rural and frontier counties with sparsely populated regions that are geographically distant.4
Focus groups were conducted across the state to assess attitudes about the inputs, processes, outputs, and outcomes of CHA-CHIP activities in local communities. Perceptions about local CHA-CHIP progress were explored in addition to perceived barriers, frustrations, and insights about the process. Recommendations for improving the CHA-CHIP process were also collected.
Stakeholders in frontier, rural, and urban counties and regions were recruited to participate in facilitated focus groups to address study questions. Focus group recruitment, facilitation, and analysis followed the standards outlined by Berg.5 Interviews were conducted, transcribed, and analyzed from April to September 2012. Transcripts were analyzed and coded for consensus themes across groups, noting similarities and dissimilarities using an integrated analysis approach that identified conceptual domains and links among responses.6 To describe the characteristics of participants, data about demographics including age, sex, and regional affiliation were collected. Human subject protection was acquired through the Human Subjects Committee at the University of Kansas School of Medicine–Wichita.
A total of 15 focus groups were conducted representing 11 of 15 public health preparedness regions (73.3%) in Kansas. Participants (N = 76) were predominantly female (86.0%) and were 51 years or older (66.7%).
CHA-CHIP definition, partners, and data sources
Participants reported uniform terms and descriptions for CHA-CHIP activities including (1) the importance of community and stakeholder involvement, (2) use of multiple data sources for the community profile, and (3) conducting the CHA-CHIP process in a structured manner (Table). Although an appreciation for an organized method for pursuing CHA-CHIP activities was reported, few participants had any specific model or plan in place. Central motivating factors for pursuing a CHA-CHIP process included public health accreditation and meeting the Affordable Care Act mandate for nonprofit hospitals to perform a community health needs assessment.
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While LHDs and nonprofit hospitals were perceived by participants to be central partners to the CHA-CHIP process, many other stakeholders were described, including local businesses, faith-based groups, local government and elected officials, physicians, mental health care providers, long-term care facilities, academics, and nonprofit organizations. Data sources for the community health profile were also explored, and a variety of CHA data sources were reported. The most frequently mentioned data sources were US census data, chronic disease information, community resources, community surveys and focus groups, vital records, health behaviors, and health care access. Kansas Health Matters7 and the County Health Rankings8 Web sites were frequently used to access data.
CHA-CHIP process: Differences in urban/rural settings
Differences between the urban and rural CHA-CHIP experience were revealed. In general, rural counties were either in the early planning stages or had just begun assembling data for their CHA. Early CHA-CHIP adopters were located in more populous, metropolitan areas and reported using quality improvement methods, consensus-building procedures, and strategic planning models to facilitate their CHA-CHIP activities. Early adopters had progressed further into the CHA-CHIP process and could clearly describe their overall CHA-CHIP plan and how it would be operationalized.
Rural, less populous regions reported (1) small health department staff size and limited opportunities for CHA-CHIP training and (2) less confidence in the ability to conduct a CHA-CHIP process. In addition, rural nonprofit hospitals that worked with LHDs to complete their community health needs assessment frequently used an external consultant to compile their community health profile. These profiles were perceived to favor health care services information versus a more expansive community health status profile. Regardless of rural/urban status, a history of collaborative activity among community stakeholder groups appeared to promote progress in CHA-CHIP completion.
Challenges to perform CHA-CHIP activities
Participant perceptions of required resources to conduct CHA-CHIP activities included:
* additional funding, time, and staff to conduct activities
* improved staff capabilities through training, external technical assistance to support (1) creation and interpretation of the community profile, (2) community meeting facilitation, and (3) adaptation of national models to the rural setting; and
* community leadership and community involvement to create a shared vision.
While barriers were closely associated with required resources, the challenge of maintaining required LHD services and the additional workload of CHA-CHIP activities was reported. In addition, CHA timing cycles, which are 5 years for public health departments versus 3 years for nonprofit hospitals, added to activity fragmentation.
Study findings revealed positive and negative perceptions toward CHA-CHIP activities that were related to public health accreditation and workforce development. Results revealed that CHA-CHIP definitions offered by local practitioners were consistent with those offered by the national public health organizations.2,9 These findings are encouraging and suggest that early dissemination efforts of accreditation guidelines may be successful. Public health accreditation was reported as a motivating factor for pursuing a CHA-CHIP activity and should be leveraged to encourage LHDs to pursue this core public health function. However, timing cycle inconsistencies for CHA activities for public health versus the mandates for local nonprofit hospitals must be addressed for communities to align and integrate their CHA-CHIP activities.
Public Health Accreditation Board Standard 1.1 calls for a collaborative process that results in a comprehensive CHA through strategic health management and effective collaborative efforts.2 In this study, communities that reported previous collaborative activity among stakeholder groups appeared to have progressed further in CHA-CHIP completion. This mediator should be leveraged to the extent possible in local communities; however, research in the value of “public health collaboration” in the progress of community activities is limited and should be studied further.10
Implications for workforce development
Obstacles to performing a quality CHA have been reported11 and pose a challenge for public health workers. Study results suggest a critical need for workforce development, particularly for rural counties that reported a lack of capacity to perform many CHA-CHIP activities. Supportive frameworks that are individualized to rural/urban needs may enable local communities to perform CHA-CHIP processes more independently. The development of a just-in-time training curriculum that emphasizes experiential learning would support rural practitioners' ability to associate evidence-based practices with their experience and existing knowledge.12 As recommended by study participants, the curriculum should address meeting facilitation skills, qualitative research methods, decision-making methods, implementation strategies, and developing communication plans. Finally, a standard organizing framework for the inputs, processes, outputs, and outcomes of the CHA-CHIP process should be developed and offered to rural LHDs. Technical assistance was a frequently reported need and should be more available to public health practitioners. Opportunities to support distance interaction and Web-based just-in-time training should be investigated.
Study limitations may include selection bias, as focus group participants consisted of a convenience sample of local stakeholders in Kansas. Findings may not be generalizable to other states. However, sampling procedures drew from the majority of rural regions in the state and therefore the threat of this bias is substantially reduced. Future research should be pursued in other rural states to assess whether similar perceptions are found. Research is needed to quantify the contribution of collaboration to the progress of CHA-CHIP completion.
CHA-CHIP implementation in Kansas is in its early stages. While the majority of Kansas regions were in the CHA planning stage or data collection stage, there were a few early adopters who had entered the CHIP phase. Study findings have implications for strengthening public health workforce development and technical assistance efforts.
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collaboration; community health assessment; community health improvement planning; public health accreditation; workforce development
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