Community health assessments (CHAs) and community health improvement plans (CHIPs) are interconnected processes that local public health agencies (LPHAs) and community partners can use to drive improvement in community health.1 The CHA involves data collection and analysis to describe community health status, determine priority health concerns, and identify strategies and community partners to help with implementation.2,3 The CHIP is a 3- to 5-year written plan to address the key health-related issues identified by the CHA.1,4,5 Although complementary, CHAs and CHIPs have distinct requirements and functions and thus may have different drivers motivating their completion.
Drivers of CHIP completion may include factors internal and external to the LPHA. The role of dedicated staff and dynamic leadership providing backbone support for the CHIP partnership are internal factors to the LPHA that may motivate CHIP completion as well as assist in convening partners, encouraging diversity, and inspiring and empowering partners for a common mission.6–9 External drivers that contribute to the success of the CHIP completion may include ensuring partner perspectives, expertise and skills, and resources to achieve partnership synergy (including trust, joint ownership, and effectiveness in reaching goals).6,10 Other external drivers such as state and federal initiatives, state-specific mandates, or funding opportunities may also motivate CHIP completion. These external drivers encourage individual agencies, such as LPHAs, nonprofit organizations, and hospitals, to work together and complete a CHIP.2,10 Prerequisites for national voluntary public health accreditation, which include the completion of CHAs and CHIPs, are also external drivers that may motivate CHIP completion.11,12
This explanatory mixed-methods study, comprising a survey and key informant interviews among 57 LPHAs, is one of the first to explore drivers that lead to CHIP completion among LPHAs in the Rocky Mountains and Western Plains and contributes to the current literature on the CHIP. The study's findings are linked to the strategic direction of the Health Resources and Services Administration (HRSA)–funded Rocky Mountain Public Health Training Center (RMPHTC) and other training centers nationally to design curriculum and training to enhance public health partnerships with health care systems. Findings from this study can also be used to direct local and state governments nationwide to rethink, redesign, and improve the process of conducting a CHIP, the components incorporated in the CHIP, and means of tracking CHIP progress.
The study used an explanatory mixed-methods design—including a survey and key informant interviews—to examine external and internal factors that motivate CHIP completion. The research was approved as exempt by Colorado Multiple Institutional Review Board.
The sample included 51 medium to large LPHAs in the Rocky Mountain region (Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming) and 2 Western Plains states (Kansas and Nebraska). These states were selected on the basis of the proximity of states to Colorado and the working relationships with 6 of the states with the HRSA-funded RMPHTC. Only medium- to large-sized LPHAs were included because these agencies have a larger, more diverse workforce and were more likely to have completed a CHA and a CHIP in the last 3 years.10,13 Established National Association of County & City Health Officials (NACCHO) criteria were used to classify LPHAs as medium or large: a medium LPHA serves a population of 50 000 to 499 999, and a large LPHA serves populations of more than 500 000.14 Directors or public health planners of all 51 LPHAs received the questionnaire. Key informant interviews were conducted with officials at 16 of 51 randomly selected (using a random number generator) LPHAs (∼2 per state). Key informant interviews were conducted only among LPHAs that reported CHIP completion or working on a CHIP.
The survey included 47 closed- and open-ended questions and was created in SurveyMonkey. While some survey questions were based on existing questionnaires, others were created for the study.15,16 All questions were reviewed and pretested by experts in the field.
The questionnaire asked about CHIP completion status (completed, in progress, not started) and to detail which steps LPHAs had completed, as recommended by NACCHO in conducting a quality CHIP process and document (ie, reviewed CHA findings, received member and partner input, chose CHIP priorities based on partner input, developed a CHIP implementation plan, devised a process for monitoring the CHIP, and distributed the CHIP in the community).17 The lead agency for the CHIP and any dedicated funding for the CHIP (external and internal) were documented (<$5000; $5000 to <$25 000; $25 000 to <$45 000; $45 000 to <$65 000; and >$65 000).
LPHAs that had completed or were in the process of completing the CHIP were then asked about drivers that motivated their agency to conduct the CHIP, the involvement of CHIP partners, characteristics of the CHIP partnership, and partnership synergy. Motivational factors were rated on 4-point scale (“a lot,” “somewhat,” “a little,” to “not at all”) and included a statement about available state or federal funding; voluntary public health accreditation; state requirements; working with a local nonprofit hospital on Community Health Needs Assessment (CHNA); belief that conducting a CHIP is a best practice; and belief that LPHAs would receive money if they conducted CHIP. LPHAs were asked to describe the level of involvement again using the responses “a lot” to “not at all” of partners in the CHIP process (Figure 1). LPHAs also described whether the CHIP partnership continued to meet if the partnership was monitoring outcomes and how those outcomes were communicated. To address “partnership synergy,” LPHAs were asked a series of questions about characteristics of the partnership including developing effective decision-making processes, valuing input of partner agencies, developing common goals, involving new partners to create new ways of thinking, tracking progress toward goals, achieving goals, creating a mutually beneficial partnership, and communicating progress to partners.
Public health directors and planners were contacted in spring 2016 using a personalized letter of invitation and e-mail invitation with an URL to the electronic version of the survey. Follow-up e-mails were sent weekly to nonresponders, with a phone call made 4 weeks after initial contact.
Statistical analysis was conducted using SPSS. All respondents that did not complete the entire survey were dropped from analysis and reporting of findings (n = 6). No major differences were found when comparing LPHAs that did not complete the entire survey with those that did complete the entire survey. All categorical variables were summarized using frequencies, and all continuous variables were summarized using descriptive statistics of central tendency (mean, median, mode, range, and standard deviation).
Key informant interview guide development
The key informant interview guide was developed and questions were designed to confirm that key informant interviewees had the same understanding of the concepts and terms used in the survey, to clarify and elaborate on issues and discrepancies that arose from survey responses, and to identify any concepts that were not included in the survey. Key informant interview questions were structured on responses from the survey and informed by the Kansas Health Institute survey instrument and key informant interview guide, which described CHA and CHIP experiences among 67 LPHAs in Kansas.15 The key informant interview questions were vetted and pretested with public health professionals with experience from local and state health departments.
Key informant interviews were conducted in fall 2016. LPHA directors or public health planners were contacted by e-mail and phone to schedule an interview. Those contacted could designate others in the agency to participate in the interview. After connecting with the interviewee, a 45- to 60-minute interview was scheduled using the phone or videoconferencing.
During the interview, all participants were asked permission to record the interview and allow quotes. A semistructured interview approach was used during the interview. Each interview was transcribed and uploaded into Atlas.ti, qualitative analysis software. A deductive coding scheme, which incorporates themes from the literature and generated from the interview process, was used for coding.18,19 All interviews were coded by the lead researcher, with a second coder coding 40% of the interviews to reduce bias.18
Codes were reviewed for duplication or similar meanings and were then condensed into dominant themes and subthemes using classical content analysis.18 Finally, distinctions and similarities found in the qualitative findings were compared with quantitative findings. For analysis, only themes mentioned more than 50% of the time, by at least 2 respondents, or responses that were not in the closed-ended response ranges in the survey are reported.
LPHA response to the survey questionnaire
Most LPHAs (79%; n = 45 of 57) completed the entire questionnaire. Of these, the majority (80%) had completed their CHIP, 13% were in progress, and the remainder had not started (Table). Of the 42 LPHAs that completed or were working on the CHIP, 100% had completed the first 2 process steps: “reviewing the CHA findings” and “engaging community partners and members,” followed by “determining CHIP priorities based on community partner input” (97%), “developing a CHIP implementation plan” (87%), devising a process for monitoring the CHIP” (85%), and “distributing the CHIP in the community (88%).”
LPHAs led the process more than 80% of the time (see the Table). Other lead agencies from the list provided included hospitals (4%), community coalitions (4%), joint ventures of LPHAs and hospitals or community coalitions (4%), nongovernmental organization (2%), and (4%) “I don't know.” About two-thirds of LPHAs (69%) reported receiving some funding to conduct the CHIP, with a quarter saying they did not (see the Table).
Figure 2 summarizes key motivators for working on or completing the CHIP from the list provided in the survey. Of the 42 LPHAs working on or that had completed the CHIP, completion of the CHIP is often driven by the belief that conducting a CHIP is a best practice (78%). Other factors include pursuing accreditation (39%), working with a nonprofit hospital (40%), meeting state requirement (18%), receiving accreditation (18%), receiving state and federal funding (5%), and belief in receiving funding (2.5%).
Figure 1 illustrates the engagement of diverse community partners to complete the CHIP from the list provided in the survey and shows some partners that are almost always included. When asked to identify which synergistic characteristics were important to the partnership's success, LPHAs selected the following more than half the time: valuing partner input (78%); developing common goals (62%); and achieving goals (56%) (see Figure 3 for a full list of responses).
Key informant interviews: LPHA leaders tell the story
The characteristics of the LPHAs interviewed are comparable with those of the survey participants (Table). Slightly more (94%) had completed at least 1 round of the CHIP than those in the survey, and 50% interviewees were working on or had completed their second CHIP.
When elaborating upon and clarifying survey responses, all the CHIP completion steps listed in the survey were mentioned in addition to 2 new steps—plan approval and adoption—as described by this director: “So, what we ended up doing was to take it [the CHIP] to all the cities and the county commission and asking them to adopt it as their guiding document and so all of those did that” (Director). Barriers to completing the CHIP process came up in 94% of the interviews. The most prominent barrier was waning commitment to the CHIP.
I think the greatest challenge with the CHIP is keeping the momentum because five years is a long time. ...we have had a lot of turnover with community partners who were working these organizations. ...they leave and suddenly they are not involved in our workgroups and coalition anymore. (Accreditation Coordinator)
The interviewees explained that waning commitment occurred because of busy partners, lack of accountability, and difficulty in sustaining energy to the CHIP over time. The next biggest barrier identified was the lack of resources and training. Funding, specifically the lack of funding, as well as discrepancies between funding priorities in communities and alignment with current state or federal funding, was also included in this theme.
Of the key informants, 88% noted that the LPHA was the instigator or lead entity whereas 13% pointed out that partner agencies were the lead entity. As the CHIP process continued, however, more than 50% of the interviewees noted that the lead entity became a joint venture, with agencies such as federally qualified health centers or local nonprofit hospitals working with the LPHA to conduct and complete the CHIP and later with partner agencies taking charge of implementation. “I would say it was the health department that spurred the process, but it took on legs of its own. Our CHIP implementation was done primarily by our partners” (Accreditation Coordinator).
Themes on motivating factor uncovered in the qualitative analysis closely matched what was reported in the survey, with the most prominent motivating factor being belief the CHIP process as a best practice as mentioned by all interviewees. Other themes cited by at least half of interviewees included pursuing accreditation and hospital requirement to do the CHNA.
Community partners mentioned in the interviews that did not show up in the close-ended survey question included United Way, human services, local libraries, media, and boards of health. Interviewees also described the roles that community partners and community members play in the CHIP process. Of greatest importance was partners taking on responsibility for and implementing the priorities selected in the CHIP, followed by partners being integral to the entire CHIP process. As one director explained, “Without them [the partners], it is not really a CHIP. It is a strategic plan, in my mind.” Community partners were also viewed as guiding the CHIP process and providing new perspectives and information. These 4 roles were mentioned by most participants.
When discussing characteristics that made their CHIP partnership successful (or contributed to a synergistic partnership), the major themes that emerged were investment or committed partners, a mutually beneficial partnership, development of common goals, and diversity. Other themes that arose around successful partnerships not found in survey responses were good leadership, which was characterized by having leadership involved through support and oversight of the process, and partnership support involved having a “backbone” agency or LPHA involvement in the CHIP process.
This study demonstrates that most LPHAs in the Rocky Mountains and Western Plains have embraced developing and publishing a CHIP as a best practice to improve the quality of their approach to changing population health. The investment and cooperation of community partners increase through the process. The quality of completed CHIPs is strengthened through engagement of diverse partners and use of standard processes.
The findings from the surveys and interviews intersect to reveal a common set of external and internal drivers that motivate CHIP completion. External drivers include the IRS requirements for nonprofit hospitals to conduct a CHNA and develop an implementation strategy, committed partners, state requirements for LPHAs to develop a CHIP, LPHAs striving for accreditation, and, to a less extent, funding. Internal drivers such as belief in best practices and other drivers such as a synergistic partnership, partnership support, and good leadership also lead to CHIP completion.
IRS requirements for nonprofit hospitals to conduct a CHNA and develop an implementation strategy have encouraged nonprofit hospital collaboration in the CHIP process.10 Hospitals are important partners in many communities to ensure population health and often contribute to CHIP completion by providing resources such as staffing and funding during the CHIP process. “They [the hospital] played a big role ... right now with this current CHIP” (Division Director). Some LPHAs plan to change the CHIP time frame to match the hospital's CHNA timeline during their next CHIP iteration and to improve hospital and LPHA collaboration further.
Committed partners such as nonprofit hospitals (NPH), community-based organizations (CBOs), and government agencies were viewed by LPHAs as driving CHIP completion. These agencies have a vested interest in working with the LPHAs to complete the CHIP.10 Many government agencies and CBOs have a long-standing history of collaboration with LPHAs and doing assessment and planning work in the community.
The passage of the Public Health Act in Colorado in 2008 mandating the completion of CHA and CHIP every 5 years is a major driver for LPHAs to complete a CHIP as noted by 100% of Colorado respondents.20 No other states in this study had such a mandate. Pursuing voluntary accreditation is also a driver that motivated CHIP completion. More than half of LPHAs in this study were pursuing or had completed the voluntary public health accreditation process, which requires completing both a CHA and a CHIP.
Although desirable, funding may be less of a motivator since many LPHAs and partner organizations were willing to complete the CHIP regardless of funding. Most LPHAs in this study reported slightly lower funding levels (<$45 000) than those described in the literature. The cost to conduct the CHA and CHIP for medium LPHAs ranges between $70 000 and $200 000 and between $225 000 and $450 000 for large LPHAs.21 LPHAs were resourceful by using a variety of funding sources to conduct the CHIP and in leveraging funds from partner organizations.
Internal drivers that motivate CHIP completion involve belief in best practices as well as partnership support and good leadership all of which contribute to partnership synergy. LPHAs mentioned the importance of doing public health work. “To me a motivator ... this is the future of public health, and we needed to get on board. A piece of that transformational change for public health” (Director). Public health's 3 core functions and 10 essential services have solidified public health work for the last 20 years. Conducting the CHIP falls in line with the essential services framework by ensuring that LPHAs identify health priorities and develop plans to improve community health and well-being.1,12 In completing their CHIPs, LPHAs also followed a common set of steps and best practices based on national frameworks, which include the investment in quality improvement activities such as regular monitoring and tracking of strategies associated with CHIP priorities as well as evaluating the longer-term impact of those CHIP strategies.3,17
Partnership support, that is, having a backbone organization, is critical to CHIP completion by having organizations such as the local LPHAs initiate CHIP activities, provide personnel to attend committee meetings, and push the process forward. “I think we [the LPHA] have people on staff who are really committed to it and willing to go the extra mile to keep it afloat” (Director). Good leadership by the LPHAs was also an integral driver to CHIP completion.
Synergistic CHIP partnerships, specifically partnerships with diverse partners, resources, and ideas, are critical to the development and completion of quality outcomes such as the CHIP.6,8 The study highlights elements of a synergistic partnership that motivate CHIP completion including a mutually beneficial partnership, development of common goals, provision of additional resources and ideas, sharing of information, and engagement of new partners.
There are several limitations to this study. The study uses a small sample size, which does not represent LPHAs across the United States. No data were collected from community partners that assisted with the CHIP process or from LPHAs that were not working on or ever completed the CHIP. Without these data, the ability to thoroughly analyze the factors that support CHIP completion is constrained.
Implications for Policy & Practice
* This explanatory mixed-methods study demonstrates that the future of CHIP creation nationally depends on LPHAs and partners investing in the CHIP as a best practice, personnel dedicated to CHIP activities, and enhancement of leadership skills to contribute to a synergistic partnership by effectively working and communicating with diverse partners and developing and achieving common goals.
* Since best practices to creating the CHIP have been established and disseminated, emphasis should shift to training and development of personnel to concentrate on leadership skills in 2 areas.
* First, it is essential to ensure implementation of the CHIP based on best practices and critical evaluation of strategies to generate data that will guide quality improvement processes and incorporation of the data in subsequent CHA and CHIP rounds.
* Second, leadership skills are essential to lead and improve the development of synergistic partnerships between LPHAs and other partners, specifically nonprofit hospitals and CBOs.
* Further guidance to stimulate the integration of strategies in LPHA CHIPs and nonprofit hospital implementation strategies is merited.
* Development of agency policies that encourage efforts to jointly schedule CHAs, CHNAs, other needs assessments, and CHIPs, implementation strategies, and improvement plans is justified, so there is sufficient alignment of resources and efforts to gain efficiencies and benefit from the collective impact.
* Adjustment to the mandated schedules of the nonprofit hospitals should then lead to recognition and in-kind contributions of the hospitals that benefit other agencies' shared efforts.
1. Centers for Disease Control and Prevention. What is a community health assessment? https://http://www.cdc.gov
/stltpublichealth/cha/plan.html. Published November 9, 2015. Accessed December 5, 2016.
2. Centers for Disease Control and Prevention. Drivers of health assessment and improvement planning. http://http://www.cdc.gov
/stltpublichealth/cha/drivers.html. Accessed November 5, 2015.
3. National Association of County & City Health Officials. Community health assessment and improvement planning. http://archived.naccho.org/topics/infrastructure/chaip. Accessed December 5, 2016.
4. Durch JS, Bailey LA, Stoto MA. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: National Academies Press; 1997.
5. Committee on Using Performance Monitoring to Improve Community Health/Institute of Medicine. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: National Academies of Sciences; 1997.
6. Lasker RD, Weiss ES, Miller R. Partnership synergy: a practical framework for studying and strengthening the collaborative advantage. Millbank Q. 2001;79(2):179–205.
7. Kellar-Guenther Y, Betts W. Collaboration Toolkit. Denver, CO: Collaboration Technical Assistance Project; 2012.
8. Weiss ES, Anderson RM, Lasker RD. Making the most of collaboration: exploring the relationship synergy and partnership functioning. Health Educ Behav. 2002;29(6):683–698.
9. Kania J, Kramer M. Collective impact. Stanford Soc Innov Rev. Winter 2011:36–41.
10. Laymon B, Shah G, Leep CJ, Elliger JJ, Kumar V. The proof's in the partnerships: are Affordable Care Act and local health department accreditation practices influencing collaborative partnerships in community health assessment and improvement planning? J Public Health Manag Pract. 2015;21(1):7–12.
11. Public Health Accreditation Board. Standards and Measures. Alexandria, VA: Public Health Accreditation Board; 2013.
12. Shirey L. Opportunities for hospital and local health department collaboration for community health assessment and improvement planning. https://live.blueskybroadcast.com/bsb/client/CL_DEFAULT.asp?Client=354947&PCAT=7116&CAT=7351. Accessed December 10, 2016.
13. National Association of County & City Health Officials. NACCHO 2013 Profile of Local Health Departments. Washington, DC: National Association of County & City Health Officials; 2013.
14. National Association of County & City Health Officials. NACCHO 2008 Profile of Local Health Departments. Washington, DC: National Association of County & City Health Officials; 2008.
15. LaClair B, Wetta R, Pezzino G, Dong F. Community Health Assessment and Health Improvement Planning in Kansas: Early Experiences and Factors that Influence Timeliness and Quality. Topeka, KS: Kansas Health Institute; 2013.
16. Stoto MS, Straus SG, Bohn C, Irnai P. A Web-based tool for assessing and improving the usefulness of community health assessments. J Public Health Manag Pract. 2008;15(1):10–17.
17. National Association of County & City Health Officials. CHAs and CHIPs for Accreditation Preparation Demonstration Project Advisors and Partners: Recommendations on Characteristics for High-Quality Community Health Assessments and Community Health Improvement. Washington, DC: National Association of County & City Health Officials; 2014.
18. Johnson RB, Onwuegbuzie AJ. Mixed methods research: a research paradigm whose time has come. Educ Res. 2004;33(7):14–26.
19. Teddlie C, Tashakkori A. Foundations of Mixed Methods Research. Los Angeles, CA: Sage; 2009.
20. Colorado Public Health Reauthorization Act SB 08-194: Executive Summary. https://http://www.colorado.gov
/pacific/sites/default/files/OPP_Public-Health-Act-Summary_0.pdf. Accessed December 15, 2016.
21. Thielen L, Leff M. Ready, set, go: the costs of prerequisites for National Voluntary Accreditation of Public Health Agencies. Robert Wood Johnson Foundation Web site. http://http://www.rwjf.org
/en/library/research/2010/01/ready-set-go.html. Published 2010. Accessed December 10, 2016.
community health planning; motivation; public health systems research