Graduates of health disciplines such as public health, nursing, and social work may recall a time in their education that they were required to conduct a community health assessment. The stated purpose of this academic exercise was to learn as much as could be about the community in which dedicated work would be done to guide clear plans that fit the needs and assets of that community. The concept of knowing the community that one serves is a major cornerstone both of public health practice and of health department accreditation. Well-conducted community health assessment and community health improvement plans provide the basis for everything else that is documented regarding the capacity of the health department to serve that community.
For accreditation purposes, the Public Health Accreditation Board (PHAB) defines a community health assessment as a collaborative process of collecting and analyzing data and information for use in educating and mobilizing communities, developing priorities, garnering resources or using resources in different ways, adopting or revising policies, and planning and evaluating actions to improve the population's health. A well-developed community health assessment involves the systematic collection and analysis of data and information to provide a sound basis for decision making and action. Community health assessments should be conducted in partnership with other organizations and members of the community and include data and information on demographics, socioeconomic characteristics, quality of life, community resources, behavioral factors, the environment (including the built environment), morbidity and mortality, and other determinants of health. Following on, PHAB expects a community health assessment to lead to a community health improvement plan. For accreditation purposes, a community health improvement plan describes how the health department and the community it serves will work together to improve the health of the population of the jurisdiction that the health department serves. The community, stakeholders, and partners can use a solid community health improvement plan to set priorities, direct the use of resources, and develop and implement projects, programs, and policies. The plan reflects the results of a collaborative planning process that includes significant involvement by a variety of community sectors.1
When public health department accreditation first began in 2007, many health departments had not formalized participatory community health assessment and improvement planning processes. However, since that time, we have observed that most health departments preparing for the accreditation process are now comfortable with their process and engage with their communities in a variety of ways to achieve their goals. The National Association of County & City Health Officials 2016 National Profile of Local Health Departments, for example, noted that the percentages of local health departments with the current community health assessment and community health improvement plans have increased steadily since 2010, from 60% to 78% for the health assessments and from 51% to 67% for the improvement plans.2 In addition, 36 state health departments have either been accredited or are officially working on accreditation in the PHAB system. All of them have completed the recent community health assessment and improvement plans.3
To be accredited, health departments must submit their community health assessment and improvement plans for review. The initial accreditation process looks at the health department's capacity to conduct these activities using the following concepts:
Community Health Assessment
* Purpose is to learn about the health status of the population that the health department serves.
* Describes the health status of the population, identifies areas for health improvement, determines factors that contribute to health issues, and identifies assets and resources that can be mobilized to address population health improvement.
* Developed through a participatory, collaborative process with various sectors of the community.
* Required elements of a community health assessment:
* Various sources of data;
* Population demographics;
* Health issues identified;
* Special populations with health issues;
* Contributing causes of health issues;
* Description of assets to address health issues; and
* Documented input from stakeholders.1
Community Health Improvement Plan
* Purpose is to describe how the health department and the community will work together to improve the health of the population that it serves.
* Based on the community health assessment.
* Community-driven with participation of public health system partners and process to set priorities.
* More comprehensive than roles and responsibilities of health department alone; includes community partners' roles and responsibilities.
* Required elements of a community health improvement plan:
* Community health priorities, objectives, strategies, measures, and time-framed targets;
* Policy changes needed to accomplish objectives;
* Individuals and organizations responsible for implementation;
* Measurable health outcomes or indicators; and
* Alignment with other levels of health departments' and national priorities.1
PHAB emphasizes that the community health assessment/improvement plans work best when a health department is part of a broader coalition of community partners working together. A more detailed review of a selected sample of accredited health departments' community health assessment and improvement plans (n = 53) revealed that the important concept or cross-sector partnerships are being realized among accredited health departments. The Table notes the number and type of partners that were involved in creating the community health improvement plans.4
In that same sample, health status indicators were extracted from the community health improvement plans and were categorized according to whether they were related to population outcomes (eg, reduce the percentage of adults who report a body mass index of 30 or more by at least 1%), community outcomes (eg, increase the number of healthy food outlets), or process outcomes/implementation steps (eg, conduct an assessment of built environment). The indicators were also categorized on the basis of the Healthy People 2020 Leading Health Indicators. A total of 1524 indicators were identified, with an average of 29 indicators per health department. Categories of indicators included nutrition, physical activity, and obesity; access to health services; maternal, infant, and child health; tobacco prevention and control; social determinants/health equity; injury and violence; substance abuse; mental health; clinical preventive services; chronic disease; environmental quality; reproductive and sexual health; oral health; data; overall health and well-being; organizational capacity; and emergency preparedness. From this small sample, one can tell that the community health improvement planning process is an important and powerful tool to bring the community together to work on health status improvement for all.4
PHAB believes so strongly in the power of these tools that accredited health departments are required to report annually what progress has been made in addressing their objectives. PHAB uses this information in 2 major ways: one, is to keep the focus on the practical use of the health assessment and improvement plans in the daily work of health departments with their community partners and stakeholders; and the second is to get a sense at the national level of the types of issues that communities find important. In addition, for reaccreditation, PHAB asks health departments to not only submit their updated community health assessment and improvement plans but also report on the progress that has been made in achieving or revising their health improvement planning goals. In this matter, then, the reaccreditation requirements have been designed to ensure that accredited health departments continue to evolve, improve, and advance, thereby becoming increasingly effective at improving the health of the population they serve.5
The future of the community health assessment and improvement plans is stronger than ever. We have come a long way since the days of the students who wondered about the practical application of a community health assessment. In the 10 years since PHAB was incorporated, health departments working with their communities to conduct the health assessment and improvement plans have become common. Most health departments now have those documents, and updated reports, on their Web sites. There is a shared commitment by many health departments and their communities to keep getting better and more sophisticated at using timely data to track their progress, in understanding their total community and involving the community in setting goals and making decisions, and in being transparent about all of that work.
Looking into the future, the Institute for Alternative Futures published a scenario exploration of what public health might look like in 2030. Working with the public health field, 4 potential scenarios were considered. One of them, clearly the most popular among public health practitioners, describes a country in which health status is paramount.
National and local economies gradually grew, and large-scale changes in values and demographics over time pushed for “common sense” policies and support for health equity. Public health agencies became health development agencies that identify problems and opportunities to improve community health, and catalyze and incentivize action by community, business, health care, and other sectors. Their success as chief health strategists using advanced analytics, gamification, and diverse partnerships led to quality improvements in housing, economic opportunity, education, and other social determinants of health. Although some disparities persisted, in 2030, the vast majority of Americans had attained greater opportunity for good health.6(p19)
Since that report was published in 2014, much attention has been given to the concept of the chief health strategist. The Public Health Leadership Forum, coordinated by RESOLVE, with funding from the Robert Wood Johnson Foundation, released a paper in May 2014 in which key questions were explored.7
What are (and will in the future be) the greatest health threats, and who is (and will be) most at risk? What will it take to reduce these threats and reach the greatest number of high risk populations with whatever resources are available? A starting point is to have access to accurate, timely, and understandable data.7(p7)
While the functional title of chief health strategist might not resonate in all environments, and especially in these changing political times, all of the national public health associations and organizations since that time have released their own commentaries (all positive) about the future need to understand the communities that health departments serve; to develop strong data analysis skills (including qualitative approaches) to analyze and interpret the needs and assets of those communities; and to be able to track and report on health status issues and threats so that policy and practice can be better informed. It is a tall order, and resources are not robust in many parts of the country to accomplish all of this in short order. The shared goals are worthy, and the community health assessment and community health improvement planning processes remain powerful tools to accomplish them.