The Subcommittee has held hearings over the last three years and heard testimony from individuals from federal, state, and local governments and from the private sector, concerning efforts to promote and conduct community health assessment at the local level. There is a growing interest in community assessment in this country. This interest is fueled by changes in the health care industry--the growth of managed care and a new view of the role of hospitals in the community; by a renewed emphasis on assessment as a core function of public health agencies--with a consequent shift away from the provision of health services and toward assessment at the local level; and by changes in information technology which make it easier to share and manipulate information about health outcomes, risk factors and services.
All of these factors coincide with a new emphasis on giving state and local governments more flexibility in solving their problems. Information shared for the community assessment process must comply with statutory and regulatory measures in place to protect the privacy of individuals.
In this context we feel that it is incumbent upon this Subcommittee to provide recommendations that would identify essential aspects of the community health assessment process and indicate ways to facilitate these processes at the community level. Recommendations are provided under three headings: the first concerns characteristics of the community health assessment process itself, the second concerns the role of state health agencies in the process, and the third concerns the role of the federal government in the process.
The literature on community health assessment, including guides and instruction manuals, is growing rapidly. There is no lack of good information from many sources on the process of community health assessment. However, not everything that is done in the name of community health assessment is based on the best principles of data collection, data interpretation, or community interest. At the same time there is no one right way to go about a community health assessment. A good process should have the following characteristics,
Community health assessment is a process--it involves the community in identifying problems, setting priorities, developing an action plan, measuring progress, deciding whether the actions are effective, modifying the actions if necessary, and reevaluating the community's problems and priorities. The importance of these aspects of the process are reiterated below.
Adopt a broad definition of health--consistent with the well-known World Health Organization definition: "A state of complete well-being, physical, social, and mental, and not merely the absence of disease or infirmity." This definition encompasses everybody's concerns and recognizes that aspects of the social and economic environment have an important impact on health.
Involve the community--in the process of reviewing the data, setting priorities, developing an action plan, monitoring progress, changing the plan, celebrating the successes, and moving on to the next problem. Ideally the health department can be the catalyst in this process. If not, the health department should at least be involved in a process which includes board representation from other groups and business in the community.
Involve stakeholders and partners--in the process. When particular issues or problems are identified it may become obvious that the solution involves specific individuals.
Make use of data--and present it to the community in a way that helps them identify problems and set priorities. Make use of data from any and all sources. Examine data for sub-areas and sub-populations when feasible and appropriate. Use both quantitative and qualitative data. Rely on community partners to identify new sources of data. Collect new data if necessary.
Develop an action plan--to address one or more of the problems that have been identified in the community. If the community health assessment does not lead to some sort of action, then it is not worth doing.
An ongoing effort with feedback-- should be implemented. Use data to measure progress. Determine whether the actions taken are having the desired effect, if not, find out why and change the plan. The ongoing effort to measure progress should utilize, whenever possible, nationally recommended or accepted measures of outcomes and/or performance.
Make data available: State health agencies are the repository of many important data bases (vital statistics; hospital discharge records; cancer, trauma, and birth defects registries; communicable diseases; health care resources [long term care facilities, hospitals, HMO's, and health care providers]; health care costs; health care services; and environmental characteristics. While some of these data originate at the local level they may not be available for analysis at the local level, and data for other areas or for the state are frequently needed for comparison purposes. The state health agency should make these data available for use at the local level.
Enhance state-based data systems to provide information at appropriate levels of geographic detail: County level data is frequently inadequate. Data may be needed for towns, zip codes, census tracts, health service area, etc. Data systems must be enhanced to provide additional levels of geographic detail. Geographic information systems (GIS) are now available and are beginning to be used in community health assessment activities. These systems need data coded in terms of latitude and longitude in order to make maximum use of the capability of these systems. States should add geographic detail to appropriate data files.
Enhance and augment state data bases: States and communities should take advantage of opportunities to participate in national data collection efforts that would provide state and/or community level data needed for community assessment.
Increase access to data using appropriate technology: While printed reports and tables are still an important source of information for many areas, local health officials are increasingly anxious to access the primary statistical files. From printed reports to on-line access to data files there is a continuum of access. Information should be provided in ways that are most useful to communities.
Explore access to private sector data: State health agencies should explore the desirability and feasibility of accessing private sector data. The potential to integrate these data with public sector data to obtain a more complete picture of the community should be considered, and the possibility of linking private and public sector data to study health outcomes should be explored. These data could make a significant contribution to local community assessment.
Provide leadership and training: Here again there is a wide continuum of expertise in using data, involving the community and mobilizing for action among communities. The state health agency can play a substantial role in training local health agencies and individuals from the community in the process of community health assessment. Training in the tabulation, analysis, interpretation and presentation of data are among the needs most often mentioned by local health departments.
Promote flexibility in the use of federal and state funds: The process of community health assessment should address a broad range of health outcomes, risk factors, and community services. Funding sources should make it easier for communities to use funds to hire and make effective use of staff for such board-based efforts.
Encourage flexibility and coordination of programs: State health agencies can also encourage innovation at the local level by making it possible for communities to pool staff, equipment and resources at the local level to achieve shared program goals.
Promote community health assessment through Healthy People 2010: National and state objectives for the Year 2000 have played an important part in many community health assessment efforts. Healthy People 2000 includes objectives for Surveillance and Data Systems. One or more objectives for the year 2010 should be developed to promote the process of community assessment and community action at the local level.
Support development of the Guide to Community Preventive Services: The process of community health assessment should lead to the identification of particular problems that require action. Unfortunately, the information required to select effective programs is often fugitive. The Centers for Disease Control and Prevention has initiated an effort to develop a Guide to Community Preventive Services. This guide should bring together all of the available information about the effectiveness of community-based prevention efforts. This would be an invaluable resource to state and local health departments who want to initiate new programs or make existing programs more effective. This activity should be adequately staffed and funded to fulfill its promise.
Provide support for State Centers for Health Statistics: The NCVHS previously made a number of specific recommendations to revitalize and enhance State Centers for Health Statistics to provide the necessary support for state and community health assessment. These recommendations should be pursued.
Provide leadership in exploring access to private sector data: As noted above in recommendations for states, the ability to combine data from the public and private sectors would provide a more complete picture of health care in communities. The federal government should provide leadership to states in their efforts to explore access and use of data from the private sector.
Promote flexibility in the use of federal funds: It has always been difficult to fund data systems and other broad-based assessment activities. The mandate to use federal dollars to support data collection, analysis, dissemination and planning should be more explicit. While increased flexibility is desired, appropriate accountability for the funds is necesary (see below).
Revise Federal audit procedures: Federal audit procedures are frequently cited as a reason why states have not been able to pool federal dollars or share staff between projects. These procedures should be revised and clarified so that states are assured that they can use funds in a more flexible way with appropriate documentation.
Provide technical support for state and local efforts: The Guide to Community Preventive Services is one example of the kind of technical assistance that the federal government can provide for the entire public health community. Development of the Health Status Indicators associated with Heathy People 2000 objective 22.1 is another example of an effort to promote standardized comparisons of health measures at the federal, state and local level. Additional opportunities should be identified to prepare model reports that state and local health departments could emulate (such as leading causes of death, reports on behavioral risk factors, reports on hospital discharge data, etc.) and additional opportunities should be explored to provide statistical training to state health department personnel and to develop materials for use in training local health department personnel. The federal statistical agencies also need to have available the technical staff to provide consultation and assistance to state health agencies.
Enhance collection, analysis, and dissemination of data: Federal statistical agencies can continue to provide leadership in the area of data collection and processing. The current effort to re-engineer the completion of death certificates is an important step in automating the process of death certification. Similarly the federal government can encourage states to code and tabulate data at the finer levels of geographic detail that are called for in community health assessment. National data systems (like the National Health Interview Survey) should be designed to provide state level data wherever possible and/or allow states the opportunity to buy into a national data collection effort for geographic areas of interest.