essay on health needs assessment

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Guide to Writing an Excellent Community Health Assessment Analysis Essay

Rachel r.n..

• May 20, 2024
• How to Guides

A Community Health Assessment Analysis Essay is a comprehensive academic paper that requires nursing students to conduct an in-depth evaluation of the health status, needs, and concerns of a specific community. The primary goal is to demonstrate proficiency in data collection, analysis, and proposing evidence-based interventions to address identified health issues.

As a nursing student, you’ll likely be tasked with writing a community health assessment analysis essay. This assignment evaluates your ability to assess a community’s health needs, analyze data, and propose evidence-based solutions. To excel, you’ll need to follow a systematic approach and provide in-depth analysis. This guide will walk you through the process step-by-step.

Step 1: Choose a Specific Community Define the community you’ll focus on narrowly. For example, instead of a general “urban community,” choose a particular neighborhood like “Downtown Oakville” or a group like “Hispanic immigrants in Oakland County.”

Step 2: Gather Comprehensive Data Collect extensive data from reliable sources on the community’s:

• Demographics (age, gender, race/ethnicity, income levels)
• Health statistics (rates of diseases, infant mortality, life expectancy)
• Access to healthcare services (number of clinics, hospitals, uninsured rates)
• Environmental factors (air/water quality, toxic exposures, crime rates)
• Social determinants (education, housing, transportation, food access)

Use government databases like County Health Rankings, CDC reports, academic journals, and local non-profit organizations.

Step 3: Identify Key Health Issues Thoroughly analyze the data to pinpoint the critical health concerns. For example, if your data shows the community has high rates of obesity, diabetes, and low fruit/vegetable consumption, you could identify “Diet-related chronic diseases” as a major issue.

Step 4: Analyze Root Causes Don’t just state the issues superficially. Dive deeper to analyze the potential underlying reasons. Continuing the previous example, you could discuss:

• Lack of affordable fresh food options
• Prevalence of food deserts
• Low health literacy
• Cultural dietary patterns
• Poverty and inability to access healthy foods

Step 5: Propose Multi-Faceted Interventions Develop a comprehensive intervention plan to address the issues and root causes. For diet-related diseases, you could recommend:

• Launching community gardens and nutrition education programs
• Attracting a full-service grocery store through tax incentives
• Partnering with food banks for healthy food distribution
• Promoting corporate wellness programs and preventative screenings

Step 6: Justify with Evidence Support every recommendation using strong evidence and reasoning from authoritative sources. For example, you could cite studies demonstrating the effectiveness of community gardens for increasing vegetable consumption and reducing obesity rates.

Step 7: Structuring Your Essay Your essay should follow a clear, logical structure:

• Introduction (Describe community and health issues)
• Body Paragraphs
• Health Data Analysis (Quantitative assessments using statistics/charts)
• Root Cause Analysis (Qualitative assessments examining social factors)
• Intervention Plan (Describe multifaceted strategies in detail)
• Justifications (Provide evidence for why interventions will work)
• Conclusion (Summarize main points and importance of your proposals)

Step 8: Edit Meticulously Ensure your writing is clear, coherent, and free of errors. Use appropriate nursing terminology. Formatting and citations should comply with guidelines.

What You'll Learn

Structure of a Community Health Assessment Analysis Essay

Introduction

• Clearly define and describe the chosen community (e.g., Downtown Oakville neighborhood, Hispanic immigrants in Oakland County).
• Provide an overview of the major health concerns or issues identified through preliminary research.

Body A. Health Data Analysis

• Demographics (e.g., age, gender, race/ethnicity, income levels) from census data
• Health statistics (e.g., disease rates, infant mortality, life expectancy) from CDC reports
• Access to healthcare services (e.g., number of clinics, hospitals, uninsured rates) from local health department
• Environmental factors (e.g., air/water quality, toxic exposures, crime rates) from EPA databases
• Use charts, graphs, and tables to effectively visualize and interpret the data.
• Example: A chart showing the community has higher rates of obesity (35%) compared to the national average (27%).

B. Root Cause Analysis

• Examine the potential underlying reasons or social determinants contributing to the identified health issues.
• Explore factors such as income levels, education, housing conditions, access to healthcare, environmental exposures, cultural practices, and health literacy.
• Example: For the high obesity rates, analyze factors like prevalence of food deserts, lack of affordable fresh food options, low health literacy, and cultural dietary patterns.

C. Intervention Plan

• Develop a comprehensive, multi-faceted plan to address the health concerns and their root causes.
• Interventions may include community education programs, policy changes, improvements to healthcare access, environmental modifications, or partnerships with local organizations.
• Example: For obesity, propose interventions like launching community gardens, nutrition education, attracting a grocery store through tax incentives, promoting corporate wellness programs.

D. Justifications

• Provide evidence from authoritative sources (research studies, best practices, expert recommendations) to support the proposed interventions and their potential effectiveness.
• Explain how the interventions align with nursing principles, theories, and practices.
• Example: Cite studies demonstrating the effectiveness of community gardens for increasing vegetable consumption and reducing obesity rates.
• Summarize the main points and key findings from the assessment.
• Reinforce the importance and potential impact of the proposed interventions on improving the community’s health outcomes.
• Highlight the role of nurses in promoting community health and addressing public health challenges.

Tips for Writing a Community Health Assessment Analysis Essay

• Proficiency in data collection and analysis from various sources
• Critical thinking and ability to interpret data to identify health concerns
• Understanding of social determinants of health and their impact
• Knowledge of evidence-based interventions and strategies in community health nursing
• Effective communication and academic writing skills
• Proper use of nursing terminology, formatting, and citation styles (e.g., APA)

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Community Health Assessment Essay

50 potential community health assessment analysis essay topics:

• Assessing mental health needs in urban low-income neighborhoods
• Analysis of childhood obesity rates and interventions in your local school district
• Evaluation of prenatal care access and outcomes in rural communities
• Assessment of environmental pollution impacts on respiratory health in industrial areas
• Analyzing food insecurity and nutrition programs for senior citizens
• Assessing healthcare access barriers for immigrant and refugee populations
• Evaluation of substance abuse prevention programs for at-risk youth
• Analysis of chronic disease management resources for the uninsured
• Assessment of community resilience and disaster preparedness plans
• Evaluating workplace wellness programs and employee health initiatives
• Assessing oral health education and dental care access in underserved areas
• Analysis of community support services for new mothers and infants
• Evaluation of fall prevention programs for elderly community residents
• Assessing health literacy campaigns and impacts on preventative screenings
• Analysis of HIV/AIDS education, testing, and treatment resources
• Evaluating community violence intervention and anti-bullying programs
• Assessment of tobacco cessation services and policies in your county
• Analysis of housing conditions and effects on respiratory health
• Evaluating recreation facilities, green spaces, and community physical activity
• Assessing access to healthy food options in food deserts
• Analysis of community water quality, sanitation, and waterborne illnesses
• Evaluating mental health support services for veterans and their families
• Assessment of vaccination rates and vaccine-preventable disease outbreaks
• Analysis of noise pollution levels and impacts on cardiovascular health
• Evaluating workplace safety regulations and occupational injury rates
• Assessment of heat illness prevention for outdoor workers
• Analysis of community approach to Alzheimer’s disease and dementia care
• Evaluating drunk driving prevention and alcohol awareness programs
• Assessment of services for homeless individuals with chronic illnesses
• Analysis of support resources for children with developmental disabilities
• Evaluating community pools, water safety education, and drowning prevention
• Assessment of health education campaigns around infectious disease outbreaks
• Analysis of services for LGBTQ+ community members’ specific health needs
• Evaluating community approaches to tackling the opioid crisis
• Assessment of language barriers impacting healthcare access and compliance
• Analysis of traffic safety measures and pedestrian accident rates
• Evaluating fall prevention education and home modification programs
• Assessment of cancer screening promotion and early detection initiatives
• Analysis of mosquito control efforts and impacts on mosquito-borne illnesses
• Evaluating community gardens and their effects on nutrition and food access
• Assessment of vision and hearing screening programs for school-aged children
• Analysis of pet overpopulation and impacts on community public health
• Evaluating workplace stress management resources and mental health support
• Assessment of community preparedness for extreme weather events
• Analysis of women’s health education and breast/cervical cancer awareness
• Evaluating anti-vaping campaigns and e-cigarette prevention for youth
• Assessment of skin cancer prevention education and tanning bed regulations
• Analysis of suicide prevention resources, awareness, and crisis intervention
• Evaluating community approaches to addressing loneliness and social isolation
• Assessment of neighborhood walkability, pedestrian infrastructure, and benefits

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11.1 Health needs assessment

• Published: February 2015
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This chapter begins with a consideration of the technical processes used for conducting health needs assessment. The relationship between health needs assessment and health economics is then examined and the philosophy of utilitarianism and its influence on health economics is explored. Cost utility analysis and its links to studies of quality of life are described and the important relationships between equity and efficiency are considered. The chapter then proceeds to explore the political and philosophical issues attaching to health needs assessment. This leads to an elaboration of the concept of justice derived from the work of Sen. Using ideas about the importance of human capabilities an argument is developed about the relational approach to understanding justice. The relational as against the individualistic position is found to provide a novel and useful way of describing health need and of attempting to meet that need. It also provides a set of precepts about the ways that services might be configured.

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A Needs Assessment in Health Promotion Essay

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Health promotion is an important aspect, which purpose might be seen in increasing control and health improvement. In that regard, planning community organizing in the name of the town/city, state, began with recognizing an existing problem, which was a high number of reported health problems. The present paper provides a protocol for mobilization of the aforementioned community, audience segmentation, and needs assessment.

The first step is to conduct a needs assessment. With the issue being recognized being sufficient to bring attention to the problem, it can be seen as too general to create efficient strategies to target the problems. Thus, needs assessment, i.e. “a process by which data about the issue of concern are collected and analyzed” (McKenzie, Pinger, & Kotecki, 2008, p. 127), should help identify the problems to be addressed more specifically. The determination of the process for data collection for needs assessment is largely defined by the type of information needed and the sources of such information.

With the purpose of community mobilization being health promotion, the limits of the data set for collection would be health problems related to lack of health behavior and life styles. In that regard, as the problems are health problems related to registered problems by the community members as well as life style issues, it can be stated that the health department and the human service department would be the sources for data collection, which will be expanded through conducting a survey in the community. The reason for conducting the survey will be filling the gap on health problems related to lifestyle.

Another purpose of conducting a survey can be seen in segmenting the audience, in order to define sub-groups and priority audiences. The choice of segmenting on a variety of dimensions, other than demographic and geographic characteristics, is rationalized by the intention of identifying “attitudinal beliefs and perceptions of relevant social norms… [and] salience of, and involvement with, the health behavior and presence of relevant social norms” (Siegel & Doner, 2007, p. 304).

After the needs are identified and the audience is segmented, a public forum will be conducted to determine the capacities of the available human and financial resources. Based on such determination, the issues will be prioritized (McKenzie, et al., 2008, p. 128), reaching a consensus on the issue that will be addressed first. The VMOSA (Vision, Mission, Objectives, Strategies, and Action Plans) model will be chosen as the framework for strategic planning, in which the objects are community-oriented, with the mission and the vision being identified through the course of the assessment (CTB, 2010).

The intervention strategy will be based on communication and education. In the first case, appropriate communication vehicles will be selected for such purposes, which are pamphlets and booklets. In terms of education, lectures and group work will be chosen as activities. The rationale for such selection can be explained through community involvement through attendance of lectures and group work as well as the ability to distribute communication materials, i.e. the pamphlets and the booklets.

It can be concluded that health promotion through community mobilization is an important aspect of community development. The aforementioned protocol indicates the framework for community mobilization, audience segmentation and needs assessment. The implementation of the protocol might include other steps during the process.

CTB. (2010). The Community Tool Box. Work Group for Community Health and Development . Web.

McKenzie, J. F., Pinger, R. R., & Kotecki, J. E. (2008). An introduction to community health (6th ed.). Sudbury, Mass.: Jones and Bartlett Publishers.

Siegel, M., & Doner, L. (2007). Marketing public health : strategies to promote social change (2nd ed.). Sudbury, Mass.: Jones and Bartlett Publishers.

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IvyPanda. (2022, March 18). A Needs Assessment in Health Promotion. https://ivypanda.com/essays/a-needs-assessment-in-health-promotion/

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Health Needs Assessment Process Health And Social Care Essay

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A scoping review of community health needs and assets assessment: concepts, rationale, tools and uses

• Hamid Ravaghi 1 ,
• Ann-Lise Guisset 2 ,
• Samar Elfeky 3 ,
• Naima Nasir 4 ,
• Sedigheh Khani 5 ,
• Elham Ahmadnezhad 6 &
• Zhaleh Abdi 7  

BMC Health Services Research volume  23 , Article number:  44 ( 2023 ) Cite this article

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Community health needs and assets assessment is a means of identifying and describing community health needs and resources, serving as a mechanism to gain the necessary information to make informed choices about community health. The current review of the literature was performed in order to shed more light on concepts, rationale, tools and uses of community health needs and assets assessment.

We conducted a scoping review of the literature published in English using PubMed, Embase, Scopus, Web of Science, PDQ evidence, NIH database, Cochrane library, CDC library, Trip, and Global Health Library databases until March 2021.

A total of 169 articles including both empirical papers and theoretical and conceptual work were ultimately retained for analysis. Relevant concepts were examined guided by a conceptual framework. The empirical papers were dominantly conducted in the  United States. Qualitative, quantitative and mixed-method approaches were used to collect data on community health needs and assets, with an increasing trend of using mixed-method approaches. Almost half of the included empirical studies used participatory approaches to incorporate community inputs into the process.

Our findings highlight the need for having holistic approaches to assess community’s health needs focusing on physical, mental and social wellbeing, along with considering the broader systems factors and structural challenges to individual and population health. Furthermore, the findings emphasize assessing community health assets as an integral component of the process, beginning foremost with community capabilities and knowledge. There has been a trend toward using mixed-methods approaches to conduct the assessment in recent years that led to the inclusion of the voices of all community members, particularly vulnerable and disadvantaged groups. A notable gap in the existing literature is the lack of long-term or longitudinal–assessment of the community health needs assessment impacts.

Peer Review reports

The population-based health approach aims to improve the population’s health, promote community resilience and reduce health inequities across the socioeconomic gradient via inter-sectoral partnerships among community groups, government, healthcare systems, and other stakeholders [ 1 ]. One key feature for adopting a population-based health approach is to ensure that it is grounded on a solid understanding of community health needs and assets by triangulating evidence from service providers and community members on services availability, accessibility, utilization and experience [ 2 , 3 ]. The process of identification of unmet health needs in a population is crucial for local authorities seeking to plan appropriate and effective programmes to meet these needs [ 3 , 4 ]. If these needs are ignored, then there is a risk of a top-down approach for providing health services, reflecting what a few people perceive to be the needs of the population rather than what they actually are [ 4 , 5 ].

In this context, community health needs assessment is a means of developing a comprehensive understanding of a community’s health and health needs as well as designing interventions to improve community health [ 6 ]. Though the process of community health needs assessment can be conducted in several ways, the primary purpose is to provide community leaders or healthcare providers with an overview of local policy, systems, and environmental change strategies currently in place and help to identify areas for improvement [ 7 ]. Community health needs assessment can provide them with a more nuanced understanding of the communities they serve, making them aware of pressing issues that require system-level changes and support their efforts for resource mobilization to initiate innovative programmes [ 8 , 9 ]. The process to gather evidence on community health needs can also serve as a springboard to strengthen community engagement [ 10 ].

In general, needs assessments are usually designed to evaluate gaps between current situations and desired outcomes, along with possible solutions to address the gaps. Recently, there has been a trend to move away from framing a community with a deficit perspective (need-based approach) to focus on community assets and resources, called community health needs and assets assessment [ 11 , 12 ]. In contrast to a need-based perspective which focuses on local deficits and resources outside the community, an asset-based perspective focuses on honing and leveraging existing strengths within the community to address community needs [ 12 , 13 , 14 ].

Studies have shown that community health needs assessment is used widely by different users and across different settings [ 15 , 16 ]. However, these studies varied widely in terms of purpose, process and methods of conducting community health needs assessment. Furthermore, the extent to which an asset-based approach is used is unclear, beyond the inclusion in guidance and recommendations. Thus, to support national or local decision-makers to make informed choices about the scope, tools, methods and use of community health needs and assets assessment, this scoping review of the literature aimed at: 1) Providing conceptual clarity on community health needs and assets assessment, 2) Determining for what purpose and with what methods community health needs and assets assessment are used globally, 3) Drawing the lessons learnt from previous experience with community health needs and assets assessment: what works in what context and under what conditions, 4) Documenting evidence of impact of community health needs and assets assessment, 5) Consolidating tools and methods used to collect evidence/data underpinning community health needs and assets assessment processes.

Search strategy

Ten databases, including PubMed, Embase, Scopus, Web of Science, PDQ evidence, NIH database, Cochrane library, CDC library, Trip, and Global Health Library were searched in February and March 2021. The search strategy was developed through discussion with experts in the field of population health, a research librarian, and a narrative review of the literature. Preliminary search terms were developed by the research team to reflect a number of core concepts including needs, population, needs assessment, assets assessment and participation. The search process was performed by a librarian with expertise in the use of literature databases (SK). The search terms were pilot-tested and agreed upon within the research team. The PubMed database search strategy presented in Additional file  1 .

Inclusion and exclusion criteria

Studies that focus on community health needs and assets assessment in terms of concepts, rationale, uses and tools were considered in both high-income countries (HICs) and low-and middle-income counties (LIMCs). We included studies in the review if they met the following criteria: 1) Papers providing conceptual clarity and explaining rationale for community health needs and (assets) assessment (This can be articles describing community health needs assessment or community assets assessment or community health needs and assets assessments at the same time or separately). The terms capabilities/ strengths/ resources can be used in place of assets and were considered.); 2) Papers describing or evaluating experiences implementing community health needs (and assets) assessment in a single site or multiple sites; 3) Methodological papers describing tools/approaches for community health needs (and assets) assessment; 4) Review of the literature on community health needs (and assets) assessment.

Types of papers not include in the review were: 1) Studies without a clear description of the community health needs and (assets) assessment methods, 2) Studies assessed a single dimension (i.e. health outcomes only, or healthcare providers’ capabilities only such as patient surveys, health outcomes dashboard, health facility assessment), 3) Studies related to a single disease or programme, 4) Studies focused only on engaging individual patient in their own care, and 5) Studies were not in English.

Three reviewers participated in the selection of the relevant studies (HR, ZA, NN). The eligibility and relevance of the articles were determined by two reviewers independently using the above predefined criteria. In the event of disagreement, a consensus was found between all the reviewers about the status of the article.

Data extraction

Separate data extraction forms were developed for the extraction of the three main categories of papers: conceptual, empirical and review papers. Totally, 121 empirical papers (including 6 review papers) and 48 conceptual and methodological papers were reviewed. Following topics were extracted for empirical papers: 1) General characteristics including author(s), year of publication, country of implementation, study objective(s) and study method; 2) Community health needs and (assets) assessment framing including rational, definitions of community health needs and (assets) assessment/ needs/ assets/ community, initiator(s) or user(s) of the process; 3) Key steps of the process, collected data, data collection tools; 4) Community engagement and the level of engagement; 5) Use of community health needs and (assets) assessment findings, impact of community health needs and (assets) assessment; 6) Facilitators and barriers. Data extraction forms are presented in Additional file  2 .

Data extraction forms were pilot-tested prior to the implementation. Two authors (ZA, HR) independently performed a pilot data extraction of a random sample of ten original articles. After piloting, the authors assessed the extracted data in relation to the scoping review questions and revised them accordingly. The content of the form was finalized by discussion within the team. Regarding conceptual papers, two authors (NN and ZA) initially extracted data from three randomly selected papers and subsequently refined and amended the form having research team inputs.

Four reviewers extracted included studies independently. The data extracted were cross-checked by one of the authors and mutual consensus resolved discrepancies. Individual data extraction forms of empirical papers were then merged into a single, unifying document used for the interpretation and presentation of the results. Following typical scoping review methods, the methodological quality of the included articles was not assessed systematically, however, only peer-reviewed articles were included in our review process [ 17 ].

Synthesis of results

Following reading and extracting conceptual papers, a preliminary conceptual framework (Fig.  1 ) was developed and discussed and agreed upon by team members. The integrative synthesis of the evidence was employed. Specifically, it involved the narrative description of concepts and definitions, key steps of the community health needs assessment and barriers and facilitators of the implementing community health needs assessment.

Conceptual framework of the review

The study selection process is summarized in Fig.  2 . Just over 12,000 records were obtained from the ten databases searched. Articles with obviously irrelevant titles were excluded, as were news items, letters, editorials, book reviews, and articles appearing in newsletters or magazines rather than peer review journals. The remaining abstracts were retrieved, read and assessed. A total of 169 articles including both empirical papers and theoretical and conceptual work were ultimately retained for analysis. A list of all studies with a short description, including the year of publication, key focus, study period, and methods, is presented in Additional files  3 and 4 . The first part of the results section focuses on definitions and concepts of community health needs assessment using both conceptual and empirical papers. In the second part of the results section, we describe key steps of the community health needs assessment and tools and methods used to collect data through content analysis of 121 included empirical papers. We also report some important challenges and facilitators faced by included studies while performing community health needs assessment. Role of community participation in the process and the spectrum and types of the participation is discussed in the last part.

Information flow in scoping review

General characteristics of the included studies

The review showed that community health needs assessment is used widely by different users and across different settings in both HICs and LMICs. Among included empirical studies, 81 (out of 121) were conducted in the  United States (US). There were papers from Australia ( n  = 4), South Africa ( n  = 3), Kenya ( n  = 3), Uinted Kingdom (UK) ( n  = 2), Canada ( n  = 2), China ( n  = 2), Dominican Republic ( n  = 2), Republic of Ireland ( n  = 2), Iran ( n  = 2), India (2), Honduras ( n  = 1), Netherland ( n  = 1), Vietnam ( n  = 1), Sudan ( n  = 1), New Zealand ( n  = 1), Madagascar ( n  = 1), Malaysia ( n  = 1), Ecuador ( n  = 1), Indonesia ( n  = 1), Uganda ( n  = 1), Taiwan ( n  = 1), Kyrgyzstan ( n  = 1), Saudi Arabia ( n  = 1), Haiti ( n  = 1), Honduras ( n  = 1) and Korea ( n  = 1).

Definition of needs

The review showed “need” was a multi-faceted concept with no universal definition. There was a differentiation between “health need” and “healthcare need” in the reviewed literature. Healthcare needs can benefit from health care (health education, disease prevention, diagnosis, treatment, rehabilitation and terminal care). Healthcare providers usually consider needs in terms of healthcare services that they can supply. However, health needs incorporate the wider social and environmental determinants of health, such as deprivation, housing, diet, education and employment. This broader definition allows looking beyond the confines of the medical model based on health services, to the wider influences on health [ 3 ].

In this review, relatively few empirical studies focus narrowly on healthcare needs, without attention to other determinants of health that can affect health [ 18 , 19 , 20 , 21 , 22 , 23 ]. Most of the included empirical studies looked beyond “physical health needs” to consider wider “social determinants of health” or non-medical factors that can affect a person’s overall health and health outcomes as the conditions—shaped by political, social, and economic forces—in which people are born, grow, live, work, and age [ 24 ]. Notably, the need was recognised as a “dynamic concept” whose definition will vary with time according to context and resources available to address these needs [ 16 ].

Definition of community

In general, “community” has been defined as “people with a basis of common interests and network of personal interactions grouped either based on locality or on a specific shared concerns or both” [ 25 ]. Shared common interests are particularly important as they can be assessed and, hopefully, met at a community level [ 26 ]. Importantly, community is a dynamic concept as individuals can belong to several communities at various times. In our review, community was defined by included studies, particularly those initiated by local authorities or healthcare providers (e.g., hospitals), based on geographical indicators such as county designations or based on the location of the hospital’s/facility’s/authority’s existing or potential service users. Some included empirical studies considered community based on shared interests or characteristics such as race/ethnicity, sexual orientation, or occupation. Medically underserved populations including rural areas [ 27 , 28 , 29 , 30 ], impoverished urban sectors [ 31 ], the homeless [ 32 , 33 , 34 , 35 ], persons in poverty or of low socioeconomic status, vulnerable children and families [ 18 , 28 , 36 , 37 , 38 ], the elderly [ 8 , 39 , 40 , 41 , 42 ], women and girls [ 43 , 44 , 45 , 46 , 47 ], LGBT (Lesbian, gay, bisexual, and transgender) individuals [ 48 , 49 , 50 , 51 ], displaced populations, immigrants and racial, ethnic and religious minority groups [ 12 , 19 , 36 , 42 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 ] and persons with severe and chronic health problems [ 79 ] were considered as a “community” by a number of included studies.

While defining community, a number of its characteristics were determined by included studies including: history, existing groups, physical aspects (i.e. geographic location, community size, its topography and etc.), infrastructure (i.e. health and social care facilities, public transportation, roads, bridges, electricity, mobile telephone services and etc.), demographics (i.e. age, gender, race and ethnicity, marital status, education, number of people in household, first language and etc.), economic conditions, deprivation and/or inequalities, government/politics, community leaders (formal and informal), community culture (formal and informal), existing institutions, crime and community safety, lifestyle and leisure, general health problems and epidemiology.

In our review, community health needs and assets assessment were performed by different organizations as the first step in community health promotion planning, including local health authorities (district/local), community entities [i.e. non-governmental organizations (NGOs), civil society organizations (CSOs), faith-based organizations (FBOs), community-based organizations (CBOs)] and hospitals (public/private). Included studies mostly conducted health needs assessment at the local level (e.g. cities, counties, or other municipalities). The broader understanding of health and its determinants suggests that many public and private entities have a stake in or can affect the community’s health. To engage stakeholders in the process, a number of included empirical studies ( n  = 56, 49%) sought representatives from the community that were best positioned to speak about community health based on their specific knowledge or line of work. These stakeholders were individuals from community and entities who may explicitly be concerned with health or not, which varied by the community context and culture. To have a comprehensive overview of a community needs, it was asserted that defining communities needs to be dynamic and socially constructed to take into account all voices and members, especially those not ordinarily included [ 80 ]. Community should be defined in a manner that does not exclude medically underserved, low-income, or minority populations. Integrating community voices is especially important in designing plans and programmes aimed at reducing health disparities in the community [ 58 , 81 , 82 ].

Definition of assets

Overall, there were limited definitions for “community assets” in the reviewed literature. Assets were described as resources, places, businesses, organizations, and people that can be mobilized to improve the community [ 11 , 83 ]. This includes members of the community themselves and their capabilities. Assets can therefore be described as the collective resources which individuals and communities have at their disposal, which protect against adverse health outcomes and promote health status [ 83 , 84 ].

Of 115 included empirical studies, 30 studies addressed community assets while performing community health needs assessment. A wide range of assets, from tangible resources to intangible ones, were considered that can be classified into seven broad categories as follows:

Community demographic characteristics: Literacy rates [ 13 ], youth population [ 58 , 68 ], and elderly population [ 68 ];

Natural capitals: Geographical location and natural resources [ 21 , 81 , 85 ];

Economic and financial capitals: Community business [ 12 , 81 ] community members’ income [ 21 ], and housing land ownership [ 13 ];

Community infrastructure: Level of technology/mobile phone coverage [ 13 , 21 ], transportation [ 86 ], parks and sidewalks [ 12 ], sport and recreational facilities [ 31 , 87 , 88 ], public libraries and community centres [ 88 ];

Community social and educational facilities: Non-profit and non-governmental organizations [ 59 , 87 ], media [ 89 ], educational institutions [ 12 , 31 , 81 , 90 ], faith communities [ 58 , 81 , 90 ], and community associations [ 31 ];

Community health and social facilities: Health and social facilities and providers [ 72 , 81 , 85 , 86 , 89 ], traditional medicine providers [ 72 ], and ongoing health programmes [ 13 , 87 ];

Community’s social and cultural values and resources: Tribal and community culture [ 58 , 68 , 74 , 91 ], cultural diversity [ 81 ], spirituality and religion [ 58 , 74 ], strong family bonds and values [ 59 , 74 ], strong community connections, teamwork and willingness to volunteer [ 21 , 81 , 86 , 91 ], mutual support, social support and networks [ 45 , 58 , 81 , 85 ], unity, community cohesion and collectivity [ 21 , 59 , 74 ], community capacity [ 58 ], community-led activities [ 86 , 91 ], and community values and traditions [ 68 , 74 , 86 ], resiliency [ 58 ], unifying power of communities [ 13 ], community administration units e.g. women’s committees [ 13 ], an existing group of dedicated healthcare providers [ 39 ], a group of concerned citizens [ 39 ], community safety [ 12 ], the knowledge base of the community members themselves [ 39 ] and members’ desire to be healthy [ 58 ].

Various qualitative methods such as individual interviews (one-on-one structured conversations) or focus groups (guided, structured, small group discussions) with community members, or key informants’ interviews (formal and informal conversations with leaders and stakeholder groups) or a combination of these methods were reported as the main methods to collect information on community’s assets among reviewed studies. Of these, focus group was the widely used method in community assets assessment [ 8 , 21 , 31 , 45 , 58 , 59 , 67 , 81 , 82 , 85 , 87 , 90 , 92 , 93 ].

Definition of community health needs (and assets) assessment

The terms “Community Needs Assessment (CNA)”, “Community Health Needs Assessment (CHNA)”, and “Community Health Needs and Assets Assessment (CHNAA)” were used interchangeably in the literature referring to the process of identifying health needs (and assets) of a given community. Since this review focuses on both community needs and assets, we will use the CHNAA term for the description of the process in this paper.

None of the papers reviewed provided a specific definition for CHNAA. In general, reviewed papers defined CHNAA as: A collaborative, community-engaged, systematic, ongoing, continuous, proactive, comprehensive, cyclical, regular, modifying method or process [ 28 , 33 , 69 , 92 , 94 , 95 , 96 , 97 , 98 ]; For the identification, collection, assembly, analysis, distribution, and dissemination of information on key health needs, social needs, concerns, problems, gaps, issues, factors, capabilities, strengths, assets, resources; About communities (or individuals) [ 21 , 23 , 28 , 31 , 33 , 37 , 41 , 45 , 54 , 79 , 89 , 94 , 95 , 96 , 97 , 99 , 100 , 101 , 102 ]; To achieve agreed priorities, create a shared vision, plan actions, garner resources, engage stakeholders, work collaboratively, establish relationships, implement culturally appropriate, multi-sectoral/multilevel intervention strategies, empower residents and enhance community capacity and participation in decision-making process [ 12 , 13 , 20 , 27 , 28 , 37 , 45 , 70 , 79 , 89 , 91 , 92 , 94 , 95 , 97 , 98 , 99 , 101 , 102 , 103 , 104 ]; Towards improving health and wellbeing, building and transforming health of the communities, increasing community benefits, reducing inequalities; Through which primary/secondary healthcare can respond to local and national priorities [ 20 , 23 , 28 , 40 , 51 , 59 , 69 , 97 , 103 , 105 , 106 ].

The included studies listed a number of reasons as the rationale for conducting CHNAA. Legislative requirements were most cited as the main rational for conducting CHNAA, particularly among studies conducted in the UK and US. Since the late 1980s, the concept of health needs assessment has gained increasing prominence within the National Health Service (NHS) in the UK. This has been prompted by a series of policy initiatives requiring health facilities to assess needs of their populations and to use these assessments to set priorities to improve the health of their local population [ 107 , 108 ]. In the US, several national, federal, state, and local funding sources require entities to conduct CHNAA to demonstrate a significant need for their services and programmes to be funded. The most important one is Patient Protection and Affordable Care Act (ACA-2010), requiring non-profit hospitals as tax-exempt entities to perform CHNAAs to maintain non-profit status regularly [ 92 ]. Other reasons were mentioned by included studies as the rationales for conducting CHNAA were: lack of information of health needs of a specific community, to facilitate health research and related interventions in a community, to inform the design of contextually relevant programmes and policies, to develop community health improvement plans or health promotion interventions, to develop or update strategic plans, and to receive resources and funds.

Key steps to conduct CHNAA

The number and nature of CHNAA process steps varied among reviewed studies. However, broadly CHNAAs involved six main steps as follow:

Formulation of a leadership team

Forming a leadership team, which was called by different names such as the steering committee/ the research advisory committee (RAC)/ the collaborative task force/ or the community advisory board (CAB), was known as the preliminary step of a CHNAA process. The steering committee was usually composed of local representatives from local agencies and organizations (e.g. non-profit organizations, community service agencies, media outlets, county and municipal governments, colleges and universities, faith-based organizations, and healthcare providers), community members, community stakeholders and leaders, academic partners, health and social officials, and representatives from the investigator body to help guide the development of the CHNAA project.

Leadership team responsibilities were reported as providing inputs on the research purpose, selecting and verifying study methodology and design, providing inputs and feedback on initial survey/topic content and selecting final survey/ topic guide questions, reviewing survey/topic guide length, and ensuring culturally relevant and resonant wording, comprehension and face validity, and monitoring the progress of the data collection. Feedback and recommendations from the steering committee were incorporated throughout the CHNAA process as well. Steering committees usually met on a regular basis.

Identification of needs, assets and prioritisation

To collect information on community health, needs and assets, both primary and secondary data were utilized by included studies. Secondary data included information on community socio-demographic and indicators on health status, access, utilization and satisfaction with health and social services at different levels (e.g. community, sub-national and national) to develop a picture of the overall community health. Primary data were collected through quantitative and qualitative methods and mixed-methods approaches.

Quantitative studies 

Some empirical studies used individual/household surveys as the only source to identify community needs and concerns ( n  = 28, 24.%). Surveys were a popular method of gathering opinions, preferences and perceptions of needs. Needs assessment surveys typically have written, closed-ended questions filled through the interview (face to face/telephone) or self-completion (paper or online) by community members. Generally, two main kinds of surveys were used by included studies: a) community health assessment survey, and b) community concerns survey. A number of included studies used health assessment surveys as the key data sources of the CHNAA process ( n  = 22, 19%) or along with other types of data, mainly qualitative data ( n  = 21, 18.%). Health assessment surveys typically collected information on demographics, socio-economic variables, respondents’ health status, choice of healthcare providers, and healthcare access issues among community members. Survey questionnaires were mostly developed with inputs from the literature review (similar health assessment surveys conducted at the local or national level), community members and project team discussions. Additional file  5 shows the most important data and indicators collected by included studies through conducting community health  assessment surveys.

Another form of surveys, used alone or in combination with qualitative methods ( n  = 15, 13.5%), was the community concerns survey in which people (community members and/or key informants) are asked to help identify what they see as the most important issues facing their community leading to an inventory of their health priorities [ 12 , 20 , 23 , 27 , 29 , 55 , 69 , 74 , 101 , 103 , 109 , 110 , 111 , 112 , 113 ]. A straightforward way to estimate the needs of a community was to simply ask residents their opinion on what particular services are most needed in the community. The focus of this methodology was to create an agenda based on the perceived needs and concerns of community residents. The concerns surveys were based on either focus group discussion with community members and experts or literature review by the researchers or both. Generally, while filling community concerns survey, individuals were asked to rate the importance of each issue in their community on a scale (e.g. 0 = not important, 5 = extremely important) [ 23 , 27 , 29 , 55 , 74 , 110 ]. Participants could also add and rate concerns or service needs that were not listed. Finally, each health problem identified by the community was weighted based on the frequency it was selected on the survey.

General coverage of the surveys was the population aged 18 or over currently residing in the community for a minimum period of time (at least a few months) and able to provide consent for participation. Most surveys were written, closed-ended questions filled through face to face or telephone interviews or self-completion by community members. In addition to the paper-form survey, some studies used email and social media platforms to allow residents to anonymously complete online surveys [ 29 , 51 , 57 , 96 , 103 , 110 , 114 ]. A few studies reported that residents received monetary or nonmonetary incentives for their participation upon survey completion [ 19 , 71 , 74 , 77 , 110 ]. Sampling techniques commonly used are those that promote participation in CHNAAs such as convenience sampling [ 20 , 35 , 40 , 51 , 52 , 57 , 64 , 65 , 71 , 74 , 75 , 77 , 86 , 96 , 101 , 103 , 104 , 110 , 114 , 115 ]. Only a few studies used random sampling or demonstrated the representativeness of their samples. Their response rates varied between 8 to 95.5%. Most surveys recruited local surveyors and provided them with research training to ensure consistent survey administration to attract community participation. Some studies that assessed health needs among immigrant communities or minority groups recruited bilingual surveyors or/and provided participants with two versions of the instruments, one in the native language to maximize community engagement [ 12 , 27 , 52 , 65 , 71 , 86 , 103 ]. Surveys that took a participatory approach to the design, content, terminology, and language level, were reported more understandable and culturally relevant to the community members [ 52 , 65 , 75 ].

Health needs assessment surveys (both concerns surveys and health assessment surveys) reported limitations to data collection based on the assessment timing, data availability, and sample response. As said earlier, using a convenience sampling and non-representative samples, small sample size and inter-rater reliability between surveyors were among some important methodological limitations reported by these studies, which limited the generalisability of the study findings to the entire community population [ 35 , 57 , 65 , 71 , 74 , 75 , 77 , 96 , 106 , 116 ]. Convenience sampling method and using community events as sampling sites led to sampling bias in some studies (e.g., an over-representation of some specific groups of the population such as women and low –income or high-income groups) [ 57 , 63 , 65 , 66 , 71 , 74 , 75 , 78 , 103 , 114 , 115 ].

Qualitative studies

Among included studies, about 34% ( n  = 39) used qualitative methods as the main source of data collection on community needs and assets. Some of these studies justified the use of qualitative approach by explaining how the overreliance on quantitative, population-level data resulted in CHNAAs failing to identify health needs and interests of all community members, particularly those of vulnerable population and underrepresented marginalized segments of the community. In addition, these studies concluded that integrating qualitative methods into the CHNAA process has the potential to involve community members in a more participatory fashion, perhaps improving future collaborations between communities and service providers. Such collaborations can help to design focused initiatives, making them more meaningful and culturally appropriate [ 12 , 59 , 91 , 102 ].

Key informant interviews, individual interviews with community members, focus groups with community members and community forums were among the qualitative data collection techniques used individually or in combination with each other by these studies to collect data on community needs and assets. They asserted that qualitative techniques specifically targeted to underrepresented segments of the population proved to be effective mechanisms to explore the participants’ perceptions on issues surrounding community health needs and assets. The most used technique to elicit community members’ opinions were focus group discussions and key informant interviews.

Small sample size and single-site setting were mentioned as the most cited limitations of  the qualitative CHNAAs that limit these studies generalisability. Because the studied communities were unique communities with unique assets, constraints, and health needs, the CHNAA findings cannot be generalised to other communities [ 32 , 39 , 62 , 70 , 72 , 73 , 91 , 117 , 118 ]. Another limitation mentioned by some studies was that the demographic composition of the focus group participants, specifically with regards to race, gender, socio-economic status and age group, did not fully reflect the population of studied community as a whole [ 13 , 61 , 62 , 72 , 97 , 119 ]. Some studies reported that they could not include all influencing key informants in the community to facilitate broader understandings of health needs [ 13 , 120 ].

Mixed- methods studies

A variety of data collection methods were used in a number of included studies to ensure that a comprehensive picture of community health needs and resources was obtained ( n  = 48, 42%). Some of these studies were two-phase explanatory mixed-methods studies, with the quantitative phase preceding the qualitative phase ( n  = 14, 12%). They conducted targeted focus groups or community listening sessions or interview with community members/key informants following needs assessment survey to supplement the findings from the survey and provide further information about health status, needs of daily living, barrier to health and access to community resources [ 8 , 21 , 41 , 53 , 55 , 66 , 67 , 93 , 94 , 95 , 99 , 113 , 114 , 121 ]. In addition to these studies, some studies used triangulation mixed-method design to obtain complementary qualitative and quantitative data on community health needs and issues ( n  = 13, 11%). These studies confirmed that using multiple data sources ensured researchers obtain a complete picture of the community health needs. Applying qualitative methods in the form of focus groups and semi-structured interviews enabled exploration of problems and needs within their social context and provided a wider perspective on issues raised. However, to conduct such studies CHNAA teams had to have members who have qualitative and quantitative expertise. There were some limitations specific to the mixed-method studies, including lack of rigor in integrating qualitative and quantitative findings, relying heavily on quantitative data for health need determination, and absence of the voices of the communities most in need [ 69 , 91 ].

Data analysis and interpretation

Qualitative data from focus group discussions and key informant interviews were mainly audio-recorded and transcribed verbatim by the research team and all identifying information was removed. Different analytical approaches, mostly content analysis and thematic analysis, were used to identify main themes related to assets, needs and gaps in the service system and priority populations.

Quantitative data from surveys were analysed using statistical software. Descriptive statistics were used to describe the sample in terms of socioeconomic background and present the prevalence of chronic diseases, risk factors, and health behaviours. Statistical analytical tests were also used to compare results between different groups of community members. Results also were compared by those at the state/ national level or from a similar community. Those diseases or risk factors that had a high prevalence among community members are regarded as priorities that to be addressed further.

Formulation of recommendations across various levels (individual, institution, community, policy levels)

Following analysis of the quantitative and qualitative data, the studies included in the review provided a thorough list of health needs and assets of the community. Included studies mainly used CHNAA outputs: 1) as a resource to provide baseline data of community’s health; 2) as a resource to prioritize and plan services; 3) as a resource for writing grant applications; 4) as a resource to guide a comprehensive health promotion strategy.

Not all included CHNAAs proposed interventions to address identified needs and issues. Some of the included studies ( n  = 45, 39%) just provided a snapshot of the most important issues faced by the studied community. They demonstrated several areas where CHNAAs provide more information to researchers, community organizations, and policy-makers. On the other hand, not all identified issues and needs were addressed by those studies performed CHNAA in order to implement interventions or strategies. In practice, specific populations or a number of specific health conditions or health risks, or overarching issues such as health inequality and disparities were prioritized by these studies.

In most cases, decisions on implementation were carried out by the CHNAA steering committees or the research teams. Only a number of studies used a clear and explicit set of criteria for deciding the importance of each issue [ 22 , 27 , 43 , 67 , 94 , 118 , 122 ]. A wide range of criteria were used by included studies such as: impact, urgency, community concern, achievability within the set time [ 94 ], seriousness, urgency, solvability, and financial burden of the problems [ 27 ], perception of survey participants on importance of the identified issues and feasibility of intervention, prevalence, fatality, social and cultural stigma [ 22 ], possible interventions, organizational capacity, and community assets and resources [ 13 ], importance and possibility of the effecting change [ 43 ], prevalence, impact on the duration of sickness, impact on mortality, and the availability of treatment [ 122 ], impact of the problem on the overall wellness, quality of life, and resources of their community [ 118 ], factors of health issue, size, seriousness, and effectiveness of available interventions [ 101 ], importance and feasibility [ 67 ].

Different techniques for ranking priorities were applied by included studies such as: 1) Multi-voting technique (decide on priorities by agreeing or disagreeing in group discussions and continuing process/rounds until a final list is developed), 2) Strategy lists (determine if the health needs are of “high or low importance” by placing emphasis on problems whose solutions have maximum impact, with the possibility of limited resource), 3) Nominal group technique (rate health problems from 1 to 10 through group discussion), and 4) Prioritization matrix (weigh and rank multiple criteria for prioritization with numeric values to determine health needs with high importance).

Overall, health priority types were categorized into four main categories by included studies:

Medical conditions (e.g. obesity, diabetes, heart diseases, asthma, mental health disorders, substance abuse, vision/ dental problems, HIV/AIDS and sexually transmitted diseases, injuries and health consultations).

Health behaviours (e.g. physical activity, eating habits/ nutrition, tobacco consumption, teen pregnancy and violence/gangs).

Community conditions (e.g. poverty and unemployment, environmental and infrastructural conditions, such as air quality/pollution, transportation, access to clean water and sanitation, community collaboration, and access to healthy food, exercise facilities and occupational concerns).

Health systems priorities (e.g. access to care, including primary care and higher levels of care, specialty care, mental/ behavioural health care and dental care, quality and acceptability of health services, lack of cultural competence in health systems, flexible hours and waiting time).

However, guided by a community-based participatory research (CBPR) approach, a number of studies involved community members and stakeholders in priority identification or ranking [ 12 , 21 , 22 , 23 , 27 , 29 , 31 , 36 , 41 , 43 , 49 , 53 , 55 , 56 , 58 , 59 , 60 , 62 , 63 , 68 , 70 , 74 , 86 , 87 , 88 , 90 , 92 , 99 , 100 , 103 , 104 , 110 , 114 , 117 , 118 , 119 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 ], in potential strategy selection [ 13 , 19 , 67 , 82 , 89 , 130 ], and in carrying out strategies [ 8 , 37 , 69 , 81 , 93 , 105 , 113 ]. They asserted that by involving the perspectives of the relevant stakeholders, a comprehensive overview of the issues and possible effective solutions was created.

Planning of programmes and interventions, implementation and evaluation

The results of CHNAA were used in various ways by included studies. In some studies, particularly researcher-led studies with limited support or involvement of the local authorities, CHNAA just led to the identification of new, locally relevant issues and priorities without any further actions ( n  = 45, 39%). The results of these CHNAAs provided more information to researchers, community organizations, and local policy-makers. Their results also may guide further research agenda in the community [ 18 , 21 , 23 , 29 , 35 , 39 , 40 , 42 , 44 , 48 , 49 , 50 , 52 , 54 , 55 , 62 , 64 , 65 , 66 , 69 , 70 , 71 , 72 , 73 , 76 , 77 , 78 , 85 , 96 , 106 , 122 , 123 , 131 , 132 , 133 , 134 , 135 ]. Some of these studies tried to present their results to the local authorities through various channels in the hope that it would modify existing programmes or implement new ones to meet the needs of the community residents. In addition to identification of relevant issues and priorities, included studies listed at least one outcome associated with the reported CHNAA activity as follows:

Development or modification of health and social policy and programmes: The knowledge provided by CHNAAs helped develop better tailored, and thereby potentially more effective interventions by a number of studies. Further, the information gathered from the CHNAA process was used as the baseline against which to measure future targets for assessment efforts and progress in areas were targeted ( n  = 36).

Formation of new partnership: In some cases, a new partnership among entities involved in CHNAA was formed to address health issues. One of the partnerships reported successful was the community–academic partnership in which communities used the research capacity of academic institutions to conduct the CHNAAs ( n  = 20). Another type of the partnership reported by some studies was the collaboration among healthcare organizations serving the same geographic area to conduct CHNAA jointly. Conducting a joint CHNAA may avoid duplication of planning efforts and obviate the creation of multiple community health needs assessments for the same population ( n  = 5).

Development of new recommendations: Several suggestions were proposed to be considered while designing health improvement interventions in the future by some of the included studies ( n  = 18).

Setting or altering strategic direction: Strategic agency direction was established or altered in some cases, which might indicate that the CHNAA was used to redirect resources better to meet the needs of the community ( n  = 4).

Raising awareness about health issues: One of the most important insights brought by CHNAA findings was the recognition of the health priorities and contributing factors by the community members, leaders and researchers, leading to an increased awareness of community issues among them ( n  = 8).

Engaging and motivating policy-makers and stakeholders: A few studies reported that CHNAAs provided health organizations with the opportunity to identify and interact with key policy-makers, community leaders, and key stakeholders about health priorities and concerns, which might foster a sense of collective ownership and trust in the results and increase the likelihood that the CHNAA will be used ( n  = 5).

Having an impact on obtaining resources and resource allocation: The CHNAAs provided the community partners with locally relevant information regarding the current status of health and perceived community needs to inform resource allocation and applications for new grants for the initiation of new programmes ( n  = 14)

Contribution to the development of CHNAA process: Some studies reported that the specific methods used in their CHNAA processes could contribute to more relevant and effective community health need assessment process ( n  = 10).

Dissemination of findings

Disseminating of the findings and knowledge gained to all partners involved was a foremost step of CHNAAs. The most cited product of the CHNAA process in the included studies was the community needs assessment report. This report includes information about the health of the community as well as the community’s capacity to improve the lives of residents. The report provides the basis for discussion and future actions. In addition to the final report, other channels to disseminate CHNAAs findings were reported as: publishing CHNAA main results in local newspapers, communicating research results with community members and stakeholders in public forums or meetings, presentation results to the steering committee and various stakeholders, posting the report on the local authorities websites, individual meetings with community leaders and stakeholders, posters, and presentation of findings in academic conferences.

Community participation

Among included studies, around 50 studies (44%) reported using participatory approaches and techniques to encourage community members' participation in CHNAA process. Unlike traditional approaches to health needs assessment, participatory approaches aimed to incorporate community inputs at all stages of the research process to enhance capacity building and overcome barriers to research raised by matters of trust, communication, cultural differences, power and representation. A variety of participatory approaches (e.g. community based participatory research (CBPR), participatory rural appraisal, participatory action research (PAR), rapid participatory appraisal (RPA), tribal participatory research, community-based collaborative action research (CBCAR), precede-proceed model, concept mapping and photovoice) were used by these studies to ensure that communities participate in CHNAA, from defining the community to identifying needs and assets and developing new interventions.

Pennel and colleagues classified the depth of the community participation in CHNAA activities into four main categories [ 136 ]. In this classification, depth of the community participation was assessed by the types of activities in which participants were involved throughout the assessment and planning process as follows:

No participation: No attempt to engage community stakeholders or members;

Consultation-only: Engagement of health-related stakeholders, broader community stakeholders, and/or community members to identify health needs through surveys, interviews, and/or focus groups; verified or validated health needs/priorities with local experts;

Moderate participation: Involvement of community stakeholders/ or community members in priority identification; involvement of community stakeholders in strategy selection;

Extensive participation: Involvement of community stakeholders/or community members to develop and carry out strategies.

The above classification was used to assess the depth of the community participation by included studies. Based on the content analysis, community participation in CHNAA process varied considerably across the included empirical studies, from minimal to in-depth participation (Table 1 ). Around 65% of the included studies were involved in consultation-only to identify health needs through one-way communication using tools such as surveys, interviews, and focus group to identify community needs and resources. Around 22% of the included studies solicited moderate participation from the community by involving community in verifying needs and final priority selection and only about 10% of the included studies reported a broad and deep community participation including community involvement in designing and implementing strategies to improve community health.

Three categories of challenges were cited by the reviewed studies while performing CHNAA projects.

Methodological challenges: These are mainly associated with quantitative and qualitative data collection methods, which were discussed earlier. Other methodological challenges cited were: difficulties in aggregating and making sense of data collected from various sources (triangulation), non-generalisability of site-specific data and limitations of the use of existing epidemiological data alone, which does not provide a comprehensive view of health needs, yet is often the most available source of information. Traditional approaches to data collection were challenging where language and literacy barriers existed [ 12 , 52 , 65 , 71 ]. Another major challenge reported by studies used community-based participatory research approaches was the challenge of involving the community in decisions related to research design and data collection methods while maintaining an appropriate level of methodological validity and reliability [ 56 , 81 , 121 ]. In addition, participation was not without challenges. Including the perspectives of stakeholders and residents can lead to differing accounts of what services are seen as essential, and each party may push their own agenda based on their personal or professional interests. Further, linguistic and cultural barriers may be a major factor among minority groups hindering participation in such endeavors [ 81 , 137 ].

Logistical challenges: The major logistical challenges reported were the need for a considerable amount of time (often inadequate), and resources required to conduct a comprehensive assessment [ 80 , 138 ]. Good quality local data on the needs and utilization of health services are usually difficult to obtain [ 9 ]. Financial costs are considerable and the depth of information obtained will ultimately depend upon the methods employed [ 139 , 140 ]. In addition, health professionals, managers and others involved in health services planning and delivery may not have the requisite skills to conduct CHNAAs. This goes beyond technical skills and places an emphasis on soft skills and flexibility including good listening skills, the ability to establish trusting relationships, empathy, working with diverse groups and reflexivity [ 140 , 141 ]. Moreover, limited health information infrastructure and systems in developing countries settings may have hindered the availability of good quality information to conduct CHNAAs [ 13 , 28 , 30 , 142 ].

Ethical challenges: Concerns were raised about the ethical issues associated with community consultation about felt needs followed by priority setting process that leaves many needs unaddressed and the bulk of expectations dashed. Labelling, stigma and stereo- typing are other problems raised by needs assessment [ 143 ]. Needs assessment results may not be utilised, leaving unmet expectations and may require extensive financial and political support to lead to changes in health service planning and delivery [ 9 ]. Comprehensive health needs assessment is likely to produce different, potentially conflicting needs, exposing hidden conflicts and tensions in communities without any mechanisms to address these issues [ 5 ]. Further, local participation may only allow those who are able to voice their needs to do so, leaving behind the silent or hidden voices [ 81 ]. Involvement of the community in the needs assessment process also impacts upon possible outcomes of the project especially since it is likely that expectations of changes to programmes and service delivery may have arisen from local participation [ 144 ].

Facilitators and enablers

CHNAA projects need to be organized in such a way that they have clear objectives, and are adequately resourced by experienced staff. In addition, factors such as clear objectives, decisive leadership, teamwork, communication, sound study design, adequate resourcing, skilled staff, sufficient time and ownership by stakeholders are among those factors that contribute to the successful implementation of CHNAAs [ 15 , 145 ]. Most studies cited community participation as a major facilitator of the CHNAA process and outcomes. Participation was shown to foster bidirectional learning and communications, where both health authorities and the community learnt about needs and priorities. Different benefits for community engagement were mentioned by reviewed literature including, improved participants’ recruitment, enhanced capacity among stakeholders, productive conflict resolution, increased quality of outputs and outcomes, increased sustainability of project goals beyond funding and timelines and development of linguistically and culturally appropriate measures. In addition, incorporating community voices has the potential to inform the development of sound measures to tackle health disparities in the basis of race, social class and ethnicity [ 12 , 27 , 30 , 91 , 103 , 110 , 126 , 146 ].

The main objective of our scoping review was to provide an overview of why and how community health needs and assets assessments (CHNAAs) have been used globally. Substantial variation was found among the studies reviewed concerning definitions, process, participants, methods, goals, and products, yet there were many common characteristics.

Some CHNAAs focused narrowly on health care in assessing needs, with scant attention to other community issues that can affect health. However, most of the included studies looked beyond health needs and considered social and environmental conditions influencing community health. We argue all CHNAAs should approach community health needs assessment holistically, focusing on both individual physical and mental wellbeing as well as casting a social determinants of health lens on the population health.

The review showed that community health needs assessment is used widely by different users and across different settings in both HICs and LMICs. However, in countries such as the US it has become institutionalized and has accordingly been developed, as service providers, particularly hospitals, are mandated to perform CHNAA to compliance with legislative mandates. However, though federal and state laws impose requirements on hospitals to conduct CHNAAs, the methods for needs assessments are generally left to the discretion of each hospital [ 147 ]. As a result, assessment methods vary widely. US-based CHNAAs either develop their own CHNAA processes or utilize a process developed at the state or national level to guide their efforts. A number of toolkits have been provided by different organizations across US to help healthcare providers to conduct CHNAA projects [ 6 , 148 , 149 ]. This highlights the need for consensus guidance across many countries and settings while maintaining the responsiveness to contextual needs, assets and priorities.

Both qualitative and quantitative approaches were employed to collect data on community health needs and assets. Overall, there has been a growing use of mixed-methods approaches to conduct CHNAA in recent years, owing to the recognition in the literature that using qualitative and quantitative approaches simultaneously can provide complementary insights determining community health needs and assets [ 69 , 91 , 104 ]. Although quantitative approaches yield concrete evidence of community needs and assets, qualitative approaches provide a context for how these issues can be addressed using available resources [ 91 , 102 ]. Using qualitative methods in conjunction with more traditional quantitative approaches is especially appropriate for studying complex public health issues and promotes the alignment of implementation plans with the local needs of community members [ 59 , 69 , 91 ]. The growing use of mixed-methods approaches has practical implications for research training and capacity building within entities performing CHNAAs. Organizations who wish to conduct CHNAAs will need to ensure that the competencies and expertise required for mixed-methods studies are available.

Although only a small number of studies provided definitions of assets, there is a growing interest in the literature in asset-based assessment, which examines and mobilizes community assets, instead of focusing on only the needs of communities [ 11 , 84 ]. Unlike need-based or deficit approaches, asset-based approaches document resources and focus on strengths to enhance and preserve rather than deficits to be remedied. Related to principles of empowerment, it postulates that solutions to community problems already exist within a community’s assets. By recognizing existing capacity, communities can become empowered to take ownership of their health and improve as a population [ 11 , 31 , 125 ]. An asset-based approach was recognized as essential for enhancing trust and community coalitions [ 83 ]. Further, it is more participatory in nature through involving community stakeholders throughout the needs assessment process [ 82 , 83 ]. In particular, it highlights community resilience, resources, and opportunities for positive growth rather than focusing solely on health problems or other concerns [ 14 , 84 , 88 ]. In developing countries, assets identified from within the community are crucial for later use in the implementation of health programmes. The shift from a traditional needs-based perspective to an asset-based perspective to health needs assessment can help to address resource constraints in these countries [ 13 , 30 , 150 ].

There was a growing interest in the use of participatory approaches and in their value in identifying and addressing community health needs over recent years among included studies. About half of the reviewed studies applied CBPR or other community-engaged approaches to perform CHNAA. There are several opportunities to fully engage patients, families, and communities in healthcare delivery redesign to ensure that they are provided in a way that address the community members’ needs and preferences. The CHNAA process is one mechanism for this engagement—and a good precursor to deeper engagement and collaboration [ 91 , 97 , 123 ]. Integrating community voices into CHNAA process may be crucially important for confronting health disparities at the community level, which stemming from socio-historical processes, including racial and ethnic discrimination and economic inequality [ 33 , 74 , 86 , 91 ]. To eliminate health disparities, it is critical first to understand social, cultural, and economic determinants of health. CHNAAs, particularly when they include the voices of community residents, can provide an opportunity to understand local processes contributing to health disparities. This knowledge can then be used to inform health and equity initiatives [ 91 , 110 , 126 ]. The development process and implementation of a CHNAA project is an important example of evidence-based public health practice. It is a way to address health and health care disparities experienced by medically underserved populations [ 86 , 92 , 126 ]. Those studies used a participatory approach reported that by having community participation, concerns and issues of the most marginalized and vulnerable populations were voiced. The inclusion of these voices allowed for a broader and deeper understanding of the concerns of those who are typically marginalized and that may be missed in traditional health needs assessment methodologies [ 33 , 56 , 58 , 74 , 86 , 110 , 137 , 146 ]. Hence, defining communities while performing CHNAA needs to be dynamic and socially constructed to take into account all voices and members especially those not ordinarily included. This deeper understanding is critical to move public health practice and research upstream to address structural and social determinants of health necessary for population-level reductions in health inequities [ 80 , 91 ].

Although there is widespread theoretical recognition of the importance of in-depth community participation in CHNAA, this has not been fully embraced in practice based on our review. Included studies reported community involvement in various stages of CHNAA with varying depth reflecting a continuum from no participation to extensive participation, in which most studies were located at the middle of the participation continuum. The literature review suggests while certain community stakeholders were engaged in the CHNAA process, most studies did not involve a broad range of stakeholders through adopting a full participation approach. One reason for this could be that for most studies conducted in the US, CHNAA was performed to comply with ACA requirements, which requires hospitals to incorporate inputs of the population served as part of the CHNAA process. Since community inputs as well as the process as a whole is not well-defined by these regulations [ 20 ], it seems that the majority of included US-based studies tried to meet legislative requirements by incorporating a minimum level of community and stakeholders’ participation in CHNAA process. In addition, the concept of community engagement in health services planning and implementation has evolved over recent years, from one-way consultative processes to bi-directional collaboration and shared leadership. Although undertaking an in-depth participatory approach through extensive participation of community stakeholders in CHNAAs may pose certain challenges for healthcare providers including requiring additional time and other resources to collaborate with community residents, we argue the benefits to this approach are important to improve health, as reported by some included studies [ 80 , 118 , 151 ].

A notable gap in the existing literature is the lack of long-term or longitudinal–assessment of CHNAA. The review showed that additional research into CHNAA implementation and outcomes is needed. Currently, there are limited data describing the impact of CHNAAs on health outcomes. However, there is ample evidence on different short-term impacts associated with CHNAA implementation, including, the development of health and social interventions, forming the new partnership, raising awareness on health issues, engaging policy-makers, and facilitating obtaining resources. In other words, it is unclear how CHNAA projects are linked directly to health outcomes. Furthermore, the mechanisms between the conduct and use of CHNAA remain largely unknown in the literature [ 152 , 153 ]. Clearly, not all CHNAA projects result in changes to policies or programmes, and conversely, many programme and policy decisions are made in the absence of CHNAA data [ 154 , 155 ]. Still, further research to understand these mechanisms and the long term impact of CHNAA is needed to support evidence of its use and value in addressing individual and population health needs.

This scoping review aimed to provide clarity and supplement the evidence on the key concepts, rationale, methods, tools and outcomes of community health needs and assets assessments (CHNAAs). Importantly, it highlights the need for holistic approaches to needs assessments to focus on physical, mental and social wellbeing, along with considering wider systems factors and structural challenges to individual and population health. Furthermore, the findings emphasize the inclusion of community assets in community health assessments, beginning foremost with community capabilities and knowledge. It is encouraging to see the use of pragmatic approaches including both qualitative and quantitative methods in CHNAA process in the literature. This will help to ensure that a robust and in-depth exploration of needs and assets is available to guide decision making. Although we recognize the challenges with providing consensus on definitions, processes and tools for CHNAA, we argue that more clarity is needed on the key considerations, steps and outcomes for this process across various settings. This study attempts to provide some theoretical insights and empirical information concerning the process, which hopefully will provide useful guidance to community organizations, policy- makers, health service providers and researchers seeking to develop and implement community health needs and assets assessment.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

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Acknowledgements

We acknowledge contribution of the research assistants helped with data extraction.

This work was funded by department of UHC Life course/Integrated Health Services (IHS), World Health Organization (WHO) headquarter (HQ). ZA received the research grant. The authors HR, AS, and SE from WHO commissioned the study, contributed to the direction of the work, and commented on the drafts.

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AG, HR and SE conceived the study and participated in its design. SK conducted the literature search and prepared the search results for analysis. NN developed the study framework, the data abstraction forms and the manuscript outline. The literature was analysed by ZA, EA and NN under the supervision of HR and AG. ZA drafted the final version of the manuscript and HR, NN, AG and SE reviewed it. All authors read and approved the final manuscript.

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Additional file 1..

PubMed database search strategy.

Additional file 2.

Content of the extraction forms.

Additional file 3.

List of included empirical papers [ 156 – 159 ].

Additional file 4.

List of included non-empirical papers [ 160 -– 175 ] .

Additional file 5.

Health indicators collected by community health assessment surveys.

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Ravaghi, H., Guisset, AL., Elfeky, S. et al. A scoping review of community health needs and assets assessment: concepts, rationale, tools and uses. BMC Health Serv Res 23 , 44 (2023). https://doi.org/10.1186/s12913-022-08983-3

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HEALTH NEEDS ASSESSMENT

Ibrahim a. bani.

Department of Family and Community Medicine, Faculty of Medicine, University of Jazan, Jazan, Saudi Arabia

This paper takes a public health approach to briefly examine: (i) the concept of community health care need assessment; (ii) the roles of academic institutions in health needs assessment; (iii) Jazan study to address the health care needs in Jazan region, Saudi Arabia. The methods included an analysis of the literature, distillation of experience from the recently Jazan Health Need Assessment Survey, and WHO reports. The most important perceived health problems in Jazan region are shortage of health care providers, increased prevalence of communicable diseases and poor environmental health. The academic institutions, Ministry of Health and other health care institutions need to work together to look for innovative approaches, especially to increase the awareness of the society on public health issues, and give more support to increase national and regional funding for community based studies.

The findings of the assessment of the health needs of Jazan presented in this review could be utilized as a baseline and reference information for policy formulation, subsequent planning and cost effective intervention programs. It could also be utilized for the curriculum development or review for a community oriented medical schools.

INTRODUCTION

“Health needs assessment” is a process of determining the health and health care needs of any given population or sub-group in an area. It is a complex task requiring epidemiological expertise, the ability to work across organizational boundaries as well as an understanding of, and an ability to engage with all appropriate population groups. The “health needs assessment” process needs to take account of the diversity within these populations. Health improvement programs provide opportunities to engage in such assessments in the national and regional population.

Research has shown that preventive programs can improve community health when properly implemented. 1 There are examples of successful prevention programs in local communities. However, many still have significant challenges, which demonstrate a gap between science and practice. Though in the United States, there are such common strategies (training–programs), to address this issue, outcomes are still unsatisfactory. Building the capacity of the community to implement high quality prevention can help communities achieve positive health outcomes, thereby narrowing the gap between theory and practice. While there is ample research on the efficacy of evidence-based programs, there is little on how to improve community capacity to improve the quality of prevention. What is being proposed is a new model of research: one based on Community Science that improves the latest theoretical understanding of community capacity and evaluates technologies designed to enhance it.

In most developing countries, the evolution of health services has been dominated by Western models of health care 2 . These have rarely taken into account how local people explain illness, seek advice, or use traditional healing methods. The emphasis has been on hospitals and curative care rather than on trying to address local health needs equitably and effectively. Since the Alma Ata declaration on primary health care, more attention has been given to increasing coverage of basic services and preventing common diseases. However, the bias in resource allocation towards secondary care and urban areas remains.

Health care needs are changing and new challenges arising from chronic diseases and HIV infection must be faced. Better coverage of preventive and essential healthcare services has led to greater emphasis on improving the quality of health care to ensure the efficient and judicious use of scarce resources. For example, infant mortality has fallen dramatically in the past two decades through such interventions as oral rehydration for diarrhea and immunization programs. With fewer children dying, there has been greater emphasis on the need to tackle the causes of infant and child morbidity. The size of families can be reduced with the improvement of the availability of family planning.

If health services are to respond to the changing health needs of their local populations, planners and managers would need useful and timely information about the health status of these populations. Some of this information can come from routine data sources or may be collected from large, one-off population studies. Some information can be obtained from community surveys.

COMMUNITY HEALTH NEED ASSESSMENT

Community appraisals describe approaches to needs assessments that emphasize the involvement of local people. A confusing number of terms describe similar methods: rapid evaluation methods, rapid appraisal methods, rapid community surveys, rapid rural appraisal, relaxed rural appraisal, participatory rural appraisal 3 . The development of rapid appraisal methods in the 1980s came in recognition of the time consuming and rigid nature of traditional epidemiological and questionnaire surveys. Experience with these appraisal methods showed that when they were perfectly executed, they provided valuable, reliable, and timely information on health status, knowledge, attitudes, and behaviors. More recently, emphasis has been placed on encouraging people to participate in their own appraisal (for example, participatory rural appraisal) 4 .

The hardest part of any needs assessment is translating the results into policies and practices to elicit and (or) initiate beneficial change. The involvement of health care workers in techniques such as rapid or rural appraisal will encourage changes at an individual level. Local workshops can provide opportunities to review the lessons learnt with other health care workers. If this change is going to be sustainable and adaptable, then the appraisal should be a continuous process with ongoing feedback. Implementation of strategic changes can be facilitated if the policy-makers themselves are active in the process. Active collaboration between communities and researchers is critical in developing appropriate public health research strategies that address community concerns. 5

Partners for Healthy Communities conducted interviews with community members from the ethnically diverse neighborhoods of Central and Southeast Seattle. The results suggest that effective community-researcher collaborations require a paradigm shift from traditional practices to an approach that involves: acknowledging community contributions, recruiting and training minority people to participate in research teams, improving communication, sharing power, and valuing respect and diversity.

ACADEMIC APPROACH TO COMMUNITY HEALTH

Academic institutions have always found it a challenge to persuade community members to participate in academic research projects 6 . Starting an open dialogue is usually the critical first step. To begin this dialogue with community members in Dayton, Ohio, in 1999, staff from Wright State University decided to organize a community forum, “The History of Health in Dayton.” The forum was intended as the first project of a new research organization, Alliance for Research in Community Health (ARCH), established with federal funding from the Health Resources and Services Administration in 1998. ARCH was created as a bridge between the Department of Family Medicine of Wright State University School of Medicine and the Center for Healthy Communities, a health advocacy and service organization committed to health profession education. ARCH's mission is to improve the health of citizens of Dayton through research involving community participation. Through ARCH, community members help researchers define priorities, resolve ethical issues, refine procedures, and interpret results.

Guidelines for participatory research, proposed by the National Primary Care Research Group in 1998 adopted by the alliance, emphasize the importance of open dialogue among researchers, subjects, academics, and community members. The initial response to the forum was enthusiastic, with a majority of community residents expressing interest in attending future presentations.

Barker (1999) described the different ways in which academics and community groups may work together, including academic/practice/ community partnerships. Several principles of practice for engaging in these research partnerships are presented followed by a description of how these principles have been put into operation in a family violence prevention program 7 . The principles presented are: (1) Identification of the best processes/models to be used based on the nature of the issue and the intended outcome; (2) Acknowledgement of most of the differences between community input and active community involvement; (3) Development of relationships based on mutual trust and respect; (4) Acknowledgment and honoring of the different agendas of partners; (5) Consideration of multi-disciplinary approaches; (6) Use of evaluation strategies that are consistent with the overall approach taken in the academic/practice/ community partnership; and (7) Awareness of partnership maturation and associated transition periods. The limitations of these principles and their application in various settings are discussed.

While many members of the public are deeply interested in and supportive of the three traditional missions of academic medicine--education, research, and clinical care, they also want to know what academic health centers (AHCs) are doing to improve the overall health of their communities 8 . Much is already being done toward this goal, but improving communities’ health in a measurable way requires a far broader agenda. AHCs must bring together the approaches of medicine and public health, and need to form partnerships with many other players. This agenda must proceed despite all the other challenges that AHCs face. The author reviewed illustrative and emerging national, state, and local efforts, both public and private; in both medicine and public health, in partnerships with individuals and institutions in the larger community. He also highlights the physician's role in assisting stakeholders’ efforts to deal with health threats from the environment, and offers advice on how such efforts should proceed. He closes by emphasizing the importance of community-based research in learning about the health status, problems, and resources of particular communities; and presents a set of principles for such community-based research.

Lillie-Blanton and Hoffman (1995) examined strategies and methodological issues for researchers to consider when conducting community-based research within a racial/ethnic minority group. 9 Members of minority communities have considerable skepticism about the health care system and researchers who work under its auspices. To facilitate quality research, it is necessary to build a mutually beneficial partnership between the community and researchers. Suggested strategies for accomplishing this, such as searching for information on the social and political forces shaping the community and developing the community's capacity to undertake research of this type, are described. Methodological issues include the importance of community input in defining the minority population group and its leadership, the benefits and limitations of conducting comparative analysis, and the need for measurement tools and techniques that are culturally and socially appropriate. Minority and non-minority researchers must make a concerted effort to understand and have respect for a community whose culture, values, and beliefs may differ.

PRIMARY HEALTH CARE IN SAUDI ARABIA

A recent study reported that nearly a quarter of the children in Riyadh contracted diarrhea during the two weeks preceding the data collection, giving about six episodes of diarrhea per child per year 10 . Diarrhea was more common in children over 6 months of age, in children who had no vaccination or follow-up cards, and in those who were being cared for by friends and neighbors as their mothers were working outside home. The mothers of the affected children were young, married before 25 years of age, with 2–6 years of normal schooling. During diarrheal episodes, about 25% of mothers stopped or reduced breast-feeding, 11.3% reduced the volume of fluids given to their children, and 22.7% of the children were fed less solid/semi-solid foods. Mothers used oral rehydration salt in more than 40% of diarrheal episodes and unprescribed antibiotics were used in 17% of cases. The mothers who were not taking appropriate action included young mothers with low level of education and those working outside the home.

In response to the need for comprehensive, cost-effective and cost-benefit services, there have been major changes in the health care system of Saudi Arabia since the early 1980s. This followed government's commitment to the Alma Ata declaration in 1980. Currently, there are nearly 1800 governmental PHC centers distributed evenly throughout the country, 1707 of which belong to the Ministry of Health (MOH) 11 . The remainder are run by various health care providers, including universities, the military, the National Guard and the Security Forces. Entry into the health care system is through PHC centers. More than 180 secondary and tertiary care hospitals serve as referral units and each group of PHC centers is attached to a hospital.

HEALTH NEED ASSESSMENT: PRIMARY HEALTH CARE APPROACH

A number of themes emerged as important to the impact of health needs assessments on policy and planning 12 . These included careful design, strict methodology, decisive leadership, good communication, involvement and the ownership of the work from relevant stakeholders, support from senior decision-makers, appreciation of political dynamics, and engagement with local priorities, availability of resources and, finally, an element of chance. These themes can be categorized broadly into contextual factors, and quality or robustness of the work. Although this study has demonstrated that there are conditions under which needs assessment are more likely to be effective in terms of its influence on policy and planning, it is clear that it is not central in the decision-making process of the health service, for it remains vulnerable to a range of factors over which those responsible for implementation of the decisions have little or no control.

It has been reported that quality of life was unrelated to satisfaction of services, but was strongly associated with unmet needs of mental and physical health, and of rehabilitation. 13 The quality of life decreased as needs increased. Needs are also strongly related to diagnosis and cognitive functioning. Furthermore, more intensive care settings were provided as needs increased.

Primary health care can meet the needs of the population in an equitable way only if these needs are known. The WHO Regional Office for Europe convened a working group to examine the consequences of the assessment of the health needs of the population at the district level for primary care. 14 The group discussed a useful model for community-oriented primary care (COPC), which involved the delivery of programs tailored to community needs. The group considered needs assessment as the basis for allocating resources, prioritizing the needs of community health programs, planning and evaluating these programs; in the third area, they stressed the need to develop further the model for a community-oriented planning and evaluation cycle (COPEC).

The impact of community needs assessments was used in South Australia where the data was collected from regional health planning officers. 15 The needs assessments were found to vary from the regional to the locally driven. Approaches ensured local involvement, but the process was slower and more arduous for the planner. The use of community health needs assessment was useful, but for greater impact these should not be broad, but focused on feasible changes that the health services could support. Other priority-setting techniques, such as marginal analysis, should be used to determine where it could also be used to determine where maximum health gains are possible.

An area of controversy of need assessment is that which asks the question “whose need”? Several researchers stress the importance of collecting both quantitative and qualitative data from a variety of sources to ensure that community needs are examined from a variety of perspectives 16 , 17 . Other studies have described four types of need that should be considered in needs assessment. These include comparative, normative, expressed and felt. 18 , 19 Indicators of normative needs can be seen as the “vision of health” or benchmarks or targets that are described by experts, task forces, commissions, etc. Indicators of comparative needs include information about the determinants of health for the population as they compare with benchmarks of other populations and other areas of health. Expressed needs are described as information about demands or as ‘wants to put into action’ related to health gathered from key informants, survivors, advocacy groups, government directives, etc. Felt needs are wants or attitudes related to personnel or the community's visions of health, e.g., “we want to feel safe walking alone at night” The proposed framework is based on indicators of needs for each of these dimensions.

Doctors, sociologists, philosophers, and economists all have different views on what needs are. 20 – 22 In recognition of the scarcity of resources available to meet these needs, health needs are often differentiated as needs, demands and supply. Need in health care is commonly defined as the capacity to benefit. If health needs are to be identified then an effective intervention should be available to meet these needs and improve health. There will be no benefit from an intervention that is not effective or if there are no resources. Demand is what patients ask for; it is the need that most doctors encounter. General Practitioners play a key role as gatekeepers in controlling this demand, and waiting lists become a surrogate marker with an influence on this demand. Demand for a service from patients can depend on characteristic of the patient or on the media interest in that service. Supply is the health care provided. This depends on health interests of the professionals, the priorities of politicians, and the amount of money available. The demand and supply of needs overlap. This relationship should be an important consideration when assessing health needs.

A lead article which introduced the community survey concept, detailed reasons for a community survey, and outlined mythological framework for completing such a study. 23 The article defined a community survey as “a survey of population researched by health services provider within a defined geographic area such as hospital service area”. The most critical step in conducting a community survey is for the manager to specify what types of information are needed and how that will be used. To assess health needs of a rural community, it is also important to include a cross-section of health care providers in the “information identification process” to avoid focusing only on services offered by major health care providers (i.e. the local hospital).

Recently, a study reported the awareness of General Practitioners (GP) and their experiences of needs assessment. 24 Most GPs were unfamiliar with the concept of needs assessment, and there was no evidence that needs assessment had influenced commissioning decisions. Most of the GPs argued that it was not a core activity. Besides, they lacked training in the relevant skills. The motivation and attitude of the majority of the GPs is a barrier to needs assessment in primary care. GPs require more resources and training if they are to bear this responsibility.

Over the past 20 years, governments throughout Western Europe and North America have encouraged patients to contribute to the planning and development of health care services. 25 In England and Wales, the involvement of patients is central to current efforts to improve the quality of health care. Underlying these changes, is the belief that involving patients leads to more accessible and acceptable services and the improvement of health and quality of life of patients.

Rapid appraisal can be used to involve the public in the identification of local health needs and supplement more informal methods of assessing needs. 26 Rapid Appraisal is best used in homogenous communities. The process of rapid appraisal can give structured orientation to new workers in the community. Rapid appraisal can be adapted to introduce medical students to the concept of community diagnosis as a natural adjunct to individual clinical diagnosis.

Palmer identified the need for reproductive health care in a community affected by conflict in Southern Sudan. 27 The study comprised interviews with key informants, in-depth interviews, and group discussions. Secondary data were collected. Reproductive health in general, and sexually transmitted diseases in particular were important issues for these communities. Perceptions of reproductive issues varied between service providers and community leaders.

To improve the health of any population or subgroup of that population requires coordinated efforts of many partners in health. These are the health authorities, the local authorities, local business, the voluntary sector, the pharmaceutical industry, and organized groups of the society. 28 Improving health is far more complex and long-term than the provision of health care, as some of the root causes of ill health (poverty, housing, lifestyle, employment and crime) are beyond the control of health services.

JAZAN HEALTH NEED ASSESSMENT

Occupying an area of about 16000 km 2 and with a population of about one million (1421 census), the Jazan region is in the south-western region of Saudi Arabia. It has three geographically distinct zones: the mountain zone which is 2000-2500m above sea level with >300mm of rain/year, the hill zone, 400-600m above sea level with <300mm of rain/year, and the coastal zone that is <400m above sea level with very little rain. The region is intersected by perennial streams.

As a result of its special climate and topography, poor sanitation, inadequate water supply and a middle to low socio-economic status of some communities in the mountainous areas, water borne and water associated diseases such as malaria, schistosomiasis, leishmaniasis, hepatitis, typhoid etc. are prevalent. Tuberculosis is highly endemic. Health statistics from the area indicate high rates of morbidity, mortality & low health care coverage compared to other regions of Saudi Arabia.

The people of Jazan are mostly livestock farmers. The close association and proximity of man and animal has resulted in endemicity of such zoonotic diseases as brucellosis. Jazan city is only 70km from the Yemen border. The 1999 epidemic of the Rift Valley Fever occurred at the border areas as a result of the movements of the border population and the introduction of animals from neighboring countries.

The recent Ministry of Health annual report 29 has shown that the prevalence of infectious diseases in Jazan region as follows: TB 147/2322 (6.3%), Bilharzias 18.35%, Malaria 67.48 %, Hepatitis A 100\2250 (4.4%), and measles 26/617 (4.2%). There are 135 Primary Health Care Centers (PHCC), and 13 hospitals, only two of which are specialized.

Academic public health plays an important role in teaching and research, as well as supporting service departments of public health at national and local levels. 30 The academic-service is a continuum and is essential in providing high quality public health delivery for the nation.

Concerns with health conditions of the population have become a part of a wider concern with the direction of development of human resources. All social and economic development is underpinned by the development of the country's human resources to their full potential. Thus, the training of Saudi personnel in various health fields is important for the success of the Kingdom's plans for health development. The Jazan College of Medicine was therefore, established in 2001.

The expected mission of Jazan Medical College is to raise the standard of health in this area by training health personnel who would be involved in community programs to combat health problems, and work with other health agents in the region in preventive and curative programs.

The Jazan Medical College conducted a comprehensive health survey of Jazan 31 which involved three techniques: key informant interviews, focus group interviews and a household survey.

The key findings were as follows: (1) the most important perceived health problems in Jazan were the shortage of health care providers, and an increased prevalence of communicable diseases and poor environmental health, (2) high level of awareness of communicable diseases with weakness in prevention, (3) most frequently reported chronic conditions: hypertension, bronchial asthma, diabetes mellitus and joint diseases, (4) diarrhea in around 15.6 percent of children, and malaria treatment of 35.9% at the health facility, (5) an estimated 33% of the rural and 37.7% of the urban are current cigarette smokers, and the 61.7% current Khat users in rural compared to 45.7% in the urban areas. The overall Khat use is 48.7%. The data and information generated from this study will be utilized as a baseline and reference information for policy formulation, subsequent planning and cost effective intervention programs, and will be important in the development of the curriculum of Jazan Medical College. It will also help decision makers in the Jazan region in the planning of any future health program.

Though a combination of quantitative and qualitative approaches is recommended in health service research, it has advantages and disadvantages. The incorporation of the view point of the general population through development in the health service has the potential of improving the relevance and impact of research and the quality of subsequent services provided. 32 , 33

A very recent study documented important lessons learned from the use of community key informants in needs assessment surveys to identify health problems and needs. The study suggested the means to control and prevent major health problems in the region of Jazan. The study also emphasized the role of the Jazan medical college in providing skilled manpower and expertise to improve the health care service delivery in the region of Jazan. 34

CONCLUSIONS AND RECOMMENDATIONS

The historical development of health services has been dominated by Western models of health care and health beliefs. 35 These have rarely taken into account how local people explain illness or seek advice. However, the assessment of health needs is not simply a process of listening to patients or reliance on personal experience and anecdotes. It is a systematic method of identifying unmet need and making changes to fill this need. In public health, it is the need of the population, which perhaps could be that of a district or perhaps a section of the population such as women of childbearing age, which have to be assessed.

In conclusion: the academic institutions, Ministry of Health, and other health care institutions should cooperate in looking for innovative approaches to increase awareness of the broader social and public health issues, and increase funding from both regional and national sources to support community based studies.

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Connecting Your Needs Assessment With the Blueprint for Change

The National Center for a System of Services for CYSHCN created this tool as a resource for state or jurisdiction Title V CYSHCN programs to approach their needs assessment process in alignment with the  Blueprint for Change . This resource outlines key questions to consider and how each question intersects with the required areas of the Title V needs assessment, universal National Performance Measures and the critical areas of the Blueprint.  These questions were informed by National Center resources, project activities and the Blueprint for Change articles. We encourage you to use this as a starting point and develop additional research questions to inform your needs assessment, including both your 5-year needs assessment and ongoing needs assessment. Questions can be perceived differently and may fit into more/less categories than as outlined below. 

Principles and associated strategies are described in Guiding Principles for a System of Services for Children and Youth With Special Health Care Needs and Their Families .

Children and Youth With Special Health Care Needs: A Profile

Health equity, family and child well-being and quality of life, access to services, financing of services, printable version.

A downloadable version of the "Connecting your Needs Assessment with the Blueprint for Change: Key Questions" resource is available.

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What is corporate social responsibility in healthcare?

Corporate social responsibility in healthcare can include sdoh work and investing in community benefits..

• Sara Heath, Executive Editor

As businesses across the country continue to assess the impacts they have on the environment and society around them, corporate social responsibility in healthcare is likewise becoming prominent.

Indeed, corporate social responsibility ( CSR ) is not a concept unique to healthcare. Rather, it can apply to all businesses and corporations, and since most hospitals and health systems are corporations, it applies to healthcare, too.

As more business sectors embrace principles of ethics and CSR, so too are healthcare organizations. Those trends, plus obligations for claiming tax-exempt nonprofit status and pushes for more social determinants of health (SDOH) work, are pushing more hospitals and health systems to assess their CSR strategies.

Defining corporate social responsibility in healthcare

According to the Harvard Business School, corporate social responsibility is "the idea that a business has a responsibility to the society that exists around it."

IBM says that corporate social responsibility means companies prioritize not just profit but also the impact they have on the environment and society around them.

"Through CSR, companies make decisions driven by financial gain and profitability, and the impact of their actions on their communities and the world at large," IBM says on its website . "CSR goes beyond legal obligations: by voluntarily adopting ethical, sustainable and responsible business practices, companies seek to deliver benefits to consumers, shareholders, employees and society."

Like other industries, many healthcare organizations have embraced their social responsibility. According to Charity Miles, an organization that facilitates corporate walks and runs for charitable causes, healthcare social responsibility is closely linked to SDOH.

"Corporate Social Responsibility (CSR) in healthcare involves healthcare organizations ethically contributing to community health and well-being through sustainable practices, enhanced healthcare access, and initiatives tackling social health determinants like poverty and education to better health outcomes," Charity Miles says .

According to the American College of Healthcare Executives (ACHE), which counts CSR among its chief commitments, social responsibility can be exemplified in six pillars:

• Responsible advocacy.
• Environmental and economic stability.
• Public protection through ethical practices, self-regulation and support of human rights.
• Philanthropy and community service.
• Socially responsible leadership.

The benefits of CSR are manifold. Of course, CSR can support the community a hospital or health system serves, but most experts agree the practice can also support the healthcare organization itself.

Hospitals and health systems that practice CSR might improve their public image, boosting consumer trust and patient loyalty . On the flip side, they might also help close health disparities by supporting SDOH.

Notably, CSR is voluntary for nearly every corporation, including hospitals and health systems. However, for hospitals and health systems with nonprofit and tax-exempt status, CSR might seem like a de facto requirement.

Corporate social responsibility and nonprofit status

Nonprofit 501(c)(3) hospitals receive tax-exempt status from the IRS in exchange for practices related to charity care and social responsibility. Those requirements, mandated as part of the Affordable Care Act (ACA), include the following:

• Completion of a community health needs assessment.
• Operating an emergency department open to everyone, regardless of ability to pay.
• Financial assistance policy.
• Limitations on charges for individuals who qualify.
• Compliance with certain billing and collections policies.

To be clear, the IRS does not mandate CSR for nonprofit hospitals. However, the community benefits that nonprofit hospitals do have to provide, which can include charity care and other charitable programs to benefit the community, often align with a strong CSR strategy.

In essence, nonprofit hospitals are required to design their operations to support the communities they serve rather than funneling all profits to shareholders. This means operating under a CSR structure.

However, murky requirements make it difficult to measure a hospital or health system's social responsibility. There is no minimum amount nonprofit hospitals need to spend on community benefits, meaning some hospitals spend as little as $.01 on the dollar in community benefits, according to one 2018 Health Affairs study .

Oversight might also be lacking. A 2020 Government Accountability Office (GAO) report showed as many as 30 hospitals did not spend anything on community benefits.

This has led to some discrepancies regarding how much nonprofit hospitals and health systems put toward community services and whether that is enough.

According to a 2023 American Hospital Association (AHA) report, nonprofit hospitals gave more than $20 billion in community benefits in 2020, accounting for 15.5% of total expenses.

That conflicts with a 2024 report from the Lown Institute showing that nonprofit hospitals spent 3.87% of their budgets on community benefits , making the tax breaks they see as 501(c)(3) organizations exceed their total community benefit spend.

There is little evidence explaining the discrepancy between community benefit and social responsibility giving. Factors like variable definitions and standards, accounting practices, reporting requirements and data sources could be at play.

Regardless, nonprofit hospitals and health systems looking to improve their community benefit practices or public image and patient loyalty might turn to common CST practices.

Examples of CSR in healthcare

There is no one-size-fits-all approach for CSR in healthcare. Social responsibility in one community might look different than it does in another.

For example, a hospital prioritizing CSR in a community with many food deserts might invest in food delivery modalities and fund community food banks or farmer's markets.

Meanwhile, a different health system's CSR might manifest as financially backing affordable housing complexes because it treats a larger unhoused population .

CSR does not need to be informed by community needs assessments, but it does help to know what types of resources would support the community a hospital serves. From there, health systems can assess their own resources and community partnerships to identify high-yield intervention areas.

Some leading examples of CSR in healthcare include the following:

• Mobile health clinics to support free or subsidized patient care access.
• Workforce development.
• Environmental conservation.
• Donating of medical supplies.
• Investments in affordable housing.
• Social determinants of health interventions.

As noted above, CSR work can be closely linked to a nonprofit hospital's community benefits. Offering charity care is considered CSR work, as is reviewing financial assistance programs.

Practicing CSR is part of a key cultural shift focusing on social responsibility and business ethics. As key anchor institutions, healthcare organizations might consider different CSR strategies as they work not just to improve the health of communities but also their own public image and consumer loyalty.

Sara Heath has covered news related to patient engagement and health equity since 2015.

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Fulton County Medical Center launches Tri-Annual Community Health Needs Assessment Survey

McCONNELLSBURG — The Fulton County Medical Center, Tri-State Community Health Center and the Fulton County Family Partnership have launched a collaborative community health needs assessment survey.

This survey, which is conducted once every three years, is aimed at helping health and human service agencies make informed decisions about programs and services that will benefit the community.

To complete the survey, go to https://forvis.questionpro.com/t/AJvMUZ3dX5 . After finishing the online survey, enter for a chance to win a $100 gift card.

To request a printed copy to complete or for more information, call Misty Hershey at 717-485-6115.

The deadline to complete the survey is Oct. 21.

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OSF Saint Anthony’s requests public input on Community Health Needs Assessment (CHNA) survey

8/05/2024 - Alton, Illinois

OSF Saint Anthony's Health Center

OSF HealthCare Saint Anthony’s Health Center is requesting help from the local community to determine and prioritize health needs. A survey is now available in English and Spanish, and residents of the Riverbend region (and throughout Madison County) can participate by filling it out online or by picking up a paper copy at OSF Saint Anthony’s (1 Saint Anthony’s Way, Alton).

“Every community has different health care needs,” says Lisa Schepers, DNP, MBA, RN, NE-BC, Interim President of OSF Saint Anthony’s. “Through this survey, we hope to get input from a broad set of community members to help us focus our efforts on the challenges and opportunities unique to Alton, the Riverbend region, and Madison County.”

According to Federal law, all not-for-profit hospitals are required to conduct a Community Health Needs Assessment (CHNA) every three years and put together an Implementation Strategy to meet the community needs that the assessment identifies.

The English language survey can be accessed here:

https://bradley.az1.qualtrics.com/jfe/form/SV_3jShygGqPJkgdCu

The Spanish language survey can be accessed here:

https://bradley.az1.qualtrics.com/jfe/form/SV_7NITNj5K3UuO7C6

“Our assessment team pulls together a broad set of health care consumers throughout our service area to help us identify the health needs of the communities we serve,” Schepers says. “The CHNA is not only a Federal requirement, it aligns closely to our OSF Healthcare Mission, ‘to serve persons with the greatest care and love in a community that celebrates the Gift of Life.”

After the data is collected and the local community's health needs are prioritized by greatest need, administrative and caregiver teams at OSF Saint Anthony’s work together to further support current community-based health programs and services as well as starting new programs to help meet the needs for each community.

“Our last survey identified behavioral health (including mental health and substance abuse) and healthy behaviors (defined as healthy eating and active living, and impact on obesity) as the greatest opportunities for improvement in our community,” Schepers states. “We took feedback from the survey and, through a collaborative approach, were able to implement programs and services to meet that need.”

More information on OSF Saint Anthony’s current CHNA can be obtained by visiting www.osfsaintanthonys.org and subsequently clicking on the “Community Health” link at the bottom of the landing page.

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AMHC releases 2024 Community Needs Assessment on substance use epidemic in Aroostook

PRESQUE ISLE, Maine — Aroostook Mental Health Services, Inc. and its consortium members conducted a community  needs assessment focused on substance use in Aroostook County earlier this year. The assessment was funded by a Health  Resources Services Administration Rural Community Opioid Response Planning Implementation III grant, which aims  to reduce the morbidity and mortality of substance use disorder, including opioid use disorder.  

“AMHC and its consortium members completed the last substance use needs assessment in 2020,” explained Debra Jacques, AMHC director of marketing and development and project director for the grant. “A great deal has taken place since then and it was time  for an update. We had a record 547 responses to the online community survey, and several focus groups included individuals in  recovery, youth, healthcare and law enforcement. Our goal was to hear from as many individuals as possible from northern, central, and southern Aroostook about what is working and not working as we address the substance use crisis in our communities.” 

With the number of overdose deaths in Aroostook County rising from 14 in 2019 to 39 in 2023 (a 179 percent increase), learning how the  community feels about the substance use epidemic can inform what services and resources to offer. The Community Health Needs Assessment provides updated findings on people’s thoughts about alcohol use disorder, opioid use disorder, and substance use disorder in Aroostook County. The overall sentiment from survey respondents and focus group participants was that while positive strides have been made in addressing the county’s SUD epidemic, there are still unmet needs. 

Priority areas  include: youth engagement, workforce shortages, expansion of recovery services and education on how to access naloxone and reduce stigma. 

AMHC and its consortium members, Northern Maine Medical Center, Mi’kmaq Health Center, Northern Light A.R. Gould Hospital, Houlton Regional Hospital and the Aroostook County Sheriff’s Office, appreciate the partnership with the University of New England  in developing and completing the assessment.  

The 2024 Community Needs Assessment and Gap Analysis Update is available at ShareFactsSaveLives.org/Publications . For more  information, please contact Deb Jacques at [email protected] .

This material is supported by the Federal Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services under grant #GA1RH42873-01-00. The information, conclusions, and  opinions expressed in this product are those of the authors, and no endorsement by FORHP, HRSA or HHS is intended or should be inferred. 

With 60 years of dedicated service, AMHC has become the largest behavioral healthcare provider in the region, operating 27 service  locations across Aroostook, Hancock and Washington counties. The agency annually supports up to 5,500 clientele, with a team of  350-plus employees delivering a comprehensive range of services in mental health, substance use, crisis, sexual assault, prevention, brain injury, and programs for adults with intellectual disabilities. Guided by our mission, we strive to provide integrated healthcare services that empower individuals to recover and enhance their overall quality of life. 

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What Kamala Harris has said so far on key issues in her campaign

As she ramps up her nascent presidential campaign, Vice President Kamala Harris is revealing how she will address the key issues facing the nation.

In speeches and rallies, she has voiced support for continuing many of President Joe Biden’s measures, such as lowering drug costs , forgiving student loan debt and eliminating so-called junk fees. But Harris has made it clear that she has her own views on some key matters, particularly Israel’s treatment of Gazans in its war with Hamas.

In a departure from her presidential run in 2020, the Harris campaign has confirmed that she’s moved away from many of her more progressive stances, such as her interest in a single-payer health insurance system and a ban on fracking.

Harris is also expected to put her own stamp and style on matters ranging from abortion to the economy to immigration, as she aims to walk a fine line of taking credit for the administration’s accomplishments while not being jointly blamed by voters for its shortcomings.

Her early presidential campaign speeches have offered insights into her priorities, though she’s mainly voiced general talking points and has yet to release more nuanced plans. Like Biden, she intends to contrast her vision for America with that of former President Donald Trump. ( See Trump’s campaign promises here .)

“In this moment, I believe we face a choice between two different visions for our nation: one focused on the future, the other focused on the past,” she told members of the historically Black sorority Zeta Phi Beta at an event in Indianapolis in late July. “And with your support, I am fighting for our nation’s future.”

Here’s what we know about Harris’ views:

Harris took on the lead role of championing abortion rights for the administration after Roe v. Wade was overturned in June 2022. This past January, she started a “ reproductive freedoms tour ” to multiple states, including a stop in Minnesota thought to be the first by a sitting US president or vice president at an abortion clinic .

On abortion access, Harris embraced more progressive policies than Biden in the 2020 campaign, as a candidate criticizing his previous support for the Hyde Amendment , a measure that blocks federal funds from being used for most abortions.

Policy experts suggested that although Harris’ current policies on abortion and reproductive rights may not differ significantly from Biden’s, as a result of her national tour and her own focus on maternal health , she may be a stronger messenger.

High prices are a top concern for many Americans who are struggling to afford the cost of living after a spell of steep inflation. Many voters give Biden poor marks for his handling of the economy, and Harris may also face their wrath.

In her early campaign speeches, Harris has echoed many of the same themes as Biden, saying she wants to give Americans more opportunities to get ahead. She’s particularly concerned about making care – health care, child care, elder care and family leave – more affordable and available.

Harris promised at a late July rally to continue the Biden administration’s drive to eliminate so-called “junk fees” and to fully disclose all charges, such as for events, lodging and car rentals. In early August, the administration proposed a rule that would ban airlines from charging parents extra fees to have their kids sit next to them.

On day one, I will take on price gouging and bring down costs. We will ban more of those hidden fees and surprise late charges that banks and other companies use to pad their profits.”

Since becoming vice president, Harris has taken more moderate positions, but a look at her 2020 campaign promises reveals a more progressive bent than Biden.

As a senator and 2020 presidential candidate, Harris proposed providing middle-class and working families with a refundable tax credit of up to $6,000 a year (per couple) to help keep up with living expenses. Titled the LIFT the Middle Class Act, or Livable Incomes for Families Today, the measure would have cost at the time an estimated $3 trillion over 10 years.

Unlike a typical tax credit, the bill would allow taxpayers to receive the benefit – up to $500 – on a monthly basis so families don’t have to turn to payday loans with very high interest rates.

As a presidential candidate, Harris also advocated for raising the corporate income tax rate to 35%, where it was before the 2017 Tax Cuts and Jobs Act that Trump and congressional Republicans pushed through Congress reduced the rate to 21%. That’s higher than the 28% Biden has proposed.

Affordable housing was also on Harris’ radar. As a senator, she introduced the Rent Relief Act, which would establish a refundable tax credit for renters who annually spend more than 30% of their gross income on rent and utilities. The amount of the credit would range from 25% to 100% of the excess rent, depending on the renter’s income.

Harris called housing a human right and said in a 2019 news release on the bill that every American deserves to have basic security and dignity in their own home.

Consumer debt

Hefty debt loads, which weigh on people’s finances and hurt their ability to buy homes, get car loans or start small businesses, are also an area of interest to Harris.

As vice president, she has promoted the Biden administration’s initiatives on student debt, which have so far forgiven more than $168 billion for nearly 4.8 million borrowers . In mid-July, Harris said in a post on X that “nearly 950,000 public servants have benefitted” from student debt forgiveness, compared with only 7,000 when Biden was inaugurated.

A potential Harris administration could keep that momentum going – though some of Biden’s efforts have gotten tangled up in litigation, such as a program aimed at cutting monthly student loan payments for roughly 3 million borrowers enrolled in a repayment plan the administration implemented last year.

The vice president has also been a leader in the White House efforts to ban medical debt from credit reports, noting that those with medical debt are no less likely to repay a loan than those who don’t have unpaid medical bills.

In a late July statement praising North Carolina’s move to relieve the medical debt of about 2 million residents, Harris said that she is “committed to continuing to relieve the burden of medical debt and creating a future where every person has the opportunity to build wealth and thrive.”

Health care

Harris, who has had shifting stances on health care in the past, confirmed in late July through her campaign that she no longer supports a single-payer health care system .

During her 2020 campaign, Harris advocated for shifting the US to a government-backed health insurance system but stopped short of wanting to completely eliminate private insurance.

The measure called for transitioning to a Medicare-for-All-type system over 10 years but continuing to allow private insurance companies to offer Medicare plans.

The proposal would not have raised taxes on the middle class to pay for the coverage expansion. Instead, it would raise the needed funds by taxing Wall Street trades and transactions and changing the taxation of offshore corporate income.

When it comes to reducing drug costs, Harris previously proposed allowing the federal government to set “a fair price” for any drug sold at a cheaper price in any economically comparable country, including Canada, the United Kingdom, France, Japan or Australia. If manufacturers were found to be price gouging, the government could import their drugs from abroad or, in egregious cases, use its existing but never-used “march-in” authority to license a drug company’s patent to a rival that would produce the medication at a lower cost.

Harris has been a champion on climate and environmental justice for decades. As California’s attorney general, Harris sued big oil companies like BP and ConocoPhillips, and investigated Exxon Mobil for its role in climate change disinformation. While in the Senate, she sponsored the Green New Deal resolution.

During her 2020 campaign, she enthusiastically supported a ban on fracking — but a Harris campaign official said in late July that she no longer supports such a ban.

Fracking is the process of using liquid to free natural gas from rock formations – and the primary mode for extracting gas for energy in battleground Pennsylvania. During a September 2019 climate crisis town hall hosted by CNN, she said she would start “with what we can do on Day 1 around public lands.” She walked that back later when she became Biden’s running mate.

Biden has been the most pro-climate president in history, and climate advocates find Harris to be an exciting candidate in her own right. Democrats and climate activists are planning to campaign on the stark contrasts between Harris and Trump , who vowed to push America decisively back to fossil fuels, promising to unwind Biden’s climate and clean energy legacy and pull America out of its global climate commitments.

If elected, one of the biggest climate goals Harris would have to craft early in her administration is how much the US would reduce its climate pollution by 2035 – a requirement of the Paris climate agreement .

Immigration

Harris has quickly started trying to counter Trump’s attacks on her immigration record.

Her campaign released a video in late July citing Harris’ support for increasing the number of Border Patrol agents and Trump’s successful push to scuttle a bipartisan immigration deal that included some of the toughest border security measures in recent memory.

The vice president has changed her position on border control since her 2020 campaign, when she suggested that Democrats needed to “critically examine” the role of Immigration and Customs Enforcement, or ICE, after being asked whether she sided with those in the party arguing to abolish the department.

In June of this year, the White House announced a crackdown on asylum claims meant to continue reducing crossings at the US-Mexico border – a policy that Harris’ campaign manager, Julie Chavez Rodriguez, indicated in late July to CBS News would continue under a Harris administration.

Trump’s attacks stem from Biden having tasked Harris with overseeing diplomatic efforts in Central America in March 2021. While Harris focused on long-term fixes, the Department of Homeland Security remained responsible for overseeing border security.

She has only occasionally talked about her efforts as the situation along the US-Mexico border became a political vulnerability for Biden. But she put her own stamp on the administration’s efforts, engaging the private sector.

Harris pulled together the Partnership for Central America, which has acted as a liaison between companies and the US government. Her team and the partnership are closely coordinating on initiatives that have led to job creation in the region. Harris has also engaged directly with foreign leaders in the region.

Experts credit Harris’ ability to secure private-sector investments as her most visible action in the region to date but have cautioned about the long-term durability of those investments.

Israel-Hamas

The Israel-Hamas war is the most fraught foreign policy issue facing the country and has spurred a multitude of protests around the US since it began in October.

After meeting with Israeli Prime Minister Benjamin Netanyahu in late July, Harris gave a forceful and notable speech about the situation in Gaza.

We cannot look away in the face of these tragedies. We cannot allow ourselves to become numb to the suffering. And I will not be silent.”

Harris echoed Biden’s repeated comments about the “ironclad support” and “unwavering commitment” to Israel. The country has a right to defend itself, she said, while noting, “how it does so, matters.”

However, the empathy she expressed regarding the Palestinian plight and suffering was far more forceful than what Biden has said on the matter in recent months. Harris mentioned twice the “serious concern” she expressed to Netanyahu about the civilian deaths in Gaza, the humanitarian situation and destruction she called “catastrophic” and “devastating.”

She went on to describe “the images of dead children and desperate hungry people fleeing for safety, sometimes displaced for the second, third or fourth time.”

Harris emphasized the need to get the Israeli hostages back from Hamas captivity, naming the eight Israeli-American hostages – three of whom have been killed.

But when describing the ceasefire deal in the works, she didn’t highlight the hostage for prisoner exchange or aid to be let into Gaza. Instead, she singled out the fact that the deal stipulates the withdrawal by the Israeli military from populated areas in the first phase before withdrawing “entirely” from Gaza before “a permanent end to the hostilities.”

Harris didn’t preside over Netanyahu’s speech to Congress in late July, instead choosing to stick with a prescheduled trip to a sorority event in Indiana.

Harris is committed to supporting Ukraine in its fight against Russian aggression, having met with Ukrainian President Volodymyr Zelensky at least six times and announcing last month $1.5 billion for energy assistance, humanitarian needs and other aid for the war-torn country.

At the Munich Security Conference earlier this year, Harris said: “I will make clear President Joe Biden and I stand with Ukraine. In partnership with supportive, bipartisan majorities in both houses of the United States Congress, we will work to secure critical weapons and resources that Ukraine so badly needs. And let me be clear: The failure to do so would be a gift to Vladimir Putin.”

More broadly, NATO is central to our approach to global security. For President Biden and me, our sacred commitment to NATO remains ironclad. And I do believe, as I have said before, NATO is the greatest military alliance the world has ever known.”

Police funding

The Harris campaign has also walked back the “defund the police” sentiment that Harris voiced in 2020. What she meant is she supports being “tough and smart on crime,” Mitch Landrieu, national co-chair for the Harris campaign and former mayor of New Orleans, told CNN’s Pamela Brown in late July.

In the midst of nationwide 2020 protests sparked by George Floyd’s murder by a Minneapolis police officer, Harris voiced support for the “defund the police” movement, which argues for redirecting funds from law enforcement to social services. Throughout that summer, Harris supported the movement and called for demilitarizing police departments.

Democrats largely backed away from calls to defund the police after Republicans attempted to tie the movement to increases in crime during the 2022 midterm elections.

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