An Introduction to Community Health Needs Assessment (CHNA)

What is Community Health Needs Assessment?

Community health needs assessment (CHNA) is a process for determining the needs in a particular community or population through systematic, comprehensive data collection and analysis, and leveraging results to spur community change. CHNA has long been best practice within the field of public health and prompts those working to improve community health to consider local conditions—both community needs and assets--which lead to more targeted, effective community-change work. 

CHNA involves exploring both quantitative and qualitative data and can be broad, examining a community at large, or it can focus on a specific issue. Many communities and community organizations regularly conduct broad CHNAs to understand their community and get a pulse of what is most needed to promote community thriving. Public health departments and nonprofit hospitals are required to complete regular CHNAs to fulfill government requirements (the Patient Protection and Affordable Care Act of 2010 (ACA) requires tax-exempt hospitals to conduct a CHNA every three years alongside stakeholders.) In addition, a community might perform a CHNA focused on a specific topic, like opioid and substance use disorders, to inform a grant application or strategic plan to decrease local rates of substance use and overdose.

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A Holistic Approach to CHNA

CHNA is a common, widely-accepted practice within the fields of public health and health care, and the practice is applicable to any sector and/or initiative that seeks to advance equitable community well-being. Due to its widespread use by local public health agencies and organizations, as well as hospitals and hospital systems, there is potential to drastically improve the healthcare landscape and advance community well-being through improving the CHNA process. In recent years, many have advocated for the integration of more non-health data into CHNA (e.g. housing data, transportation data). Adoption of a more general, well-being frame alongside traditional health outcome data, acknowledges the interconnectedness of our physical health to the community conditions in which we live. Specifically, many have used the seven vital conditions for well-being framework to examine how the healthcare system can contribute to advancing community well-being outside of its traditionally clinical sphere.

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Advancing Equity through CHNA

While CHNA is a long-established process in the field of public health and other related fields, there are records of misusing CHNA results to further-marginalize communities of color, people with disabilities, LGBTQ+ groups, and other underserved populations. In order to advance equity through the CHNA process, we must approach CHNA in new, more inclusive ways. Careful conduction of CHNA that implements best practices (outlined below), including a community-driven process that engages people with lived experience in the community, can help identify root causes of inequity with regards to community conditions and health care, driving efforts to reverse these trends and improving health for all. 

Vulnerable populations are at risk for disparate healthcare access and outcomes because of economic, cultural, racial, or health characteristics. For example, historically, communities of color have borne a larger burden of negative health outcomes than their white counterparts. There are myriad reasons for this, including a national legacy of systemic racism, disparities in health care access, coverage, and quality, and more. Throughout the CHNA process, examining data across different populations is important and allows you to see that people in your community have different lived experiences, resulting in different health risks and needs. If data cannot be broken out by race, for example, you’ll likely miss important differences in health needs across populations; your data won’t show health disparities. Knowing the specific health needs a population faces enables you to tailor health improvement efforts to appropriate priority populations and work to minimize disparities and promote an equitable approach to health improvement planning.

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Community Engagement

Ideally, CHNAs are developed through a collaborative process, involving stakeholders from various sectors, and take into consideration present-day data quantitative and qualitative data, as well as historical data, in order to examine change over time and trend lines. Community engagement can make the community a part of the CHNA process, rather than just the subject of it, and increases the likelihood that the CHNA will achieve its desired impact of building a healthier community and advancing equitable well-being.

Those who are closest to the problems we face have more knowledge about the nature of the problems and their root causes—often learning from those most affected leads to more effective, efficient, often multi-solving implementation strategies. Without community engagement, we fail to integrate the wisdom and experience of communities. 

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CHNA Best Practices 

CHNA is a complex process, often involving stakeholders from multiple sectors, organizations, and departments. There are many approaches to CHNA and an overwhelming amount of information available to guide the process. Our team has done research to discover and outline a list of best practices below.

Co-Design Processes and Solutions for Equitable Outcomes

Even before the CHNA work has begun, it's important to co-design the anticipated process with stakeholders and people in the community with lived experience. Co-designing processes ensures that people are on the same page at the onset of the work and should include designing processes for collecting, incorporating, and sharing data, as well as prioritizing areas for investment to advance equitable well-being. When more people are involved in designing a process for assessment and implementation planning, the work will take into consideration more lived experiences, and in turn, account for the needs of more people in a community. 

Shift Power to Advance Shared Ownership, Action, and Wealth

Cultivating a culture of shared ownership of community well-being sets the stage for an effective community assessment—it's important that there is a shared definition of what well-being looks like in a given community. A culture of shared ownership around assessment and improvement planning includes community involvement and leadership with the design, data, processes, solutions, investments, and results.

Cultivate Shared Stewardship, Governance, and Investment for Accountability and Efficiency

Creating shared stewardship, governance, and investment is more than simply engaging the community—it means people feel invested enough in the process that they want to work together to enhance, maintain, and ensure the health of our systems. Together, shared ownership of community assessment, and co-designing of the process, pave the way for shared stewardship. Throughout the assessment, this includes data systems and implementation planning that is not top-down. In order to effectively advance equitable well-being, we must invoke reflective leadership, prioritize together, and collaborate to accomplish goals and act on priorities. Ideally, everyone who is part of a community has incentive to participate in bettering the community because they want to benefit themselves, and importantly, trust that everyone will reap the benefits (not just a subset of people). 

Emphasize Assets and Strengths to Reinforce and Expand Community Resilience

Emphasizing community assets and strengths in assessment involves, first, deeply committing to the belief that communities (and their shared knowledge, cultures, and existing solutions) have immense value, and second, leading with that belief during every phase of community assessment.

Operationalize and Institutionalize Equity, Justice, and Accessibility for Mutual Liberation

Operationalizing and institutionalizing equity and justice in community assessment means that processes, activities, systems, assessment phases, and leading practices are rooted in and center equity actions, including antiracism, decolonization, accessibility, and justice. It's not always clear how to operationalize equity in community assessment—consistently reflecting on the process and questioning how we are considering and centering equity throughout each phase is helpful. Considering equity implications and operationalizing equity are not the same: at its core, equity means ensuring every person has the resources they need to produce outcomes and opportunities, and to build power. This demands proactive reinforcement of assessment and planning processes, practices, and mindsets that produce equitable power, access, opportunities, treatment, and outcomes for all. 

Multi-Solve for Intergenerational Well-Being, Equity, and Sustainability

Multi-solving calls on systems stewards to work together and imagine solutions that efficiently and effectively solve complex systems challenges facing our communities. Multi-solving recognizes siloed solutions are ill equipped to solve problems at scale, and gains across multiple interrelated issues are possible. Solutions that are multi-solving in nature should be investment priorities--in that they are efficient and effective solutions for multiple, interrelated issues. Through collaboration we can identify and act on innovative, multi-solving solutions.

Foster Narrative Change to Move Hearts, Minds, and Systems

Narrative change is a tool for building public and political will to advance policy and systems transformation for health, well-being and equity. Public narrative is grounded in shared values, beliefs, norms, and assumptions that shape a collective worldview. Narrative is produced through stories that build on these commonalities, ultimately guiding behaviors and influencing how we co-create our destiny. Through narrative change strategies that use the power of story we can intentionally shift from harmful values, beliefs, norms and assumptions to those with the power to bridge divides, overcome impasses, and improve well-being and equity.

Infuse Belonging and Civic Muscle to Build Positive Community Momentum

Higher levels of social cohesion are associated with higher levels of trust, cooperation and social capital, providing the necessary foundations for creating healthy patterns for working together across groups and sectors, building the “civic infrastructure” for community members to co-create a shared future. These patterns can create a virtuous cycle—working together supports building stronger communication, develops a sense of connectedness and mutual obligation. As the sense of being valued and cared for within a community grows, people become more confident and willing to participate in the community, contributing to its vibrancy and affecting change. 

CHNA to Catalyze Community Change

CHNA should catalyze community change, not just check a box—the most important consideration for CHNA is the action taken based on the results. Once you know where your community’s biggest assets lie and what the biggest needs are, you can use that information to create a plan and take action towards a healthier, more equitable community. 

Data frameworks provide a powerful tool when using data to inform planning efforts to improve community conditions—they translate data into a solution through sorting indicators into categories that are easily tied to action. When examining data to inform an implementation plan, long lists of indicators aren’t helpful because they fail to shed light on levers you can actually pull to improve your community. Frameworks include categories that reflect common community programming, such as transportation, and housing, and thus make it easier to go from community insight to concerted action.

Stewardship, especially shared stewardship that engages people, organizations, local communities, etc., in collaborative work, is a promising mechanism by which we can shift investments and systems to support thriving communities. Stewardship is defined as “the careful and responsible management of something entrusted to one’s care” and is a good approach to acting on CHNA results to improve communities. Stewardship describes leaders—both people and organizations—who take responsibility for forming working relationships to drive transformative change in regions and communities. Importantly, stewards must have a vested interest in promoting an equity orientation in regard to purpose, power, and wealth. 

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