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INVITED COMMENTARY
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This commentary describes the community health assess-
ment process that is required of local health departments,
and it explains how action plans targeting identified priori-
ties can improve population health. It also highlights the use
of evidence-based strategies to increase the overall impact
of health improvement efforts.
Local health departments are the only health care enti-
ties responsible for protecting and promoting the
health of every resident of the county (or counties) that a
department serves. Health departments fulfill that respon-
sibility in a variety of ways—by ensuring that all restaurants
and temporary food establishments meet standards that
prevent foodborne illness; by monitoring communicable dis-
eases and working to assure that people with those diseases
receive treatment and follow appropriate control measures,
so that they do not expose or infect others; and by provid-
ing immunizations that prevent communicable diseases.
Over the past few years, local health departments have
also worked with other partners and with county commis-
sioners to implement policies restricting smoking on college
campuses and in government buildings and other locations,
to prevent exposure to secondhand smoke, and they have
established safe drop-off locations for unused prescription
medications to help prevent unintended deaths from opioid
overdoses.
For more than 20 years, local health departments have
been required to conduct comprehensive community health
needs assessments (CHNAs). A CHNA is based on data
collection and analysis, and it includes a list of community
health needs and issues, some of which are designated as
priorities. Initially, local health departments completed a
comprehensive CHNA once every 4 years. However, the
Patient Protection and Affordable Care Act of 2010 called
for changes to regulations for nonprofit hospitals, requiring
them to perform CHNAs once every 3 years [1]. As a result,
local health departments in counties with a nonprofit hospi-
tal have also moved to a 3-year cycle for CHNAs, so that the
community can simultaneously meet the needs of both the
health department and the nonprofit hospital.
In some cases, collaboration extends beyond the area
served by a single local health department. For exam-
ple, many residents in Western North Carolina travel to
Asheville for specialty hospital care, regardless of their
county of residence. The hospitals and health departments
in the Asheville area have therefore begun collaborating on
a regional assessment with county-level data, so that each
county can determine how its health status and issues relate
to those of the region as a whole. To the extent possible, hos-
pitals and health departments in Western North Carolina are
also trying to use common strategies for addressing identi-
fied health priorities, so that they can improve health not
only in the county or counties served by a particular health
department but also region-wide.
The North Carolina General Assembly approved a man-
datory accreditation system for all local health depart-
ments in 2005. CHNAs have since become the mechanism
for demonstrating that a health department is meeting 2
accreditation requirements: to monitor health status and
identify community health problems, and to diagnose and
investigate health hazards in the community [2]. Given
these requirements, staff members of the North Carolina
Division of Public Health have begun reviewing CHNAs to
ensure that they include all of the necessary components.
One requirement is that the CHNA bring together a group
of local partners to plan for, collect, and review both primary
data (collected directly from members of the community)
and secondary data (available from other sources). The
partners may vary from county to county but should include
health care providers of all types, educators, business and
civic leaders, social service professionals, elected leaders,
and concerned community members. This group then uses
the data collected to determine the community’s health
needs and to develop plans to address the community’s top
priorities. Since 2010 local health departments have also
been required to link their top priorities to the goals and
objectives of Healthy North Carolina 2020, and they are
required to select health improvement strategies that are
evidence-based, in order to provide the greatest chance for
maximum impact.
A major goal of CHNAs is to use the data collected to
Using Community Health Needs Assessments
to Improve Population Health
Joy F. Reed, Eleanor Fleming
Electronically published November 7, 2014.
Address correspondence to Dr. Joy F. Reed, 3305 Brennan Dr, Raleigh,
NC 27613 (joyreednc@gmail.com).
N C Med J. 2014;75(6):403-406. ©2014 by the North Carolina Institute
of Medicine and The Duke Endowment. All rights reserved.
0029-2559/2014/75606
NCMJ vol. 75, no. 6
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404
create a climate for change that leads to improvement in the
health of the community. The process allows communities
to understand what the data say about the health status of
their community and to find out whether subgroups of the
population are disproportionately affected by diseases.
This process also gives communities the opportunity to dis-
cover what their residents would like to see changed; which
groups, organizations, and individuals are already trying
to address key health issues; and what barriers hinder the
community’s ability to achieve optimal health. By providing
data documenting the community’s needs, CHNAs allow
the community to build or enhance partnerships and coali-
tions that are working to improve health, to plan collabora-
tive interventions that promote health, and to develop new
resources or seek funding for new initiatives. Local health
departments are encouraged to have every partner that
participated in the CHNA process take responsibility for 1
or more of the goals, strategies, or interventions that are
Gates sidebar
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Gates sidebar continued
included in the improvement plan.
Community-wide involvement in CHNAs has been espe-
cially important over the past few years, as communities
have begun to focus more on social determinants of health
and on the creation of an environment where people can be
healthy. For example, efforts to address social determinants
of health include increasing the high school graduation
rate, increasing access to affordable housing, and increas-
ing access to jobs in the community. Examples that have
focused on creating a healthy environment include eliminat-
ing “food deserts” (places in the community where it is dif-
ficult to purchase fresh fruits and vegetables) and providing
more opportunity for appropriate physical activity by add-
ing walking trails and reaching joint-use agreements. These
types of changes do not focus on individuals with a specific
health problem; rather, they target the health of the overall
community (ie, population health).
Another way of improving population health is to find
ways to increase access to health care in a community.
Addressing this priority often involves finding creative ways
to attract additional dentists, primary care providers, or
specialists to a community. Previous research has shown
that the convenience of health care services and people’s
perceptions of their access to care affect their utilization of
health care [3-5]. Travelling time and distance to care also
affect population health [6].
In December 2013, to assess statewide efforts to prevent
chronic disease, one of us (E.F., a chronic disease epidemiol-
ogist in the Chronic Disease and Injury Section of the North
Carolina Division of Public Health) analyzed the CHNAs
submitted in North Carolina in 2011, 2012, and 2013. The
purpose of this study was to analyze the health concerns
commonly identified in CHNAs, specifically those related
to disease areas and outcomes that are the focus of the
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406
Chronic Disease and Injury Section. When a health concern
that fell under the purview of the Chronic Disease and Injury
Section was selected as a priority concern in a CHNA, it was
recorded using the same description supplied in the assess-
ment. (For instance, diabetes, heart disease, and stroke
could each be designated as a priority health concern, but if
a community lumped them together and identified “chronic
disease” as a priority, then that is how the data were cap-
tured in the analysis.) Table 1 reports each health concern
identified in this analysis and the percentage of all CHNAs
that listed that concern as a priority. Obesity, diabetes,
and “chronic disease” as a general category were the top 3
health priorities identified statewide. Of the 76 counties that
designated obesity as a priority, 7 counties chose to focus
specifically on childhood obesity.
The North Carolina Division of Public Health then brought
together health directors (or their designees) from those
counties that had selected any of the top 3 health concerns
as a priority in their county, and these individuals were asked
to consider 5 evidence-based strategies that could be used
to address each health priority. They were then asked to
select a single evidence-based strategy for each health con-
cern, so that all of the counties could implement the same
strategy; the hope is that a collective effort could make a
significant impact at the statewide level.
As an evidence-based strategy to address obesity, the
health directors and their designees selected the imple-
mentation of early care and education standards and poli-
cies that are designed to give children a healthier start by
keeping them from becoming obese. The strategy selected
for addressing diabetes was implementation of the Diabetes
Education Recognition Program. The “chronic disease” pri-
ority was reframed as hypertension/stroke, and the evi-
dence-based strategy selected for addressing this priority
was the implementation of Healthy Living, a chronic-disease
self-management program. The Chronic Disease and Injury
Section will be working with the local health departments
involved in this effort to implement the selected strategies
between now and 2020, and this effort will seek to deter-
mine whether collective action can affect these health out-
comes statewide.
The North Carolina Division of Public Health, local health
departments, and community partners have an opportunity
to improve North Carolina’s health status by engaging in
more focused work and by collaborating on common goals.
Now is the right time to move population health in a new
direction. If we can together improve health outcomes for
a few key indicators, perhaps we can make inroads in other
areas as well, even with limited resources. Working together
using evidence-based strategies and data-driven approaches
may be the best way to improve the health of North Carolina’s
population.
Joy F. Reed, EdD, RN, FAAN retired head, Local Technical Assistance and
Training Branch, Division of Public Health, Department of Health and
Human Services, Raleigh, North Carolina.
Eleanor Fleming, PhD, DDS lieutenant, United States Public Health
Service; epidemiologist, Chronic Disease and Injury Section, Division
of Public Health, Department of Health and Human Services, Raleigh,
North Carolina.
Acknowledgments
Potential conflicts of interest. J.F.R. and E.F. have no relevant con-
flicts of interest.
References
1. Internal Revenue Service. Internal Revenue Bulletin 2011-30. Notice
2011-52. Notice and request for comments regarding the commu-
nity health needs assessment requirements for tax-exempt hospi-
tals. July 25, 2011. http://www.irs.gov/irb/2011-30_IRB/ar08.html
#d0e540. Accessed August 21, 2014.
2. 2005-369 NC Sess Laws 1319-1320. http://www.ncga.state.
nc.us/sessions/2005/bills/senate/html/s804v3.html. Accessed
August 21, 2014.
3. Zimmerman SM. Factors influencing Hispanic participation in pros-
tate cancer screening. Oncol Nurs Forum. 1997;24(3):499-504.
4. Facione NC. Breast cancer screening in relation to access to health
services. Oncol Nurs Forum. 1999;26(4):689-696.
5. Baron RC, Rimer BK, Breslow RA, et al; Task Force on Community
Preventive Services. Client-directed interventions to increase com-
munity demand for breast, cervical, and colorectal cancer screening:
a systematic review. Am J Prev Med. 2008; 35(1 suppl):S34-S55.
6. Gu W, Wang X, McGregor SE. Optimization of preventive health
care facility locations. Int J Health Geogr. 2010;9:17.
table 1.
Top Health Priorities Relating to Chronic Disease or Injury
Identified in Community Health Needs Assessments
(CHNAs) Conducted in North Carolina Counties, 2011–2013
Health concern Percentage of all CHNAs
choosing to make this
concern a priority
Obesity 76%
Diabetes 47%
Chronic disease (heart disease, stroke,
diabetes, respiratory disease, or cancer) 42%
Physical activity 39%
Smoking or other tobacco use 39%
Cancer 34%
Nutrition 29%
Heart disease 28%
Hypertension 11%
Injury 7%
Unintentional injury (including poisoning) 6%
Childhood obesity 4%
Asthma 3%
