Community Needs Assessment

PARTICIPANT WORKBOOK

stakeholder

areas

sites

questions

community

improvements

sector

inform

policy

question

research

needs

assess

data

decision

action plan

evidence

environment

strategy

team

community

needs

change

Community Needs

Assessment

Created: 2013

Community Needs Assessment. Atlanta, GA: Centers for Disease Control and

Prevention (CDC), 2013.

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Table of Contents

INTRODUCTION ................................................................................. 4

LEARNING OBJECTIVES ...................................................................................................... 4

ESTIMATED COMPLETION TIME ........................................................................................... 4

TARGET AUDIENCE ............................................................................................................ 4

PRE-WORK AND PREREQUISITES ........................................................................................ 4

ABOUT THE WORKBOOKS .................................................................................................. 5

ICON GLOSSARY ............................................................................................................... 5

ACKNOWLEDGEMENTS ....................................................................................................... 5

SECTION 1: OVERVIEW OF COMMUNITY NEEDS ASSESSMENT ............. 6

INTRODUCTION .................................................................................................................. 6

CHANGE TOOL AND WORKBOOK ......................................................................................... 8

OVERVIEW OF COMMUNITY NEEDS ASSESSMENT STEPS ...................................................... 8

PRACTICE EXERCISE #1 (10 MINUTES) ............................................................................. 11

SECTION 2: PLAN FOR A COMMUNITY NEEDS ASSESSMENT ............. 12

INTRODUCTION ................................................................................................................ 12

IDENTIFY AND ASSEMBLE A DIVERSE COMMUNITY TEAM ..................................................... 12

DEVELOP A TEAM STRATEGY ........................................................................................... 13

IDENTIFY THE SCOPE OF THE ASSESSMENT ....................................................................... 14

DEVELOP QUESTIONS TO ASK .......................................................................................... 17

SELECT SITES ................................................................................................................. 18

DETERMINE DATA COLLECTION METHODS OR USE EXISTING DATA ..................................... 18

IDENTIFY KEY INFORMANTS TO CONTACT .......................................................................... 23

DOCUMENTATION ............................................................................................................ 23

PRACTICE EXERCISE #2 (30 MINUTES) ............................................................................. 24

SECTION 3: KEY POINTS .................................................................................................. 26

SECTION 3: REVIEW AND RATE THE DATA ....................................... 27

INTRODUCTION ................................................................................................................ 27

POLICY AND ENVIRONMENTAL STRATEGIES ....................................................................... 27

DEVELOP A RATING SCALE .............................................................................................. 28

MAKING A TEAM DECISION ON RATINGS ............................................................................ 31

SECTION 4: KEY POINTS .................................................................................................. 32

SECTION 4: RECORD AND SUMMARIZE DATA ................................... 33

INTRODUCTION ................................................................................................................ 33

RECORD DATA ................................................................................................................ 33

SUMMARIZE DATA ........................................................................................................... 35

SECTOR DATA GRID ........................................................................................................ 36

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SECTION 5: KEY POINTS .................................................................................................. 39

SECTION 5: CREATE A COMMUNITY ACTION PLAN ........................... 40

INTRODUCTION ................................................................................................................ 40

IDENTIFY ASSETS AND NEEDS .......................................................................................... 40

PRIORITIZE NEEDS .......................................................................................................... 42

DEVELOP STRATEGIES .................................................................................................... 43

PRIORITIZE STRATEGIES .................................................................................................. 44

COMMUNITY ACTION PLAN ............................................................................................... 46

SECTION 6: KEY POINTS .................................................................................................. 48

CONCLUSION .................................................................................. 49

IMPLEMENTING THE ACTION PLAN AND SHARING PROGRESS .............................................. 49

TAKE HOME POINTS ........................................................................................................ 50

WORKBOOK REVIEW ....................................................................................................... 50

RESOURCES ................................................................................... 51

APPENDICES ................................................................................... 52

APPENDIX A .................................................................................................................... 52

APPENDIX B .................................................................................................................... 53

APPENDIX C ................................................................................................................... 76

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Introduction

LEARNING OBJECTIVES

After completion of the workbook, participants will be able to:

• Plan for a community needs assessment by:

o Identifying a community team

o Describing the scope of the assessment

o Listing the questions to ask

o Selecting sites

o Determining data collection methods or sources

o Identifying key informants

• Review and rate data collected from a community needs

assessment.

• Summarize data by creating sector data grids.

• Develop and prioritize strategies for improvement.

• Create a community action plan that includes:

o Project period objective

o Annual objective(s)

o Activities needed to complete the objectives

o Persons responsible for completing the activities, and

o Estimated completion time

ESTIMATED COMPLETION TIME

The workbook should take approximately 10 hours to complete.

TARGET AUDIENCE

The module is designed for Field Epidemiology Training Program (FETP)

residents who specialize in NCDs; however, you can also complete the

module if you are tasked to evaluate a communicable disease surveillance

system.

PRE-WORK AND PREREQUISITES

Before participating in this training module, you must complete training

in:

• NCD Data Sources

• Program Planning

• Prioritizing public health problems

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ABOUT THE WORKBOOKS

You will read information about conducting a community needs

assessment in the Participant Workbook. To practice the skills and

knowledge learned, you will refer to the Activity Workbook and complete

4 exercises.

ICON GLOSSARY

The following icons are used in this workbook:

Image Type

Image Meaning

Activity Icon

Activity, exercise, assessment or case study that you will

complete

Stop Icon

Stop and consult with your facilitator/mentor for further

instruction

Resource

Icon

A resource or website that may provide further information

on a given topic

Tip Icon

Supplemental information, or key idea to note and

remember

ACKNOWLEDGEMENTS

Thanks to Shannon Griffin-Blake, PhD (Division of Community Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention) for sharing and explaining

the CHANGE tool.

Thanks to Indu Ahluwalia, MPH, PhD (Division of Reproductive Health,

National Center for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention) for reviewing this module and

providing feedback and guidance.

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Section 1: Overview of Community

Needs Assessment

INTRODUCTION

What is a “Community?”

Communities are typically defined by a geographic area; however, they

can also be based on shared interests or characteristics such as religion,

race, age, or occupation. People within a community come from different

backgrounds and have unique cultures, customs, and values. Utilizing

this wide range of ideas and wisdom is critical to assessing the community

needs and strategizing areas for improvement. Before you conduct a

community needs assessment you should have a clear understanding of

the different cultural groups within a community and how to best work with

them to solve the community issues.

What is a Community Needs Assessment?

A community needs assessment provides community leaders with a

snapshot of local policy, systems, and environmental change strategies

currently in place and helps to identify areas for improvement. With this

data, communities can map out a course for health improvement by

creating strategies to make positive and sustainable changes in their

communities.

Components of a Needs Assessment

The main outcomes of a community needs assessment are in 3 main

categories: Policy Change, Systems Change, and Environmental Change.

Policy Change

This involves laws, regulations, rules, protocols, and procedures that are

designed to guide or influence behavior. Policies can be either legislative

or organizational. Policies often mandate environmental changes and

increase the likelihood that they will become institutionalized or

sustainable. Examples of legislative policies include taxes on tobacco

products, provision of county or city public land for green spaces or

farmers’ markets, regulations governing a national school lunch program,

and clean indoor air laws. Examples of organizational policies include

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schools requiring healthy food options for all students, menu labeling in

restaurants, and required quality assurance protocols or practices (e.g.,

clinical care processes).

System Change

This involves change that affects all community components including

social norms of an organization, institution or system. It may include a

policy or environmental change strategy. Policies are often the driving

force behind systems change. Examples are implementing a national

school lunch program across a region or provincial school system or

ensuring a hospital system becomes tobacco free.

Environmental Change

This type of change relates to the physical, social, or economic factors

designed to influence people’s practices and behaviors. Examples of

alterations or changes to the environment include:

Physical: Structural changes or the presence of programs or services,

including the presence of healthy food choices in restaurants or cafeterias,

improvements in the built environment to promote walking (e.g., walking

paths), the availability of smoking cessation services to patients or

workers, and the presence of comprehensive school health education

curricula in schools.

Social: A positive change in attitudes or behavior about policies that

promote health or an increase in supportive attitudes regarding a health

practice, including an increase in favorable attitudes of community

decision makers about the importance of nonsmoking policies or an

increase in nonacceptance of exposure to second-hand smoke from the

general public.

Economic: The presence of financial disincentives or incentives to

encourage a desired behavior including charging higher prices for tobacco

products to decrease their use or the provision of nonsmoker health

insurance discounts.

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CHANGE

TOOL AND WORKBOOK

Resource

The community needs assessment process taught in this module is based on

the Community Health Assessment and Group Evaluation (CHANGE) data-

collection tool developed by CDC’s Healthy Communities Program within the

Division of Community Health at the National Center for Chronic Disease

Prevention and Health Promotion.

The CHANGE tool was written primarily

for communities in the United States interested in creating environments that

support healthy living.

This workbook teaches a similar approach to conducting community needs

assessment as the CHANGE tool, but since this participant workbook is to be

used globally we are providing some flexibility in the tool you choose to use.

For example, after learning the process you may decide to create your own

Excel spreadsheets to record and summarize data, or something similar in

MS Word.

If you wish to use the CHANGE tool, you can download and modify (free of

charge) the Excel spreadsheets at:

http://www.cdc.gov/HealthyCommunitiesProgram

If you choose to order (free of charge) the CHANGE tool CD-ROM, you will

also receive additional resources such as an Action Guide, an MS

PowerPoint presentation template, and a policy brief or one-pager template.

Please note that the Action Guide contains slightly different “action steps”

than the ones in this workbook since the workbook is designed to be used

with or without the CHANGE tool.

OVERVIEW OF COMMUNITY NEEDS ASSESSMENT STEPS

There are different approaches to conducting community needs

assessments. In this module you learn how to gather and assess data on

community assets and determine areas for improvement. You will learn a

process that involves these main steps:

Centers for Disease Control and Prevention. Community Health Assessment aNd

Group Evaluation (CHANGE) Action Guide: Building a Foundation of Knowledge to

Prioritize Community Needs. Atlanta: U.S. Department of Health and Human Services,

2010.

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This workbook explains steps 1, 3, 4 and 5 in detail.

Step 1: Plan for a community needs assessment

• Identify and assemble a diverse community team

• Develop a team strategy

• Define community to assess (e.g., region, village)

• Identify community sectors to assess (e.g., health

care, schools)

• Identify community components to assess (e.g.,

nutrition, tobacco)

• Develop questions to ask for each community

component

• Select sites and number of sites to visit within each

sector

• Determine existing data to use or methods for

collecting new data

Identify key informants to contact

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Resource

Step 2: Conduct the needs assessment

For guidance on how to conduct a needs assessment (for example,

how to prepare for and conduct interviews and focus groups), access

the North Carolina Department of Health Community Assessment

Guide Book at

http://www.schs.state.nc.us/schs/data/databook/2002/GuideBook

2002.pdf.

Step 3: Review and rate the data

• Develop a rating scale, and,

• Make a team decision on ratings.

Step 4: Record and review consolidated data

• Enter the data,

• Total the data, and,

• Summarize the data.

Step 5: Develop a community action plan

• Identify community assets and needs,

• Prioritize needs,

• Develop and prioritize strategies for improvement,

and,

• Create an action plan for top priority strategies.

Tip

The focus of this workbook is on assessing a community’s strengths and

weaknesses through mainly qualitative collection methods; however, it is

still important to support those findings with quantitative data collection

methods (e.g., vital statistics, hospital records) to assess the health status

of a community; for example, identifying prevalence and incidence of NCDs.

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PRACTICE EXERCISE #1 (10 MINUTES)

Activity

Instructions:

1. Complete this exercise individually.

The community needs assessment can yield information about different

types of change strategies in the community: policy, systems or

environmental. Systems changes can either be policy or

environmental. Match the examples in the first column of the following

table with the appropriate category. Mark your responses. The first one

has been done for you as an example.

Example of types of strategies in a community-

Law requiring schools to provide

healthy food options for students



Policy

Environmental

Walking paths at a work site

Policy

Environmental

Higher prices for alcohol

Policy

Environmental

Smoking cessation programs for

government employees

Policy

Environmental

Food labeling

Policy

Environmental

2. Review your responses with a colleague. Then check the answers with

those in Appendix A.

Stop

Let the facilitator or mentor know you are ready for the group

discussion.

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Section 2: Plan for a Community Needs

Assessment

INTRODUCTION

Planning for a community needs assessment is just as critical as

conducting the actual assessment. You need to ensure you have the right

people to help out and that you have identified the logistics and content of

the assessment, what data to collect, how to collect the data and from

whom.

In this section you will learn how to plan for a community needs

assessment, in particular how to:

• Identify and assemble a diverse community team

• Develop a team strategy

• Identify scope of assessment

• Develop questions to ask

• Select sites

• Determine data collection methods

• Identify key informants

IDENTIFY AND ASSEMBLE A DIVERSE COMMUNITY TEAM

Representation from diverse sectors of the community is critical to

successful team work and enables easy and accurate data collection and

assessment. All members of the community team should have an active

role in the assessment process from developing questions to identifying

data collection methods to use. This process also ensures the community

team has equitable access to and informed knowledge of the process,

thereby solidifying their support.

Identifying 10-12 individuals is recommended to ensure the size is

manageable, allow for adequate representation of different perspectives,

and to account for attrition of members. Include representatives of

different stakeholder groups.

Examples of types of stakeholders to include on the community team are:

•

Law enforcer

•

Faith leader

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• Hospital administrator

• Community health worker

• School principal or headmaster (of primary school or university)

• Neighborhood council representative

• Civic leader

• Local advocates

• Local business leader

• Local health practitioner

When your community team is assembled you should clearly define the

purpose of your community team, capacity of team members and their

organizations, identify potential barriers to success, and plan for

overcoming any obstacles. Ensuring adequate funding to support the

community team’s efforts is critical to the success of the project.

DEVELOP A TEAM STRATEGY

After you have assembled your team you will meet to develop a team

strategy. This involves, at a minimum:

•

Defining goals for the needs assessment

•

Defining how the data collected will be used (e.g., to influence

policy makers, to support new programs, to support new changes in

service delivery or policies)

•

Determining the timeline for the assessment (e.g., 3 months, 6

months)

•

Determining roles and responsibilities of team members

•

Assigning tasks based on skills and available resources

•

Identifying how decisions will be made

•

Selecting a method or tool for conducting the needs assessment

(e.g., CHANGE

tool, customized Excel spreadsheets, MS Word

worksheets)

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IDENTIFY THE SCOPE OF THE ASSESSMENT

In this step you will determine the scope of your community assessment.

During this process, your team should define “community” and then keep

this definition the same throughout the needs assessment.

A community needs assessment should focus on:

• a selected community as defined by the team, such as a region or

neighborhood

• sectors within that area, such as health care and work sites

• community components to assess within each sector, such as

nutrition, chronic disease management and tobacco use

Define the Community to Assess

The community team will decide what community to assess. Previously

established areas (e.g., school districts, city limits) may be helpful, but the

community team will define its own community. As the community team

decides on the area to assess, it should consider starting with a smaller

geographic area or segment of the population. It might be easier to attain

greater impact with a smaller sized community than a larger one within the

first year.

Identify Community Sectors to Assess

Within the community identified, your team will determine which distinct

parts or sectors of the community to assess. Examples of community

sectors are:

Community-At-Large Sector: includes community-wide efforts that

impact the social and built environments such as food access, tobacco-

free policies, walkability or bikeability, and personal safety.

Community Institution/Organization (CIO) Sector: includes entities

within the community that provide a broad range of human services and

access to facilities such as childcare settings, faith-based organizations,

senior centers, health and wellness organizations, colleges and

universities.

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Health Care Sector: includes places people go to receive preventive care

or treatment, or emergency health care services such as hospitals, private

doctors’ offices, community clinics, or health posts.

Work Site Sector: includes places of employment such as agriculture,

manufacturing, private offices, restaurants, retail establishments, and

government offices.

School Sector: includes all primary and secondary learning institutions.

Identify Community Components to Assess

Within each sector, you should identify which components of the

community to assess. Choose ones that the community team believes are

most important and relevant to evaluate and that will lead to the most

useful recommendations for improvement. For example, you may want to

assess demographics, statistical data of a population such as age,

income, education level, type of work site/health facility/school. For each

sector, you will determine which demographic factors that you want to

assess. For example, in some sectors, you might collect information on

whether the population using the institution is from an urban or rural

setting.

You will also assess whether each sector has the policies and systems in

place to evaluate risk and to help those in that system to engage in health

promoting behavior. Part of this assessment may include who provides

leadership and how and assessing who are the successful change agents.

Policies, Systems and Environments

• Physical activity: the policy, systems or environmental change

strategies in place that support physical activity. For example, does

the sector assess patients’ physical activity as part of a written

checklist or screening used in all routine office visits? Does it

provide access to public recreation facilities? Does it promote

stairwell use?

• Nutrition: the policy, systems or environmental change strategies in

place that support nutrition. For example, does the sector ensure

that healthy food preparation practices (e.g., steaming, low fat, low

salt, limited frying) are always used? Does it implement a referral

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system to help patients access community-based resources or

services for nutrition?

• Tobacco Use: the tobacco control-related change strategies in

place. For example, does the sector institute a tobacco-free policy

24/7 for indoor/outdoor public places? Does it ban tobacco vending

machine sales? Does it provide access to a referral system for

tobacco cessation resources and services?

• Chronic disease management: the policy, systems or

environmental change strategies in place that support managing

chronic diseases and its related risk factors. For example, does the

sector provide chronic disease self-management education to

individuals identified with chronic conditions or diseases? Does it

implement a referral system to help patients access community-

based resources or services for chronic disease? Does it promote

chronic disease prevention?

• After school: the policy, systems or environmental change

strategies in place that support after school activities. For example,

does the school ensure appropriate active time during after-school

programs or events? Does it institute healthy food and beverage

options during after school programs?

• Leadership: the policy, systems or environmental change strategies

in place that relate to the management of the community. For

example, does the sector participate in community coalitions and

partnerships? Does it reimburse employees for preventive health

or wellness activities? Does it finance public parks/sports facilities?

• Legislative / Legal Environment

o District: the policy, systems or environment change

strategies that are in place at the school district level. For

example, does the district ban tobacco advertising on school

property, at school events, and in written educational

materials and publications? Does the school eliminate the

sale and distribution of less than healthy foods and

beverages during the school day?

o Additional governmental levels

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DEVELOP QUESTIONS TO ASK

You will develop a list of questions to ask to learn about the strengths and

weaknesses of specific community components within each sector.

Ensure you determine how the responses will be measured

(qualitative/quantitative) and include response options for quantitative

questions. (See the Managing Data training module on developing data

dictionaries with response options.)

For example, within the Health Care Sector, Physical Activity component,

some questions you may want to include in the assessment are:

To what extent does the health care facility:

• Promote stairwell use (e.g., make stairs appealing, post

motivational signs near stairs to encourage physical activity) to

patients, visitors, and staff?

• Assess patients’ physical activity as part of a written checklist or

screening used in all routine office visits?

• Provide regular counseling about the health value of physical

activity during all routine office visits?

• Implement a referral system to help patients’ access community-

based resources or services for physical activity?

Examples of questions to include if assessing the tobacco component of

the health care sector are:

To what extent does the health care facility:

• Institute a smoke-free policy 24/7 for indoor public places?

• Institute a tobacco-free policy 24/7 for indoor public places?

• Institute a smoke-free policy 24/7 for outdoor public places?

• Institute a tobacco-free policy 24/7 for outdoor public places?

• Assess patients’ tobacco use as part of written checklist or

screening used in all routine office visits?

• Assess patients’ exposure to tobacco smoke as part of written

checklist or screening used in all routine office visits?

• Provide advice and counseling about the harm of tobacco use and

exposure during all office visits?

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• Implement a referral system to help patients to access tobacco

cessation resources and services?

Refer to Appendix B for a list of questions you may wish to include in

your assessment.

SELECT SITES

Sites are the locations within each sector your team will visit to conduct

the needs assessment. At each site, the information gathered will provide

answers to the questions you have identified.

Be sure to systematically choose a variety of sites within each sector to

show the extent of work being done in the community. Some schools, for

example, may be ready to pass a physical activity policy while others have

not yet begun to consider the need. A diversity of policy implementation

enhances your data-gathering process. If you only choose sites that are

excelling, it will be more challenging to identify gaps and needs when you

develop your Community Action Plan.

It is important to document the process for site selection.

It is recommended that besides the community-at-large sector, you assess

a minimum of 3 sites per sector. For example, if you are assessing each

of the 5 sectors you would gather data from at least 13 sites as follows:

Sectors

Community-

At-Large

Community

Institution/

Organization

(CIO)

Health Care

School

Work site

Number of

Sites

Minimum of 3

Tip

The more sites your team assesses, the greater the capacity of your

team to understand the assets and needs of the community.

DETERMINE DATA COLLECTION METHODS OR USE EXISTING DATA

Use a variety of data-gathering methods to access and collect information

for each site. Data come in many forms; varying data-collection methods

provides a more comprehensive assessment of your community. For

example, direct observation enables you to better understand the

environment in which people interact and to see the things of which others

may not be aware. It may also produce useful information that may not be

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apparent from your other data-collection methods, such as a key informant

interview or focus group. This type of data-collection allows you, the

observer, to choose a location or event and watch what is happening.

A combination of 2 or more data-collection methods is recommended at

each site to confirm or support initial findings. For example, photographs

of walkable streets or congested intersections unfriendly to pedestrians

may supplement the feedback from an independent survey.

The goal of this step is to reflect the voices of the community through a

diverse set of data-collection methods and to mobilize support by

demonstrating a detailed, thorough method of data-collection.

Comprehensive data enable a more effective action plan for community

improvements, so perform this task carefully to ensure the data needed to

make decisions are available. Table 1 lists the advantages and

disadvantages of various data-gathering methods. This is not a

comprehensive list but a sample of methods you can use.

Also consider if your community has already gathered data for

another purpose. To determine if you can use that information for

the needs assessment, consider the following:

• How old are the data? If data are less than 6 months old they can

be used. If not, it is time to gather new data.

• Do you have all the information?

• Is the information relevant?

• Can you use the data in the existing format?

• Do you need more data?

• Does anyone on your team have experience with analyzing data?

If your country uses the Behavioral Risk Factor Surveillance System

(BRFSS) or a similar system to collect data on health and risk behaviors,

this is an excellent data source that collects community information that

would be helpful in your needs assessment. This is an example of a data

source older than 6 months that is acceptable to use. However, note the

frequency with which the data are collected. BRFSS alternates asking

questions on certain key indicators (e.g., physical activity, nutrition) each

year. As such, it is suggested that your team review a 2-year range of

data to ensure a complete set of data.

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BRFSS as commonly implemented does not provide policy, systems, and

environmental change strategies; however, it does document the health

behaviors and health conditions common in a community. You can use

data from this source in conjunction with the original data you collect from

sites to gain a more comprehensive picture of the community needs.

As previously mentioned, the focus of this workbook is on qualitative data;

however, it is important to use both qualitative and quantitative data

collection methods to obtain a more in-depth, reliable assessment of the

community. You will analyze data from each method separately. When

both types of data suggest similar conclusions, the results are

strengthened. If the data have different conclusions, then it is important to

find out why they differ. Further study might be warranted.

Table 1: Advantages and Disadvantages of Qualitative Data Collection Methods

Method

Definition

Advantages

Disadvantages

Individual

Interviews

Conversation with a

purpose that is

conducted between

two people either face-

to-face or by

telephone

• Interviewer can ask

what he or she wants

to know

• Can tell if questions

are understood

• Can ensure

questions are

answered

• Interviewees might

tell interview things

he or she would not

write on a survey

• Time-consuming

• Must transcribe

notes after interview

• Person being

interviewed may be

biased

Focus

Groups

Involve gathering

information and

opinions from a small

group of people (8 to

10 per group)

Group discussions

often provide insights

that might not emerge

in interviews

• Can assess body

language

• Observers can be

present without

distracting

participants. If

videotaped can

share with others

who couldn’t attend.

• Have participants’

• Responders lose

anonymity

• Higher travel

expenses when

multiple locales are

used

• Logistical challenge

in rural areas or

small towns

Community Assessment Guide Book, North Carolina Department of Health (2002);

retrieved on October 19, 2012 from

http://www.schs.state.nc.us/schs/data/databook/2002/GuideBook2002.pdf.

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Method

Definition

Advantages

Disadvantages

undivided attention

Observation

Data collection method

that allows you to use

the events around you

to gather clues and

generate conclusions

about specific locales

or experiences

• Relatively

inexpensive

• Efficient

• Can be conducted

on foot

• Provides only an

overview of

community

• Requires closer

observation to

identify previously

unrecognized

assets/issues

Postal

Survey

Mailing self-completion

questionnaires to a

targeted group of

people (e.g., a client’s

customers or people

living in a certain area)

• Relatively

inexpensive

• Less potential for

people to give

answers they

assume the

interviewer wants to

hear

• No interviewer

training required

• Suitable only for

short and

straightforward

surveys

• Data collection takes

a long time

• Relatively low

response rates

• Moderate literacy

level required

Telephone

Survey

Collection of data from

a sample population

using a standardized

questionnaire by

telephone

• Minimizes missing

data

• Can use open-ended

questions and more

complex interviewing

schedules

• Can record reasons

and characteristics of

nonconsenters

• Quick and

inexpensive

• Does not require a

high level of literacy

• Can be hard to

prevent consultation

with and/or

interference from

others

• Need to keep

questions few and

short

• Unable to ask

questions requiring

visual cues

• Some likelihood of

socially desirable

responses

Face-to-face

Survey

A face-to-face survey is

a telephone survey

without the telephone.

The interviewer

physically travels to the

respondent’s location

to conduct a personal

interview

• Allows flexibility in

number and style of

questions

• Minimizes missing

data

• Allows physical

measurements &

direct observations

• Minimizes literacy

level issues

• High likelihood of

socially desirable

responses

• Can be hard to

prevent consultation

with or interference

from others

• Very expensive,

especially if

respondents are

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PARTICIPANT WORKBOOK |2

Method

Definition

Advantages

Disadvantages

widespread

geographically

• Time-consuming

Web-based

Surveys

A group of potential

respondents is invited

to participate in

completing a web-

based survey, and their

responses are

submitted electronically

via the Internet

• Can be relatively

inexpensive

• Relatively quick

method of data-

collection

• Minimizes social

desirability biases

• High set-up costs

• Useful only for

relatively large-scale

surveys

• High level of literacy

and basic computer

skills required

• Requires access to

good hardware,

programming, and

support services

• No information on

non-respondents

• Best suited to pre-

coded questions

COMMUNITY NEEDS ASSESSMENT

PARTICIPANT WORKBOOK |23

IDENTIFY KEY INFORMANTS TO CONTACT

For each sector and site your team has identified for the assessment,

contact people (or key informants) in the community who can provide the

appropriate insight, knowledge, or documentation.

Community team members can then reach out and contact people from

the community (e.g., school principal, business leaders, city planners,

police chief, hospital administrator) who should have access to the desired

information or can point them in the right direction.

DOCUMENTATION

Keep a comprehensive file of all sources of information, key contacts, and

data to review at a later date or to share with coalition members. The file

can be in multiple forms—notebooks or bound volumes, facilitator guides,

field notes, meeting minutes, or an electronic data file. The purpose of

cataloguing all the data files is to ensure that everything your team collects

can be accessed and used.

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PRACTICE EXERCISE #2 (30 MINUTES)

Activity

Instructions:

1. Find a colleague with whom to complete this exercise. If you are from

a different country/region/district, choose one person who will provide

the responses for this exercise. The other person will contribute ideas

and feedback.

2. Answer the following questions. Then check the answers with those in

Appendix A.

Questions:

1. If you were planning a community needs assessment, what are some

components of a team strategy that you would develop?

2. Describe the community you will assess including at least 4 community

sectors.

3. For each community sector, list at least 5 community components to

assess.

4. Select one community component and list at least 3 types of questions

to ask to learn about strengths and weaknesses.

5. For one of the community sectors you will assess, list at least 2 sites to

visit.

6. For 1 of the sites you will visit, list at least one data collection method

you will use.

COMMUNITY NEEDS ASSESSMENT

PARTICIPANT WORKBOOK |2

7. For 1 of the sites you will visit, describe the key informants who your

team will contact.

Stop

Let the facilitator or mentor know you are ready for the group

discussion.

Activity

TAKE OUT THE ACTIVITY WORKBOOK AND COMPLETE SKILL

ASSESSMENT - ACTIVITY#1.

COMMUNITY NEEDS ASSESSMENT

PARTICIPANT WORKBOOK |2

SECTION 3: KEY POINTS

Tip

Planning for a community needs assessment includes:

• Identify and assemble a diverse community team

• Develop a team strategy

• Define the community to assess (e.g., school districts, city limits)

• Identify community sectors to assess (e.g., health care, schools)

• Identify community components to assess (e.g., nutrition, tobacco

use)

• Develop questions to ask for each component, including how the

responses will be measured

• Select sites and number of sites to visit within each sector

• Determine existing data to use or methods for collecting new data

• Identify key informants to contact

Identifying 10-12 individuals maximum for your community team is

recommended to ensure the size is manageable and to account for attrition

of members.

A community needs assessment should focus on a particular geographic

area, sectors within that area such as health care and work sites, and

community components to assess within each sector such as nutrition,

chronic disease management, and tobacco use.

A combination of 2 or more data-collection methods is recommended at

each site to confirm or support initial findings.

Keep a comprehensive file of all sources of information, key contacts, and

data to review at a later date or to share with coalition members.

COMMUNITY NEEDS ASSESSMENT

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Section 3: Review and Rate the Data

INTRODUCTION

Before recording the data collected from the needs assessment into a

data capturing tool, such as the CHANGE tool, your team should review

the information from each site to gain consensus on how to rate each

item. Rating the data helps to identify strengths and weaknesses. The

team should discuss the data, share what each person found, and identify

evidence to support the team’s rating.

In this section, you will learn:

• The difference between policy and environmental change

strategies,

• How to develop a rating scale, and

• How to reach consensus on rating data.

POLICY AND ENVIRONMENTAL STRATEGIES

For each site visited, you will rate the data collected about policy and

environmental change strategies. Remember that policy refers to laws,

regulations, rules, protocols, and procedures that are designed to guide or

influence behavior. They can be either legislative or organizational

policies. Environmental change relates to the physical, social, or

economic factors designed to influence people’s practices and behaviors.

Examples of Policy and Environmental Change Strategies:

Policy

Environmental

• Smoke-free policy for indoor

public places

• Ban marketing of less than

healthy foods and beverages at

work sites and schools

• Ban using or withholding

physical activity as a

punishment in schools

• Institute a requirement that

health staff measures weight

and height and calculates BMI

for every patient at each

business

• Adopt a nutrition education

curriculum in all primary schools

• Referral system to help

employees access tobacco

cessation resources or services

• Provide healthy food and

beverage options in vending

machines

• Ensure availability of proper

equipment (e.g., playground)

and facilities that meet safety

standards

• Provide screening for chronic

diseases in adults with risk

factors

• Provide adequate time to eat

school meals

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DEVELOP A RATING SCALE

Your team will develop a rating scale that can be used to assess the

strengths and weaknesses of each site within a sector.

You may wish to adapt a rating scale similar to the one that the CHANGE

tool uses, which allocates a number between 1 and 5 for policy and

environment changes in each of the five sectors. Table 2 shows the scale

with definitions of scores 1–5. A response of ‘99’ can be used only when

the item is not applicable at the site (e.g., stair promotion not suitable in a

one-story building). If you do use the CHANGE tool a response of ‘99’

does not factor into the column total or percentage calculations.

Table 2: Rating Scale

Response

Policy

Environment

Not identified as problem

Elements not in place

Problem

identification/gaining agenda

status

Few elements in place

Policy formulation and

adoption

Some elements are in place

Policy implementation

Most elements are in place

Policy evaluation and

enforcement

All elements in place

Not applicable

The Environment column can be more subjective than the Policy column,

distinguishing between the words “few”, “some” and “most”. For example,

a team has assessed the following item under the Health Care Sector,

Chronic Disease Management: Provide screening for chronic diseases

in adults with risk factors. At the site the team members conducted focus

groups and observations. Through observations within a 5-day period, 6

out of 10 adults who presented with risk factors were screened for chronic

diseases. However, during focus group discussions with medical

COMMUNITY NEEDS ASSESSMENT

PARTICIPANT WORKBOOK |29

professionals, 75% of the staff said that they always conduct screenings

and 50% of the staff said that they provide screenings inconsistently

depending on time and resources. In this example, you could rate the

environment element a ‘3’ (some of the elements are in place) or a ‘4’

(most of the elements are in place).

Table 3 provides a detailed example of the rating scale for the Health

Care Sector, Chronic Disease Management and the item that was

assessed: Does the facility provide screening for chronic diseases in

adults with risk factors?

Table 3: Policy and Environment Scale for Health Care Sector and Chronic

Disease Management

Item: Does the facility provide screening for chronic diseases in adults

with risk factors?

Response

Policy

Environment

The issue has not yet been

identified as a concern or a

problem. For example, there

has been no discussion on

requiring screening for chronic

diseases in adults with risk

factors.

No elements are in place in the

environment. For example,

there are no screenings for

chronic diseases in adults with

risk factors

The issue or problem has

received attention from the

authoritative body that must

deal with the issue. This is

usually done when the issue or

problem is categorized as a

social or public problem. For

example, the issue of chronic

disease screening has been put

on the agenda, but no formal

policy has been formulated or

adopted.

Only a few elements are in

place in the environment. For

example, a few health care

professionals at the site are

providing screenings for

chronic disease.

Policy goals and solutions have

been formulated but not

implemented. For example, the

health care facility developed

Some elements are in place in

the environment. For example,

one-third of the adult patients

with risk factors are being

COMMUNITY NEEDS ASSESSMENT

PARTICIPANT WORKBOOK |30

Response

Policy

Environment

and approved the chronic

disease screening policy, but it

has not yet been implemented

across the entire facility. It will

be implemented in the next

fiscal year.

screened for chronic disease at

the health facility.

Administrators have made a

decision about how to deploy

necessary resources (human

and financial) to actualize the

policy. For example the chronic

disease screening policy was

established and passed last

year, communicated to the

health care professional, and

implemented this year. The

end of this year will be the

review and comment period of

the policy.

Most elements are in place in

the environment. For example,

more than half the adult

patients with risk factors are

being screened for chronic

disease at the health facility.

This stage involves determining

to what extent the policy has

been enforced and what

occurred as a result of the

policy. Based on the evaluation

results, adjustments can be

made to the current policy to

ensure effectiveness. For

example, the chronic disease

policy was implemented last

year and evaluated. The policy

was revised and is now

implemented with revisions.

All elements are in place in the

environment. For example, all

the adult patients with risk

factors are being screen for

chronic disease at the health

facility.

This type of policy is not

appropriate for this community.

This type of environmental

change strategy is not

appropriate for this community.

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The following is an example of how you might rate an item for Health

Care Sector, Tobacco component: Does the facility assess patients’

tobacco use as part of written checklist or screening used in all routine

office visits?

Data Collected

Policy

Environment

Use of checklists or screenings has been discussed

at staff meetings, but no formal policy exists. One-

third of the doctors and one-quarter of the nurses

use a written checklist or screening to assess

patients’ tobacco use consistently at every office

visit.

2 3

A rating of ‘2’ was given to policy because although the issue of assessing

patient’s tobacco use has been discussed, it has not yet been formulated

as a policy. A rating of ‘3’ was given to environment, meaning some

elements are in place at this site, because one-half of the doctors and

one-third of the nurses assess patient’s tobacco use. Another community

team might rate this item as a ‘2’, deciding that only a few elements are in

place.

Tip

One or two members of your team should take note of what type of data

was collected from the site being discussed, where it came from, and add it

to the comprehensive data file.

This information will provide valuable, historical documentation.

MAKING A TEAM DECISION ON RATINGS

When you assembled your team, you should have agreed upon a

decision-making strategy. Some examples are the Delphi method (voting

is at first anonymous, scores are shown to the group, voting is done

repeatedly until a consensus is reached), simple voting, or a discussion

among members that indicates all or most are in agreement. Choose a

method based on your team’s preference, but you should use that same

method consistently throughout the process.

As a team, decide what these data mean in terms of the parameters of the

rating scale you developed. Be sure to record comments for each rating

to document why the decision was made. Ensure that the information

represents the site you assessed so information can be used from year to

year.

COMMUNITY NEEDS ASSESSMENT

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Rating the data should be based on a comprehensive review of all

sources and the agreement of the individuals on your team.

Stop

Let the facilitator or mentor know you are ready for the group

discussion.

Activity

TAKE OUT THE ACTIVITY WORKBOOK AND COMPLETE SKILL

ASSESSMENT - ACTIVITY#2.

SECTION 4: KEY POINTS

Tip

• When your team reviews the information from each site, be sure to

reach consensus on how to rate each item.

• Rating the data should be based on a comprehensive review of all

sources and the agreement of the individuals on your team.

• The rating scale presented in this workbook is as follows:

Response

Policy Environment

Not identified as problem

Elements not in place

Problem identification/

gaining agenda status

Few elements in place

Policy formulation and

adoption

Some elements are in place

Policy implementation

Most elements are in place

Policy evaluation and

enforcement

All elements in place

Not applicable

• One or two members of your team should document the type of data

that was collected from each site and where it came from.

COMMUNITY NEEDS ASSESSMENT

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Section 4: Record and Summarize Data

INTRODUCTION

Designate one person as the data manager within your community team.

This person should be responsible for entering the data for each of the

sites into the specific tool you are using. If your team is using the

CHANGE tool, the data manager should have a basic working knowledge

of MS Excel, such as opening and closing files, entering macros, and

entering data in fields.

In this section you will learn how to record and summarize data.

RECORD DATA

After your team has reached consensus on the most appropriate rating for

each item within a site, the data should be recorded in a table or

spreadsheet along with any supporting comments.

If you are using the CHANGE tool or another customized Excel

spreadsheet, your team should use 1 Excel file for each site assessed as

shown below in figure 1.

Figure 1: CHANGE tool: Example of an Excel file for one site of the

School Sector

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Enter Comments

Data managers are encouraged to enter comments on the Excel

spreadsheets to provide detailed records of how and from where the data

were collected.

In the CHANGE tool, you click on the red corner of the cell to enter a

comment, as shown in figure 2 below.

Figure 2: CHANGE tool: Entering a Comment

Total the Data

To understand a sector’s strengths and weaknesses you will need to

compile and then compare all the scores for each community component,

e.g., nutrition, tobacco use. To compare the scores you will first total all

the ratings and then give it a percentage score as shown on Table 4.

One of many advantages to using the CHANGE tool is that it automatically

completes all data calculations within each sector. If you choose to create

your own tool you will need to create a formula or do manual calculations

for totaling the data.

COMMUNITY NEEDS ASSESSMENT

PARTICIPANT WORKBOOK |3

Table 4: Sample of Competed Entries and Totals and Percentages

Scores (for one site): Community Institution/Organization: Chronic

Disease Management

To what extent does the community

institution/organization:

Policy

Response #

Environment

Response #

Provide access to chronic disease self-

management programs?

Provide routine screening, follow-up

counseling and education to patrons to help

address chronic diseases and related risk

factors?

Adopt curricula or training to raise awareness

of the signs and symptoms of heart attacks

and strokes

Promote chronic disease prevention to patrons

(e.g., post signs reminding patrons to get blood

pressure checked, to quit smoking, and avoid

secondhand smoke)?

COLUMN TOTAL:

CHRONIC DISEASE MANAGMENT SCORE:

35%

45%

Follow these steps to calculate the percentage score manually:

1. Determine the highest possible score for the column, based on the

highest rating of ‘5’ and the number of questions.

For example, in Table 4, since there are 4 questions, the highest

possible score for the column is 20 (‘5’ rating x 4 questions).

2. Divide the column total into the highest possible score.

For example, in Table 4, the column total for Policy is 7, so the

calculation is as follows: 7 ÷ 20 = .35

3. Multiply the result from step 2 by 100 to get a percentage.

For example, .35 x 100 = 35%

SUMMARIZE DATA

After you have totaled and scored the item responses for all sectors and

community components, create a summary of all the percentage scores

for each site. For example, if you assessed 3 community

institutions/organizations, you will have 3 summary pages (1 for each site)

COMMUNITY NEEDS ASSESSMENT

PARTICIPANT WORKBOOK |3

that show all the percentage scores for the Community

Institution/Organization sector, as in Table 5. Notice the percentage

scores of 35% Policy and 45% Environment from Table 4 are carried over

to the summary worksheet in Table 5.

Table 5: Sample Summary of Community Component Scores for a

Community Institution/Organization

Policy

Environment

Community Component

62%

70%

Physical Activity

50%

60%

Nutrition

75%

82%

Tobacco Use

35%

45%

Chronic Disease Management

25%

30%

Leadership

SECTOR DATA GRID

To provide a quick data reference across all sectors, you can use the

Summary Scores to create a Sector Data Grid as shown in Table 6. This

grid helps communities easily review and determine areas for

improvement. Identifying sectors and related community components with

low scores is useful for informing priority areas for improvement and

determining what specific strategies to incorporate into the action plan.

This action step supports a comprehensive view of all the data and

reveals how the sites compare to each other. It builds a spectrum against

which your community team can begin thinking about gaps, needs, assets,

and areas of change.

To create a Sector Data Grid you will refer to all Summary of Community

Component Percentage Score sheets. For each sector (Community-At-

Large, Community Institution/Organization, etc.), you will indicate where

each site’s community component (row) percentages fall in the

appropriate column.

In the Sector Data Grid you will indicate the sector’s policy community

component scores (by using a “P”) and environment community

component scores (by using an “E) for each site (denoted by a “1”, “2”,

etc.). For Community-At-Large, place a ‘CALP1’ (remember there is only

one site assessed for this sector) in each row to denote this site’s policy

community element percentages across the scale (low [0–20%] to high

[81–100%]). Use ‘CALE1’ to denote the site’s environment community

component percentages.

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PARTICIPANT WORKBOOK |3

Notice that in Table 6, The Community Institution/Organization (CIO)

sector shows the percentages for the three sites that were assessed,

indicated by the “1”, “2” and “3” at the end of each code.

Table 6: Example of a Sector Data Grid (for 2 sectors only)

Community-At-Large (CAL)

Community

Component

Low:

0-20%

Low:

21-40%

Medium:

41-60%

Medium:

61-80%

High:

81-100%

Physical

Activity

CALP1,

CALE1

Nutrition CALP1,

CALE1

Tobacco

CALP1,

CALE1

Chronic

Disease Mgt

CALE1 CALP1

Leadership

CALP1 CALP1

CALE1: ‘CAL’ = Community-At-Large Sector ‘E’ = Environment ‘1’= Site number (If

you have multiple sites, number them consecutively, 1, 2, 3 and so forth.)

COMMUNITY NEEDS ASSESSMENT

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Community Institution/Organization (CIO)

Community

Component

Low:

0-20%

Low:

21-40%

Medium:

41-60%

Medium:

61-80%

High:

81-100%

Physical

Activity

CIOP1 CIOE1

CIOP2,

CIOE2,

CIOP3

CIOE3

Nutrition CIOE1,

CIOP1,

CIOE2

CIPO2,

CIOE3

CIOP3

Tobacco

CIOP2,

CIOE3,

CIOP3

CIOP1,

CIOE1,

CIOE2

Chronic

Disease Mgt

CIOP1,

CIOE1

CIOP2

CIOE2,

CIOP3,

CIOE3

Leadership

CIOE2,

CIOP2

CIOE3

CIOP3,

CIOE1

CIOP1

Your mentor or facilitator will review in greater detail how to complete this

grid.

Stop

Let the facilitator or mentor know you are ready for the group

discussion.

Activity

TAKE OUT THE ACTIVITY WORKBOOK AND COMPLETE SKILL

ASSESSMENT - ACTIVITY#3.

COMMUNITY NEEDS ASSESSMENT

PARTICIPANT WORKBOOK |39

SECTION 5: KEY POINTS

Tip

• To ensure proper data management, there should be only one data

manager, such as the community team’s evaluator; all data should be

forwarded to this individual.

• After your team has reached consensus on rating each item within a

site, the data should be recorded in a table or spreadsheet along with

supporting comments.

• After recording the data and entering comments, the data manager

should total all the ratings and assign a percentage score.

• After totaling and scoring the item responses for all sectors and

community components, the data manager should create a summary of

all the percentage scores for each site.

• To provide a quick data reference across all sectors you can use the

Summary Scores to create a Sector Data Grid.

COMMUNITY NEEDS ASSESSMENT

PARTICIPANT WORKBOOK |40

Section 5: Create a Community Action Plan

INTRODUCTION

At this stage of the community needs assessment, you should have

summarized the data the team has collected and are ready to identify the

community assets and needs. In this final section of the workbook you will

learn how to use your summary information to identify areas for

improvement and then transform them into measurable action items.

The outcome of this step is a Community Action Plan which will contain

Specific, Measurable, Attainable, Realistic and Timely (SMART) objectives

and the activities to support those objectives.

You should present your needs assessment findings and obtain approval

from stakeholders and/or community leaders on the strategies before

developing an action plan.

IDENTIFY ASSETS AND NEEDS

You will use the Sector Data Grids to identify focal policy, systems, and

environmental change strategies that are both in place, (i.e., assets), and

missing, (i.e., needs).

Your team should designate a cut-off point–the scores to the right of the

line would be considered assets; those to the left would be the needs, as

shown in Table 7.

Table 7: Sample Needs and Assets: Needs=0-60%, Assets=61-100%

Community-At-Large (CAL)

Community

Component

Low:

0-20%

Low:

21-40%

Medium:

41-60%

Medium:

61-80%

High:

81-100%

Physical

Activity

CALP1,

CALE1

Nutrition

CALP1,

CALE1

Tobacco CALP1,

CALE1

Chronic

Disease Mgt

CALE1 CALP1

CALE1: ‘CAL’ = Community-At-Large Sector ‘E’ = Environment ‘1’= Site number (If

you have multiple sites, number them consecutively, 1, 2, 3 and so forth.)

COMMUNITY NEEDS ASSESSMENT

PARTICIPANT WORKBOOK |41

Community

Component

Low:

0-20%

Low:

21-40%

Medium:

41-60%

Medium:

61-80%

High:

81-100%

Leadership

CALP1 CALP1

Now that you have a visual depiction of each sector’s needs and assets

across all the community components, you can then create a list of all the

policy, systems, and environmental change strategies across sectors that

are assets or needs. Table 8 shows an example of a Policy, Systems

and Environmental Change Strategies Worksheet you can use to

record this information.

Table 8: Sample Policy, Systems, and Environmental Change Strategies

Worksheet: Assets and Needs

ASSETS

NEEDS

Community-At-Large Sector:

• Smoke-free and tobacco-free

policies implemented for indoor

and outdoor places.

• Strategies adopted to educate

residents on importance of

controlling high blood pressure

and cholesterol.

Community

Institution/Organization (CIO)

Sector:

• All sites instituted healthy food

and beverage options in vending

machines.

• 3 out of 4 sites provide routine

screening for cholesterol and

provide counseling and

education about tobacco use

and exposure.

• 3 out of 4 sites participated in

the last three years in

community coalitions and

partnerships related to tobacco

use and physical inactivity.

Community-At-Large Sector:

• No policies in place that ban

local restaurants and retail food

establishments from cooking

with trans fats.

• Recent budget cuts for public

shared-used paths or trails.

Community

Institution/Organization (CIO)

Sector:

• 1 site did not provide any

routine screenings for chronic

diseases management.

• No sites promoted stairwell use.

• 1 site has never participated in

community coalitions and

partnerships related to tobacco

use or physical inactivity.

Health Care Sector:

• Health care centers and private

physician’s office do not take

routine body mass index

readings (BMIs) for routine

office exams.

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ASSETS

NEEDS

Health Care Sector:

• Two facilities promoted stairwell

use to patients, visitors, and

staff

• Patients referred to smoking

cessation programs at all sites

School Sector:

• 1 of the schools was initiating a

plan to ensure the playground

equipment meets safety

standards

Work Site Sector:

• Employee wellness coalition

developed by local small

business

• All sites have designated, safe

walking paths on building

property

• 4 out of 5 sites implemented a

referral system for tobacco

cessation services

•

75% of the health care

professionals do not provide

patient education on nutrition or

physical activity

School Sector:

• No requirements for physical

activity during school day

• 2 of the 3 schools offered no

healthy food or beverage

options

Work Site Sector:

• No sites promoted stairwell use

• No sites offered healthy food or

beverage options in vending

machines

Strategies:

PRIORITIZE NEEDS

If you have identified many community needs, your team should prioritize

those needs. Some criteria you may consider when prioritizing needs

are:

• Size of problem

• Seriousness of problem

• Availability of current interventions

• Economic or social impact

• Public health concern

• Availability of resources

COMMUNITY NEEDS ASSESSMENT

PARTICIPANT WORKBOOK |4

Tip

Please refer to the Prioritize Public Health Problems module for more

information about how to prioritize needs.

DEVELOP STRATEGIES

Using your priority list of community needs, identify a specific community

strategy to address each key need. You do not have to address every

weakness.

When identifying strategies, consider the community’s strengths. For

example, in the sample needs assessment in Table 8 all the community

institution/organization sites offered healthy food and beverage options in

vending machines; however, none of the sites promoted stairwell use.

Since the institutions already have a healthy nutritional environment they

might be more acceptable of incorporating physical activity initiatives.

Your team can also combine similar strategies to streamline activities. For

example, in the sample needs assessment, work sites also did not

promote stairwell use. The community team can formulate a strategy that

encourages stairwell use at work sites and community

institutions/organizations. The team members responsible for this strategy

can use the same promotional materials (e.g., posters on the benefits of

using stairwells) for both sectors.

After developing the strategies, record them on the bottom section of the

Policy, Systems and Environmental Change Strategies Worksheet. An

example is shown below in Table 9.

Table 9: Sample Strategies (bottom of Policy, Systems, and

Environmental Change Strategies Worksheet)

COMMUNITY NEEDS ASSESSMENT

PARTICIPANT WORKBOOK |44

Strategies:

• Work with key stakeholders to formulate and implement a policy

that bans local restaurants and retail food establishments from

cooking with trans fats.

• Encourage community institutions/ organizations and work sites to

promote stairwell use.

• Encourage health care professionals to provide patient education

on nutrition and physical activity to adults with chronic disease risk

factor.

• Require schools to incorporate a minimum of 30 minutes of

physical activity during school day.

• Require schools to offer healthy food and beverage options.

PRIORITIZE STRATEGIES

Once you have identified the strategies, your team will need to prioritize

what can be implemented, given the time, resources, and other competing

community priorities. Use any method to prioritize that your team has

agreed upon. One way is to rank each strategy according to each

criterion from 1 to 5 as follows:

Table 10: Example Scale for Ranking Strategy

Time

Resources

Competing Priorities

1= Large amount of

time needed to

implement strategy

2 = Substantial amount

of time needed to

implement strategy

3 = Some amount of

time needed to

implement strategy

4 = A little amount of

time needed to

implement strategy

5 = Very little amount of

time needed to

implement strategy

1= Large amount of

resources needed to

implement strategy

2 = Substantial amount

of resources needed to

implement strategy

3 = Some amount of

resources needed to

implement strategy

4 = A little amount of

resources needed to

implement strategy

5 = Very little amount of

resources needed to

implement strategy

1= Large amount of

competing priorities

2 = Substantial amount

of competing priorities

3 = Some competing

priorities

4 = A few competing

priorities

5 = No competing

priorities

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After ranking each strategy according to time, resources, and competing

priorities, total the scores to determine the highest ranking strategies to

implement. See Table 11 for an example of how to use this ranking

method.

Table 11: Sample Prioritize Worksheet

Strategy

Time

(1-5)

Resources

(1-5)

Competing

Priorities

(1-5)

Total

(T x R x C)

Rank

Work with key

stakeholders to

formulate and implement

a policy that bans local

restaurants and retail

food establishments

from cooking with trans

fats.

1 2 2

Encourage community

institutions/organizations

and work sites to

promote stairwell use.

4 4 3 48 1

Encourage health care

professionals to provide

patient education on

nutrition and physical

activity to adults with

chronic disease risk

factor.

4 3 3 36 2

Require schools to

incorporate a minimum

of 30 minutes of physical

activity during school

day.

Require schools to offer

healthy food and

beverage options.

2 2 2 8 4

In the above example the top 2 strategies are:

1. Encourage community institutions/organizations and work sites to

promote stairwell use.

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2. Encourage health care professionals to provide patient education on

nutrition and physical activity to adults with chronic disease risk factors.

COMMUNITY ACTION PLAN

Your team will develop an action plan for each priority strategy. A quality

plan contains sufficient details to map a clear course of action. Table 12

shows an example of a Community Action Plan.

Notice there are two types of objectives listed in the Community Action

Plan: Project Period Objective and Annual Objective. The project period

objective allows your team to look at a long term perspective of what can

be accomplished over a multiyear period. For example, in Table 11 the

project period objective states: In 5 years, all ministry of health providers

will include NCD counseling to all patients, that includes lifestyle

counseling on physical activity, nutrition and smoking.. There is also

space on the worksheet to record the community component that is the

area of focus, such as nutrition or physical activity.

Annual objectives cover a 12-month timeframe and show incremental

progress toward completion of the project period objective. In Table 12

there is one annual objective: At 12 months, all clinics in district Y will

provide lifestyle NCD counseling to all patients.

Table 12: Example of a Community Action Plan

Policy/Environmental

Change Strategy

Encourage health care professionals to

provide patient education on nutrition and

physical activity to adults with chronic

disease risk factors.

Project Period Objective

Community

Component(s)

In 5 years, all ministry of health providers will include

NCD counseling to all patients that includes lifestyle

counseling on physical activity, nutrition, and

smoking.

Physical Activity

Nutrition

Annual Objective(s): Sector(s)

No. of People

Reached

At 12 months all clinics in district Y will

provide lifestyle NCD counseling to all

patients.

Health Care 250,000

Activities Person

Responsible

Timeline

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NCD counseling protocols developed J. Thomas Month 0-3

NCD counseling monitoring system

developed

W. Lee Month 0-3

Health provider reward/recognition

system established

Month 0-3

NCD physicians/health providers

trained on protocol

W. Lee Month 3

Community interventions including

establishment of exercise locations for

women and the general public, and

cooking classes

J. Thomas Months 6-9

A district-wide, multisectoral NCD plan

will be developed and implemented

W. Lee Months 6-9

All physicians/health providers trained W. Lee Months 6-9

All clinics begin counseling J. Thomas Month 12

It is important to associate each annual objective with a particular sector.

You may develop multiple annual objectives that cut across more than

one sector for a project period objective. In this example, the sector

impacted is health care.

For each annual objective, indicate the approximate number of people

who will be affected by the strategy through its successful completion.

Tip

As you craft the objectives, be sure they are SMART—specific,

measurable, achievable, realistic, and time-phased.

The last section of the Community Action Plan template is where you list

the activities that support the accomplishment of the annual objective.

When listing activities be sure to provide clear descriptions of key

milestones. For each annual objective it is recommended that you list no

In reality, more activities would be listed which would include activities for years 2

through 5 (project objective).

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more than 10 activities, which may limit these activities to key actions for

completing the annual objective.

Next to each activity that is listed identify the lead or primary contact

person, and estimate the timeline for strategy completion. Be specific and

realistic. If the strategy’s completion depends on actions by several

individuals or organizations, allow time for stakeholder coordination.

Stop

Let the facilitator or mentor know you are ready for the group

discussion.

Activity

TAKE OUT THE ACTIVITY WORKBOOK AND COMPLETE SKILL

ASSESSMENT - ACTIVITY#4.

SECTION 6: KEY POINTS

Tip

• Create a list of all the policy, systems, and environmental change

strategies across sectors that are community assets or needs.

• Use your list of community needs to identify a specific community

strategy to address each key need. You do not have to address

every weakness.

• After identifying strategies, your team will prioritize what can be

implemented given the time, resources, and other competing

community priorities.

• On the action plan a project period objective allows your team to look

at a long-term perspective of what can be accomplished over a

multiyear period. Annual objectives cover a 12-month timeframe with

incremental progress toward completion of the project period

objective.

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Conclusion

IMPLEMENTING THE ACTION PLAN AND SHARING PROGRESS

Although this workbook does not cover implementing the community

action plan or sharing results, it is worthwhile to briefly mention those here.

After completing the community needs assessment and developing a

communication action plan, coordinate your resources to make sure the

activities you have identified are completed on time. Track your progress,

note key successes, and document any obstacles to implementing the

action plan.

You will also want to share the data and accomplishments with community

leaders and other people and organizations that contributed their time and

expertise to the needs assessment. Identify the best venue for sharing

the results. You can organize a community meeting and/or write a policy

brief or one-pager.

Anonymity is important to protect the interests of those who participated in

the assessment. Community teams should not list who they talked with or

provide specific details about data that could specifically link to an

individual or organization. Share data in aggregate for a sector. For

example, when providing results of assessing work sites you may state

that “across the 6 work sites examined by the community team, 2 had

policies requiring healthy food choices in vending machines, 1 was in the

process of formulating a policy, and 3 had no formal policy regarding

vending machine healthy food choices.”

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TAKE HOME POINTS

Tip

• A community needs assessment should focus on a particular

geographic area, sectors within that area such as health care and

work sites, and community components to assess within each sector

such as nutrition, chronic disease management, and tobacco use.

• A combination of 2 or more data-collection methods is recommended

at each site to confirm or support initial findings.

• Keep a comprehensive file of all sources of information, key contacts,

and data to review at a later date or to share with coalition members.

• Rating the data should be based on a comprehensive review of all

sources and the agreement of the individuals on your team.

• To ensure proper data management there should be only one data

manager, such as the community team’s evaluator, and all data

should be forwarded to this individual.

• After your team has reached consensus on the most appropriate

rating for each item within a site, the data should be recorded in a

table or spreadsheet along with any supporting comments. The data

manager should total all the ratings, assign a percentage score, and

then create a summary of all the percentage scores for each site.

• Create Sector Data Grids to provide a quick data reference across all

sectors.

• Use your list of community needs and identify a specific community

strategy to address each key need. You do not have to address

every weakness.

• After identifying strategies your team will prioritize what can be

implemented, given the time, resources, and other competing

community priorities.

• On the action plan, a project period objective allows your team to

look at a long term perspective of what can be accomplished over a

multiyear period. Annual objectives cover a 12-month timeframe with

incremental progress toward completion of the project period

objective.

WORKBOOK REVIEW

After completing this workbook, you should be able to:

 Plan for a community needs assessment,

 Review and rate data collected from a community needs assessment,

 Summarize data,

 Identify areas for improvement, and,

 Develop a community action plan.

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Resources

For more information on topics found within this workbook:

• Community Health Assessment and Group Evaluation (CHANGE)

data-collection tool developed by CDC’s Healthy Communities

Program in the Division of Community Health at the National Center for

Chronic Disease Prevention and Health Promotion. Available at:

http://www.cdc.gov/HealthyCommunitiesProgram

• Centers for Disease Control and Prevention. Healthier Worksite

Initiative, Environmental Audits. Available at:

http://www.cdc.gov/nccdphp/dnpao/hwi/programdesign/enviro

nmental_audits.htm

• Community Assessment Guide Book, North Carolina Department of

Health (2002); retrieved on October 19, 2012 from

http://www.schs.state.nc.us/schs/data/databook/2002/GuideBo

ok2002.pdf

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Appendices

APPENDIX A

The community needs assessment can yield information about different

types of change strategies in the community: policy, systems or

environmental. Systems changes can either be policy or environmental.

Match the examples on the left side of the following table with the

appropriate category. Mark your responses.

Example of types of strategies in a community-

Law requiring schools to provide

healthy food options for students

 Policy

Environmental

Walking paths at a work site

Policy

 Environmental

Higher prices for alcohol

Policy



Environmental

Smoking cessation programs for

government employees

Policy

 Environmental

Food labeling

 Policy

Environmental

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APPENDIX B

The following is a list of sample questions you can ask for each sector and community

component. Please note that these were developed for a U.S. audience and should be

adapted accordingly:

Community-At-Large Sector

Demographic

1. Approximate number of people who reside in the community

(population).

2. Approximate size of the area (square kilometers).

3. Best description of the community setting: rural, suburban, urban.

4. The median household income of the community: provide 4 choices.

5. Approximate percentage of people in the community with no high

school diploma.

6. Approximate percentage of people in the community who are living in

poverty: < 5%, 5 – 9%, 10 – 14%, 15 – 19%, ≥ 20%.

7. Approximate percentage of people in the community who are currently

unemployed: < 5%, 5 – 9%, 10 – 14%, 15 – 19%, ≥ 20%.

Physical Activity

To what extent does the community:

1. Require sidewalks to be built for all developments (e.g., housing,

schools, commercial)?

2. Adopt a land use plan?

3. Require bike facilities (e.g., bike boulevards, bike lanes, bike ways,

multi-use paths) to be built for all developments (e.g., housing,

schools, commercial)?

4. Adopt a complete streets plan to support walking and biking

infrastructure?

5. Maintain a network of walking routes (e.g., institute a sidewalk program

to fill gaps in the sidewalk)?

6. Maintain a network of biking routes (e.g., institute a bike lane program

to repave bike lanes when necessary)?

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7. Maintain a network of parks (e.g., establish a program to repair and

upgrade existing parks and playgrounds)?

8. Provide access to parks, shared-use paths and trails, or open spaces

within reasonable walking distance of most homes?

9. Institute mixed land use?

10. Provide access to public recreation facilities (e.g., parks, play areas,

community and wellness centers) for people of all abilities?

11. Enhance access to public transportation (e.g., bus stops, light rail

stops, van pool services, subway stations) within reasonable walking

distance?

12. Provide street traffic calming measures (e.g., road narrowing, central

islands, roundabouts, speed bumps) to make areas (e.g.,

neighborhoods, major intersections) where people are or could be

physically active (e.g., walk, bike) safer?

13. Adopt strategies (e.g., neighborhood crime watch, lights) to enhance

personal safety in areas (e.g., playgrounds, parks, bike lanes, walking

paths, neighborhoods) where people are or could be physically active

(e.g., walk, bike)?

Nutrition

To what extent does the community:

1. Adopt strategies to encourage food retailers (e.g., grocery, corner or

convenience stores; bodegas) to provide healthy food and beverage

options (e.g., fresh produce) in underserved areas?

2. Encourage community garden initiatives?

3. Enhance access to public transportation (e.g., bus stops, light rail

stops, van pool services, subway stations) to supermarkets and large

grocery stores?

4. Connect locally grown foods to local restaurants and food venues?

5. Promote (e.g., signage, product placement, pricing strategies) the

purchase of fruits and vegetables at local restaurants and food

venues?

6. Institute healthy food and beverage options at local restaurants and

food venues?

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7. Institute nutritional labeling (e.g., ‘low fat,’ ‘light,’ ‘heart healthy,’ ‘no

trans fat’) at local restaurants and food venues?

8. Provide smaller portion sizes at local restaurants and food venues?

9. Ban local restaurants and retail food establishments from cooking with

trans fats?

10. Adopt strategies to recruit supermarkets and large grocery stores in

underserved areas (e.g., provide financial incentives, lower operating

costs, provide job training services)?

11. Provide comfortable, private spaces for women to nurse or use a

breast pump in public places (e.g., government buildings, restaurants,

retail establishments) to support and encourage residents’ ability to

breastfeed?

12. Protect a woman’s right to breastfeed in public places?

Tobacco

To what extent does the community:

1. Institute a smoke-free policy 24/7 for indoor public places?

2. Institute a tobacco-free policy 24/7 for indoor public places?

3. Institute a smoke-free policy 24/7 for outdoor public places?

4. Institute a tobacco-free policy 24/7 for outdoor public places?

5. Ban tobacco advertisement (e.g., restrict point-of-purchase advertising

or product placement)?

6. Ban tobacco promotions, promotional offers, and prizes?

7. Regulate the number, location, and density of tobacco retail outlets?

8. Restrict the placement of tobacco vending machines (including self-

service displays)?

9. Enforce the ban of selling single cigarettes?

10. Increase the price of tobacco products and generate revenue with a

portion of the revenue earmarked for tobacco control efforts (e.g.,

taxes, mitigation fees)?

11. Provide access to a referral system for tobacco cessation resources

and services?

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Chronic Disease Management

To what extent does the community:

1. Enhance access to chronic disease self-management programs (e.g.,

Weight Watchers for overweight/obesity)?

2. Adopt strategies to educate its residents on the importance of obesity

prevention?

3. Adopt strategies to educate its residents on the importance of

controlling high blood pressure?

4. Adopt strategies to educate its residents on the importance of

controlling cholesterol?

5. Adopt strategies to educate its residents on the importance of

controlling blood sugar or insulin levels?

6. Adopt strategies to educate its residents on heart attack and stroke

symptoms and when to call 9-1-1?

7. Adopt strategies to educate its residents on the importance of

preventive care?

8. Provide emergency medical services (e.g., 9-1-1, transport system)?

9. Adopt strategies to address chronic disease health disparities?

Leadership

To what extent does the community:

1. Participate in community coalitions and partnerships (e.g., food policy

council, tobacco-free partnership, neighborhood safety coalition) to

address chronic diseases and associated risk factors?

2. Participate in the public policy process to highlight the need for

community changes to prevent and reduce chronic disease risk factors

(e.g., poor nutrition, physical inactivity, tobacco use and exposure)?

3. Finance public shared-use paths or trails (by passing bonds, passing

mileages, levying taxes or getting grants)?

4. Finance public recreation facilities (by passing bonds, passing

mileages, levying taxes or getting grants)?

5. Finance public parks or greenways (by passing bonds, passing

mileages, levying taxes or getting grants)?

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6. Finance public sports facilities (by passing bonds, passing mileages,

levying taxes or getting grants)?

7. Finance pedestrian enhancements (e.g., sidewalks, street crossing

enhancements)?

8. Finance bicycle enhancements (e.g., bike lanes, bike parking, road

diets)?

9. Address the community’s operating budget to make walking, bicycling,

or other physical activities a priority?

10. Promote mixed land use through regulation or other incentives?

11. Institute a management program to improve safety within the

transportation system?

Community Institution/Organization Sector

Demographic

1. Best description of the community setting: rural, suburban, urban

2. Median household income in the community: insert range here

3. Sector type: private, public

4. Profit type: for-profit, not-for-profit

5. Target population: children/youth* (ages: <18), adults (ages: 18-64),

seniors/older adults (ages: 65+), other. *If serving children/youth, what

grades are being served: preschool, elementary school, middle school,

high school

6. Type of institution/organization: senior center, faith-based organization,

daycare center, boys and girls club, health and wellness center,

university/college, other

Physical Activity

To what extent does the community institution/organization:

1. Promote stairwell use (e.g., make stairs appealing, post motivational

signs near stairs to encourage physical activity)?

2. Provide a safe area outside (e.g., through lighting, signage, crime

watch) to walk or be physically active?

3. Designate a walking path on or near building property?

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4. Encourage nonmotorized commutes (e.g., active transportation such

as walk or bike) to the facility?

5. Enhance access to public transportation (e.g., bus stops, light rail

stops, van pool services, subway stations) within reasonable walking

distance?

6. Provide access to onsite fitness center, gymnasium, or physical activity

classes?

7. Provide a changing room or locker room with showers?

8. Provide bicycle parking (e.g., bike rack, shelter) for patrons?

9. Provide access to a broad range of competitive and noncompetitive

physical activities that help to develop the skills needed to participate

in lifetime physical activities?

10. Provide opportunity for unstructured play or leisure-time physical

activity?

11. Prohibit using physical activity as a punishment?

12. Restrict screen time to less than 2 hours per day for children over 2

years of age?

13. Provide direct support (e.g., money, land, pavilion, recreational

facilities, sponsorship, advertising) for supporting community-wide

physical activity opportunities (e.g., sports teams, walking clubs)?

Nutrition

To what extent does the community institution/organization:

1. Institute health food and beverage options in vending machines?

2. Institute healthy food and beverage options at institution-sponsored

meetings and events?

3. Institute healthy food and beverage options in onsite cafeteria and food

venues?

4. Institute healthy food purchasing (e.g., to reduce the caloric, sodium,

and fat content of foods offered) for cafeteria and onsite food venues?

5. Institute healthy food preparation practices (e.g., steaming, low fat, low

salt, limiting frying) in onsite cafeteria and food venues?

6. Institute pricing strategies that encourage the purchase of healthy food

and beverage options?

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7. Ban marketing (e.g. counter advertisements, posters, other print

materials) of less than healthy foods and beverages onsite?

8. Provide smaller portion sizes in onsite cafeteria and food venues?

9. Institute nutritional labeling (e.g., ‘low fat,’ ‘light,’ ‘heart healthy,’ ‘no

trans fat’) at onsite cafeteria and food venues?

10. Provide safe, unflavored, cool drinking water at no cost to patrons?

11. Prohibit using food as a reward or punishment?

12. Provide direct support (e.g., money, land, pavilion, sponsorship,

advertising) for supporting community-wide nutrition opportunities (e.g.,

farmers’ markets, community gardens)?

13. Provide a comfortable, private space for women to nurse or pump to

support and encourage patrons’ ability to breastfeed?

Tobacco

To what extent does the community institution/organization:

1. Institute a smoke-free policy 24/7 for indoor public places?

2. Institute a tobacco-free policy 24/7 for indoor public places?

3. Institute a smoke-free policy 24/7 for outdoor public places?

4. Institute a tobacco-free policy 24/7 for outdoor public places?

5. Ban tobacco vending machine sales (including self-service displays)?

6. Ban tobacco promotions, promotional offers, and prizes?

7. Ban tobacco advertisement (e.g., restrict point-of-purchase advertising

or product placement)?

8. Implement a referral system to help patrons to access tobacco

cessation resources and services

Chronic Disease Management:

To what extent does the community institution/organization:

1. Provide access to chronic disease self-management programs (e.g.,

Weight Watchers for overweight/obesity)?

2. Provide access to an onsite nurse?

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3. Provide an onsite medical clinic to monitor and address chronic

diseases and related risk factors (e.g., high blood pressure, high

cholesterol, elevated blood sugar levels)?

4. Provide routine screening, follow-up counseling and education to

patrons to help address chronic diseases and related risk factors (e.g.,

poor nutrition, physical inactivity, hypertension, high cholesterol,

elevated blood sugar levels, tobacco use and exposure)?

5. Adopt curricula or training to raise awareness of the signs and

symptoms of heart attacks and strokes?

6. Adopt curricula or training to raise awareness of the importance of

calling 9-1-1 immediately when someone is having a heart attack or

stroke?

7. Promote chronic disease prevention to patrons (e.g., post signs

reminding patrons to get blood pressure checked, quit smoking, or

avoid secondhand smoke)?

8. Have an emergency response plan (e.g., appropriate equipment such

as Automatic External Defibrillator, instructions for action) in place?

Leadership

To what extent does the community institution/organization:

1. Provide incentives to patrons participating in chronic disease

prevention measures (e.g., quit smoking, log miles walked, obtain

blood pressure or cholesterol screening)?

2. Participate in the public policy process to highlight the need for

community changes to address chronic diseases and related risk

factors (e.g., poor nutrition, physical inactivity, tobacco use and

exposure)?

3. Have a wellness coordinator?

4. Have a wellness committee?

5. Have a health promotion budget?

6. Have a mission statement (or a written policy statement) that includes

the support of or commitment to patron health and well-being?

7. Implement a needs assessment when planning a health promotion

program?

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8. Evaluate health promotion programs?

9. Provide opportunities for patron feedback (e.g., interest, satisfaction,

adherence) about health promotion programs?

10. Participate in community coalitions and partnerships (e.g., food policy

council, tobacco-free partnership, neighborhood safety coalition) to

address chronic diseases and related risk factors (e.g., poor nutrition,

physical inactivity, tobacco use and exposure)?

Health Care Sector

Demographic

1. Number of staff: fewer than 20, 20 – 99, 100 – 249, 250 – 499, 500 –

999, 1,000 – 1,499, 1,500+

2. Type of health care organization: medical/physician office, clinic,

hospital, ambulatory care, home health agency, Health Maintenance

Organization (HMO), local health department, Federally Qualified

Health Center (FQHC), other

3. Number of patients:

a. average number of patients on monthly basis

4. Sector type:

a. private, b. public

5. Profit type:

a. for-profit, b. not-for-profit

Physical Activity

To what extent does the health care facility:

1. Promote stairwell use (e.g., make stairs appealing, post motivational

signs near stairs to encourage physical activity) to patients, visitors,

and staff?

2. Assess patients’ physical activity as part of a written checklist or

screening used in all routine office visits?

3. Provide regular counseling about the health value of physical activity

during all routine office visits?

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4. Implement a referral system to help patients’ access community-based

resources or services for physical activity?

Nutrition

To what extent does the health care facility:

1. Implement breastfeeding initiative for future or current moms?

2. Assess patients’ nutrition as part of a written checklist or screening

used in all routine office visits?

3. Provide free or low cost weight management or nutrition programs?

4. Provide regular counseling about the health value of good nutrition

during all routine office visits?

5. Provide free or low cost weight management or nutrition programs?

6. Implement a referral system to help patients to access community-

based resources or services for nutrition?

7. Institute healthy food and beverage options in vending machines?

8. Institute healthy food and beverage options served to their patients?

9. Institute healthy food and beverage options in the onsite cafeteria and

food venues?

10. Institute pricing strategies that encourage the purchase of healthy food

and beverage options?

11. Institute healthy food purchasing (e.g., to reduce the caloric, sodium,

and fat content of foods offered) for cafeteria and onsite food venues?

12. Institute healthy food preparation practices (e.g., steaming, low fat, low

salt, limiting frying) in onsite cafeteria and food venues?

13. Institute nutritional labeling (e.g., ‘low fat,’ ‘light,’ ‘heart healthy,’ ‘no

trans fat’) at the onsite cafeteria and food venues?

14. Ban marketing (e.g., counter advertisements, posters, other print

materials) of less than healthy foods and beverages onsite?

15. Provide smaller portion sizes in onsite cafeteria and food venues?

Tobacco

To what extent does the health care facility:

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1. Institute a smoke-free policy 24/7 for indoor public places?

2. Institute a tobacco-free policy 24/7 for indoor public places?

3. Institute a smoke-free policy 24/7 for outdoor public places?

4. Institute a tobacco-free policy 24/7 for outdoor public places?

5. Assess patients’ tobacco use as part of written checklist or screening

used in all routine office visits?

6. Assess patients’ exposure to tobacco smoke as part of written

checklist or screening used in all routine office visits?

7. Provide advice and counseling about the harm of tobacco use and

exposure during all office visits?

8. Implement a referral system to help patients to access tobacco

cessation resources and services?

9. Provide access to free or low cost pharmacological quitting aids for

their patients?

10. Implement a provider-reminder system to assess, advise, track, and

monitor tobacco use?

Chronic Disease Management

To what extent does the health care facility:

1. Implement a referral system to help patients to access community-

based resources or services for chronic disease management?

2. Provide routine follow-up counseling and education to patients to help

address chronic diseases and related risk factors (e.g., poor nutrition,

physical inactivity, hypertension, high cholesterol, elevated blood sugar

levels, tobacco use and exposure)?

3. Provide screening for chronic diseases in adults with risk factors (e.g.,

poor nutrition, physical inactivity, hypertension, high cholesterol,

elevated blood sugar levels, tobacco use and exposure)?

4. Measure weight and height, and calculate appropriate body mass

index (BMI) for every patient at each visit?

5. Adopt a plan or process to increase patient adherence to chronic

disease (e.g., cardiovascular disease, diabetes) treatment?

6. Institute a systematic approach to the processes of diabetes care?

COMMUNITY NEEDS ASSESSMENT

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7. Institute the latest emergency heart disease and stroke treatment

guidelines (e.g., Joint National Committee 7, American Heart

Association)?

8. Provide access to resources and training for using a stroke rating

scale?

9. Provide specialized stroke care units?

10. Provide specialized heart disease units?

Leadership

To what extent does the health care facility:

1. Participate in community coalitions and partnerships (e.g., food policy

council, tobacco-free partnership, neighborhood safety coalition) to

address chronic diseases and related risk factors (e.g., poor nutrition,

physical inactivity, tobacco use and exposure)?

2. Participate in the public policy process to highlight the need for

community changes to address chronic diseases and related risk

factors (e.g., poor nutrition, physical inactivity, tobacco use and

exposure)?

3. Enhance access to childhood overweight prevention and treatment

services to reduce health disparities?

4. Promote high standards of modifiable risk factor (e.g., poor nutrition,

physical inactivity, tobacco use and exposure) practice to healthcare

and provider associations?

5. Institute standardized treatment and prevention protocols that are

consistent with national evidence-based guidelines to prevent heart

disease, stroke, and related risk factors?

6. Institute an electronic medical records system and patient data

registries to provide immediate feedback on a patient’s condition and

compliance with the treatment regimen?

7. Adopt the Chronic Care Model in hospitals?

8. Provide patient services using provider care teams that cross

specialties (e.g., physician/ pharmacist teams)?

9. Provide access to medical services outside of regular working hours

(e.g., late evenings, weekends)?

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10. Promote collaboration between health care professionals (e.g.,

physicians and specialists) for managing chronic diseases (e.g.,

cardiovascular disease, diabetes)?

11. Partner with community agencies to provide free or low cost chronic

disease health screenings, follow-up counseling, and education for

those at risk?

12. Institute annual cultural competence training for all health workers for

optimal care of all patients (regardless of their race/ethnicity, culture, or

background)?

School Sector

Demographic

1. Total # of students served

2. School level: elementary, middle, high (specify grades)

3. Type of school: private, public, parochial

4. Best description of the setting of the school: rural, suburban, urban

5. Percentage (%) of students receiving free or reduced price lunch

6. Median household income of the students in this school: insert amount

here

District

To what extent does the district:

1. Require 225 minutes per week of physical education for all middle

school and high school students?

2. Require 150 minutes per week of physical education for all elementary

school students?

3. Provide 20 minutes of recess daily for students in elementary school?

4. Ensure that students are not provided waivers or exemptions from

participation in physical education for other school and community

activities such as band, chorus, Reserve Officers’ Training Corps

(ROTC), sports participation, or community volunteering?

5. Require that either fruits or vegetables or both are available wherever

foods and beverages are offered?

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6. Eliminate the sale and distribution of less than healthy foods and

beverages during the school day?

7. Prohibit the sale of sugar-sweetened beverages (can exclude flavored,

fat-free milk) during the school day?

8. Institute a tobacco-free policy 24/7?

9. Ban tobacco advertising on school property, at school events, and in

written educational materials and publications?

10. Ban tobacco promotions, promotional offers, and prizes on school

property, at school events, and in written educational materials and

publications?

11. Ensure access to a full-time, qualified health care provider (e.g.,

registered school nurse) in every school?

12. Establish a case management plan for students with identified chronic

diseases or conditions (e.g., asthma, diabetes, epilepsy) in

consultation with their families, medical providers, and school staff?

13. Ensure immediate and reliable access to prescribed medications (e.g.,

inhaler, insulin, epinephrine pen) for chronic disease management

throughout school day?

14. Have a district health group (e.g., school health council) composed of

school personnel, parents, students, and community partners that help

plan and implement district health activities?

15. Have a designated school health coordinator who is responsible for

overseeing school health activities across the district?

16. Monitor schools’ compliance with the implementation of the district

school wellness policy enacted as a result of the Child Nutrition and

WIC Reauthorization Act of 2004 (i.e., requires that all school districts

that participate in the National School Lunch Program have local

wellness policies)?

17. Allow the use of school buildings and facilities by the public during

nonschool hours (e.g., joint use agreement)?

18. Adopt a physical education curriculum for all students in grades pre-K

to grade 12 as part of a sequential physical education course of study

consistent with state or National Physical Education Standards?

19. Adopt a nutrition education curriculum, designed to help students

adopt healthy eating behaviors for all students in grades pre-K to grade

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12 as part of a sequential health education course of study, consistent

with state or National Health Education Standards?

20. Adopt a tobacco-use prevention curriculum for all students in grades

pre-K to grade 12 as part of a sequential health education course of

study consistent with state or National Health Education Standards?

21. Require that students are physically active during the majority of time

in physical education class?

Physical Activity

To what extent does the school:

1. Ban using or withholding physical activity as a punishment?

2. Require that students are physically active during the majority of time

in physical education class?

3. Ban using or withholding physical activity as a punishment?

4. Require that students are physically active during the majority of time

in physical education class?

5. Provide access to a broad range of competitive and noncompetitive

physical activities that help to develop the skills needed to participate

in lifetime physical activities?

6. Implement a walk or bike to school initiative?

7. Ensure the availability of proper equipment and facilities (including

playground equipment, physical activity equipment, and athletic or

fitness facilities) that meet safety standards?

Nutrition

To what extent does the school:

1. Ensure that students are provided only healthy food and beverage

options beyond the school food services (e.g., all vending machines,

school stores, and food brought for celebrations)?

2. Institute school breakfast and lunch programs that meet the U.S.

Department of Agriculture School Meal Nutrition Standards?

3. Ensure that healthy food preparation practices (e.g., steaming, low fat,

low salt, limited frying) are always used in the school cafeteria or onsite

food services?

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4. Ban marketing (e.g., counter advertisements, posters, other print

materials) of less than healthy foods and beverages onsite?

5. Promote and market (e.g., through counter advertisements, posters, or

other print materials) only healthy food and beverage options?

6. Provide adequate time to eat school meals (10 minutes for

breakfast/20 minutes for lunch, from the time students are seated)?

7. Ban using food as a reward or punishment for academic performance

or behavior?

8. Provide safe, unflavored, cool drinking water throughout the school day

at no cost to students?

9. Provide school garden (e.g., access to land, container gardens, or

raised beds) and related resources (e.g., staff volunteer time, financial

incentives)?

10. Ensure that multiple channels including classroom, cafeteria, and

communications with parents are used to promote healthy eating

behaviors?

Tobacco

To what extent does the school:

1. Implement a referral system to help students to access tobacco

cessation resources or services?

Chronic Disease Management

To what extent does the school:

1. Provide access to chronic disease self-management education

programs to individuals identified with chronic diseases or conditions

(e.g., diabetes, asthma)?

2. Meet the nutritional needs of students with special health care or

dietary requirements (e.g., allergies, diabetes, physical disabilities)?

3. Provide access to chronic disease self-management education

programs to individuals identified with chronic diseases or conditions

(e.g., diabetes, asthma)?

4. Meet the nutritional needs of students with special health care or

dietary requirements (e.g., allergies, diabetes, physical disabilities)

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5. Provide opportunities to raise awareness among students of the signs

and symptoms of heart attack and stroke?

6. Ensure students are aware of the importance of calling 9-1-1 for

emergencies?

7. Ensure cardiopulmonary resuscitation (CPR) training is made available

to students?

8. Engage families in the development of school plans (e.g., school

diabetes management plans) to effectively manage students with

chronic diseases or conditions?

Leadership

To what extent does the school:

1. Participate in community coalitions and partnerships (e.g., food policy

council, tobacco-free partnership, neighborhood safety coalition) to

address chronic diseases and related risk factors (e.g., poor nutrition,

physical inactivity, tobacco use and exposure)?

2. Participate in the public policy process to highlight the need for

community changes to address chronic diseases and related risk

factors (e.g., poor nutrition, physical inactivity, tobacco use and

exposure)?

3. Have a school building health group (e.g., school health committee)

composed of school personnel, parents, students, and community

partners that help plan and implement the health activities at the

school building?

4. Have an individual who is responsible for leading school health

activities within the school building?

5. Have a health promotion budget?

6. Have a written mission or position statement that includes the

commitment to student health and well-being?

7. Recruit teachers (e.g., physical education, health) with appropriate

training, education, and background?

8. Provide training and support to food service and other relevant staff to

meet nutrition standards for preparing healthy meals?

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9. Provide access to opportunities for professional development or

continued education to staff (e.g., physical education, health, school

nurse, food service manager)?

10. Provide training for all teachers and staff on school physical activity,

nutrition, and tobacco prevention policies?

11. Permit only health-promoting fund raising efforts such as non-food

options or only healthy food and beverage options, physical activity-

related options (e.g., fun-run), or community service options (e.g., car

wash, directing parking at school events)?

After School

To what extent does the after school program:

1. Ban using or withholding physical activity as a punishment?

2. Ban using food as a reward or punishment for academic performance

or behavior?

3. Provide access to physical activity programs (e.g., intramural,

extracurricular, interscholastic)?

4. Ensure appropriate active time during after school programs or

events?

5. Institute healthy food and beverage options during after school

programs or events?

6. Prohibit the sale of sugar-sweetened beverages outside of school

hours?

Work Site Sector

Demographic

1. Number of employees: fewer than 20, 20 – 99, 100 – 249, 250 – 499,

500 – 999, 1,000 – 1,499, 1,500+

2. Type of work site: retail sales, bank or credit union, restaurant/food

service, hotel/motel, auto/repair shop, gas station or convenience

store, pharmacy or drug store, grocery store/food market,

manufacturing, factory, warehouse, construction, school/educational

institution, faith-based institution, health care (e.g., clinic, hospital,

medical practice), government, other

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3. Sector type: private, public

4. Profit type: for-profit, not-for-profit

Physical Activity

To what extent does the work site:

1. Promote stairwell use (e.g., make stairs appealing, post motivational

signs near stairs to encourage physical activity)?

2. Provide flexible work arrangements or break times for employees to

engage in physical activity?

3. Encourage nonmotorized commutes (e.g., active transportation such

as walk or bike) to work?

4. Enhance access to public transportation (e.g., bus stops, light rail

stops, van pool services, subway stations) within reasonable walking

distance?

5. Support clubs or groups (e.g., walking, biking, hiking) to encourage

physical activity among employees?

6. Provide a safe area outside (e.g., through lighting, signage, crime

watch) to walk or be physically active?

7. Designate a walking path on or near building property?

8. Provide access to onsite fitness center, gymnasium, or physical activity

classes?

9. Provide a changing room or locker room with showers?

10. Provide access to offsite workout facility or subsidized membership to

local fitness facility?

11. Provide bicycle parking (e.g., bike rack, shelter) for employees?

12. Implement activity breaks for meetings that are longer than one hour?

13. Provide direct support (e.g., money, land, pavilion, recreational

facilities, sponsorship, advertising) for supporting community-wide

physical activity opportunities (e.g., sports teams, walking clubs)?

Nutrition

To what extent does the work site:

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1. Institute healthy food and beverage options at company-sponsored

meetings and events?

2. Institute healthy food and beverage options in vending machines?

3. Institute healthy food and beverage options in onsite cafeteria and food

venues?

4. Institute healthy food purchasing practices (e.g., to reduce the caloric,

sodium, and fat content of foods offered) for onsite cafeteria and food

venues?

5. Institute healthy food preparation practices (e.g., steaming, low fat, low

salt, limiting frying) in onsite cafeteria and food venues?

6. Ban marketing (e.g., counter advertisements, posters, other print

materials) of less than healthy foods and beverages onsite?

7. Provide smaller portion sizes in onsite cafeteria and food venues?

8. Provide safe, unflavored, cool drinking water at no cost to employees?

9. Institute nutritional labeling (e.g., ‘low fat,’ ‘light,’ ‘heart healthy,’ ‘no

trans fat’) at the work site’s cafeteria and onsite food service?

10. Institute pricing strategies that encourage the purchase of healthy food

and beverage options?

11. Institute a smoke-free policy 24/7 for indoor public places?

12. Provide refrigerator access for employees?

13. Provide microwave access for employees?

14. Provide a sink with water faucet access for employees?

15. Provide direct support (e.g., money, land, a pavilion, sponsorship,

donated advertising) for community-wide nutrition opportunities (e.g.,

farmers’ markets, community gardens)?

16. Support breastfeeding by having maternity care practices, including

providing a comfortable, private space for employees to nurse or

pump?

Tobacco

To what extent does the work site:

1. Institute a smoke-free policy 24/7 for indoor public places?

2. Institute a tobacco-free policy 24/7 for indoor public places?

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3. Institute a smoke-free policy 24/7 for outdoor public places?

4. Institute a tobacco-free policy 24/7 for outdoor public places?

5. Ban tobacco vending machine sales (including self-service displays)?

6. Provide insurance coverage for tobacco cessation services?

7. Provide insurance coverage for tobacco cessation products (e.g.,

pharmacological quitting aids, medicines)?

8. Ban tobacco promotions, promotional offers, and prizes?

9. Ban tobacco advertisement (e.g., restrict point-of-purchase advertising

or product placement)?

10. Implement a referral system to help employees to access tobacco

cessation resources or services, such as a quitline (e.g., 1-800-QUIT-

NOW)?

Chronic Disease Management

To what extent does the work site:

1. Provide routine screening, follow-up counseling and education to

employees to help address chronic diseases and related risk factors

(e.g., poor nutrition, physical inactivity, hypertension, high cholesterol,

elevated blood sugar levels, tobacco use and exposure)?

2. Provide access to an onsite occupational health nurse?

3. Provide an onsite medical clinic to monitor and address chronic

diseases and related risk factors (e.g., high blood pressure, high

cholesterol, elevated blood sugar levels)?

4. Provide paid time off to attend health promotion programs or classes?

5. Provide employee insurance coverage for preventive services and

quality medical care?

6. Provide access to a free or low cost employee health risk appraisal or

health screenings?

7. Provide access to chronic disease self-management programs (e.g.,

Weight Watchers for overweight/obesity)?

8. Adopt curricula or training to raise awareness of the signs and

symptoms of heart attacks and strokes?

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9. Adopt curricula or training to raise awareness of the importance of

calling 9-1-1 immediately when someone is having a heart attack or

stroke?

10. Promote chronic disease prevention (e.g., post signs reminding

employees to get blood pressure checked, quit smoking, or avoid

secondhand smoke) to employees?

11. Adopt an emergency response plan (e.g., appropriate equipment such

as Automatic External Defibrillator, instructions for employee action)?

Leadership

To what extent does the work site:

1. Reimburse employees for preventive health or wellness activities?

2. Participate in the public policy process to highlight the need for

community changes to address chronic diseases and related risk

factors (e.g., poor nutrition, physical inactivity, tobacco use and

exposure)?

3. Have a wellness coordinator?

4. Have a wellness committee?

5. Have a health promotion budget?

6. Have a mission statement (or a written policy statement) that includes

the support of or commitment to employee health and well-being?

7. Adopt organizational or performance objectives pertaining to employee

health and well-being?

8. Provide employees with a health insurance plan?

9. Provide office-based incentives (e.g., discounted insurance premium,

gift certificates) to employees participating in health risk assessments,

initiatives, or support groups that promote chronic disease prevention

measures (e.g., quit smoking, log miles walked, obtained blood

pressure or cholesterol screening)?

10. Implement a needs assessment when planning a health promotion

program?

11. Evaluate company-sponsored health promotion programs?

12. Provide opportunities for employee feedback (e.g., employee interest,

satisfaction, adherence) about health promotion programs?

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13. Participate in community coalitions and partnerships (e.g., food policy

council, tobacco-free partnership, neighborhood safety coalition) to

address chronic diseases and related risk factors (e.g., poor nutrition,

physical inactivity, tobacco use and exposure)?

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APPENDIX C

The following are the worksheets used in this workbook.

Policy, Systems and Environmental Change Strategies Worksheet

ASSETS

NEEDS

Strategies:

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Prioritizing Strategies Worksheet

Strategy

Time

(1-5)

Resources

(1-5)

Competing

Priorities

(1-5)

Total

(T x R x C)

Rank

Community Action Plan

Policy/Environmental

Change Strategy

Project Period Objective Community Component(s)

Annual Objective(s): Sector(s) No. of People Reached

Activities Person Responsible Timeline