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Community Needs Assessment: The Resources and Examples Your Organization Needs

Free community needs assessment kit - checklist, report outline, assessment & action plan.

Addison Waters

What is a community needs assessment.

A community needs assessment is a way of collecting data and surveying stakeholders to understand gaps in community services, as well as the strengths and assets available in your community.

Whether you’re developing a new volunteer program or reviewing an existing project, it’s important to know what your community actually needs and the resources available to you. That’s where a community needs assessment comes in; it can be used to inform and improve any community development initiative.

In this article, we’ll dive into how to conduct a community needs assessment and best practices for building your program around this assessment. Plus, we’ll share valuable resources, including examples and free templates to download.  

What Are Community Needs?

Why conduct a community needs assessment, what are the benefits of a community needs assessment, when should you conduct a community needs assessment, who should be involved in the needs assessment, community needs assessment examples, define your community, identify your assets, collect community data.

• Compile a Community Needs Assessment Report

Create an Action Plan

How to compile a community needs assessment report, more examples and resources for assessing community needs.

Looking for accurate volunteer data to use in your community needs assessment? Volunteer software can help you automatically track volunteers and report on community impact. Learn more

Community Needs Assessment Defined

A community needs assessment is a systematic process of identifying the needs or gaps in service of a neighborhood, town, city, or state, as well as the resources and strengths available to meet those needs.

Charitable organizations, nonprofits, and volunteer programs like yours can analyze community needs to help guide decision-making and resource allocation while involving community members in the process.

A needs assessment requires a multi-step strategy that typically involves defining a population and gathering data based on a set of indicators.

Now that you know  what  a community needs assessment is, let’s uncover the why, when, and who of your strategy. 

Free Download

Download everything you need to write your own community needs assessment -.

• Assessment Checklist - Guide you through the process of conducting and reporting your community needs assessment
• Assessment Form - Survey community members ("participants") to help identify gaps in services based on their unique viewpoints and expertise.
• Report Outline - Follow this outline to compile your report and guide key decision-making.
• Action Plan Template - Strategize your response to the assessment findings.

The list below is some of the needs you’ll encounter  and  measure when conducting your assessment. 

But what  are  community needs, anyway?

Local community needs are gaps between the services that exist for a population and the services that  should  exist. 

Community organizations typically categorize community needs into five groups: 

• Perceived Needs - Perceived needs are gaps in services based on what individuals feel about their own needs or the needs of the community Organizations can learn about perceived needs by speaking directly to community members through avenues such as surveys, focus groups, or town meetings. 
• Expressed Needs  - A  perceived  need becomes an  expressed  need when a number of individuals take similar action. For example, a number of community families are seeking affordable local daycare services because the current services are at capacity. Be mindful of the false assumption that all people with needs always seek help.
• Normative Needs  - Normative needs are identified based on a set of agreed-upon criteria or standards. Let’s say a state-wide authority establishes the current standards for public housing; a community may identify a need for improved local public housing based on these criteria.
• Absolute Needs  - These needs are deemed universal, including those for survival. Examples of absolute needs include shelter, food, water, safety, and clothing. Many organizations and community leaders look to prioritize absolute needs over others. 
• Relative Needs  - Relative needs are identified based on equity. A relative need exists when two groups or communities with similar characteristics do not receive similar services. Students from School A who receive free lunches reported being happier at school. The program determines that School B should also receive free lunches to improve student engagement and performance.

Anybody working in a service-driven organization knows that communities can experience all types of needs, even at the same time! 

However, categorizing your community’s needs will help you understand those that are most pressing and important to your community. 

Now that we have a deeper understanding of the  types of  needs in your community, let’s get into some specifics about conducting a community needs assessment.

What is the purpose of a community needs assessment? Why should your organization or volunteer program take the time to collect data on your community?  

Need a better way to collect volunteer data? Learn more about volunteer impact reporting  

Conducting a community needs assessment will help your organization gain a deeper understanding of your community, prioritize its resources, appeal to stakeholders like your board or donors, inform new programming, and celebrate successes. 

Here’s a deeper look at each of the benefits of a community assessment:

• Understand your community more deeply. A community needs assessment will help you learn about the culture, social structure, gaps, and strengths of your community so that you can better serve its citizens.
• Prioritize programs and resources. The assessment can reveal both a community’s most pressing needs and leverageable resources so that organizations can direct funding and resources to increase return  on investment . 
• Get stakeholders on board.  Nonprofit organizations must often make the case for their programs to garner support. A community needs assessment report signals that their services and decisions are well-informed and necessary.
• Inform new programs.  Identifying community needs and assets will help you develop impactful initiatives, like your next volunteer program. Want to learn how to develop your volunteer program? Check out our guide to growing your volunteer program .
• Celebrate success . Reporting on the state of services in a community regularly can also help you  celebrate  the successes of your initiatives. 

Surveying community members and identifying needs are beneficial at any stage. Here are some of the times you may want to assess community needs:

• When planning and developing a new program or initiative 
• During your annual or periodic review of existing projects
• When given a mandate from a local government
• To justify grants, funding, and resource allocation
• To empower communities by identifying their strengths and assets 

Take the confusion out of writing a community needs assessment with our free community needs kit.

Whether you work for a government agency or manage volunteers, there are often a lot of voices in the room, especially when it comes to planning community initiatives. But uniting stakeholders will help you achieve an even greater impact than going it alone. 

Here are just some of the voices you can involve in your assessment:

• Community members experiencing the needs. These are the folks that will benefit most from the actions you take based on your needs assessment. Whether they’re residents of a neighborhood, an underserved population, or passionate caretakers of your youngest community members, they need to be at the table to address their needs in earnest.
• Your organization’s staff, board members, and supporters . It’s important that your entire team, including the board, colleagues, volunteer managers, volunteers, and donors are aware of your assessment. You’ll not only need their support, but also an array of voices and expertise. 
• Social workers and human service providers . These folks have a deep understanding and empathy for affected community members. They are willing to advocate on behalf of clients and feel connected to specific causes that support community improvement. 
• Government officials. Elected officials have significant influence and the ability to enact life-changing policies. Involving them in the process can increase buy-in from key players. 
• Influential people . Involve directors, CEOs, presidents, and other people of professional or social influence, especially if they're widely known for their positive contributions to the community.
• Subject matter experts.  In some cases, you may need to involve experts in a particular field. Let’s say your program provides green space advocacy and park maintenance. Consider tapping into the expertise of local environmental experts to understand how your public spaces can be improved.
• Businesses.  Local companies are often poised to help address community needs because they have access to a range of resources and expertise. In some cases, local businesses actually  employ  community members affected by a gap in service. 

While it’s no easy task, involving these stakeholders in your community needs assessment will help take the impact of your actions to the next level. 

Here are some examples of what a community needs assessment should look like: 

This  comprehensive needs assessment from the City of San Antonio  is one example of how  community mapping  can be used to understand a complex, city-wide need like poverty.

This United Way offers a range of  community needs assessment examples  that inform their regional initiatives, advocacy, and volunteer programs. The nonprofit even conducted a survey to understand the  impacts of COVID  on their community. 

Feeding America offers a common  community needs assessment framework and strategy  to ensure each agency evaluates its communities consistently.

Government organizations like the CDC and the U.S. Department of Health & Human Services have also developed frameworks for community needs assessments.

Now that you’ve seen what a completed community needs assessment can look like, let’s get into how to actually conduct one!

Get free resources to help you write your own community needs assessment - Download Now

Community needs assessment steps.

Assessing needs in your community is a systematic process that requires planning. 

These assessments can feel overwhelming at first, but if you follow these 5 steps, you’ll have a strong grasp of your community’s needs and strengths in no time: 

Want a free community needs assessment checklist delivered to your inbox?

The first step? Figure out the people and places that make up your community. Define your community by considering these questions:

• Population  - What is the demographic makeup of your community? Which community members are at risk? What assets do our community members offer?
• Attitudes and Values  - What do the people in your community care about? What beliefs are important to consider and respect? What are the local attitudes toward certain issues? What biases may some hold?
• Place  - How will your program address and respect the places that are important? What infrastructure exists? Is there an attribute of the location that should be addressed or improved?

Defining your community can help set the scope of your assessment by giving you a sense of who should be involved.

Your community is chock-full of helpful, knowledgeable people, important places, and useful tools. 

As part of your needs assessment, you’ll not only identify needs and challenges, but you can also uncover the resources that are already available to the community! 

Let’s examine these assets further.

What Are Community Resources?

Resources, or assets, can be anything that helps to improve the quality of life of the individuals who live in your community, from volunteers to the local library. 

Getting enough resources is one of the hardest parts of working with a service-focused organization, but don’t overlook the assets that you already have. 

These resources and assets can be:

• People . Lawmakers, volunteers, community leaders, activists, and simply anyone can be an asset to a community and your organization’s efforts. 
• Organizations and Associations . Other nonprofit organizations, local businesses, governing institutions, cultural societies, schools, and all the programs that contribute to improving the quality of life for residents are community assets. 
• Locations . Any place, building, or landscape can be a resource. Libraries, shelters, health centers, and public gardens make communities better places to live.
• Equipment and Tools . Objects like books, food, safety equipment, transportation, or free internet access are all tools that can improve people’s lives. 

Free community needs assessment tool kit

Why identify community resources.

While a community needs assessment serves to identify the challenges and gaps in services within a community, it can also help you understand unutilized or under-utilized resources and assets available to your organization and community. 

Your organization may have internal resources, such as  grants , volunteers, existing tools, and programs. But you can also leverage  external  resources to develop an effective initiative. By utilizing internal and external assets, you’ll build a more sustainable and effective infrastructure for addressing community needs.

How to Discover Assets

Start by identifying the resources that are readily available to you; this may include community organizations and individuals who already provide services or financial support to assess needs and address them. 

Then, you’ll want to identify  potential  assets. Identifying assets is fairly straightforward. We recommend gathering your team to brainstorm potential resources:

How to Identify Organizations and Associations

Gather your team to brainstorm potential partnerships with associations, organizations, and other groups. Google (or your preferred search engine) and yellow pages can help you identify relevant associations in your geographical area. Other community nonprofits and volunteer centers can offer a wealth of information and referrals.

Example A food pantry is looking to collect data on the populations most in need of free meals. So, they connect with several local ministries and homeless shelters to understand more about their clients’ needs and how to best serve them. 

How to Identify People

Local Facebook and advocacy groups, volunteer centers, faith-based organizations, universities, and neighborhood associations are made up of like-minded individuals who can offer their skills, expertise, or time. 

Example An animal shelter is looking to develop an annual 5K and 1-mile dog walk to raise funds and awareness for its spay and neuter program. The shelter must identify the assets available to it to help garner interest in the event. So, the organization leverages Facebook and other community boards to identify the organizers of local dog park meet-ups and running clubs.

How to Identify Places

What physical locations are available to your organization? How will leveraging these spaces benefit your clients? You’ll want to list the buildings, locations, and public and private spaces available to your organization. 

Example A neighborhood association wants to reduce gun violence in the area. A growing body of research suggests that changing environmental conditions that facilitate community violence is an effective strategy for improving safety. So, the association identifies public spaces and lots throughout the neighborhood that can be improved through cleaning, the addition of greenery and community gardens, and art installations created by residents of the neighborhood. 

How to Identify Equipment and Tools

Resources like computers, food donations, gardening tools, and public transportation can help you improve the quality of life for community members. 

Example An after-school mentorship program has noticed that children who lack access to computers and the internet at home fall behind in school. The organization wants to build a program that expands access to technology and the internet for families. They identify local businesses that can donate old and unused laptops. They also list the region’s libraries that offer free internet and partner with the superintendent to identify transportation options from the district’s schools to the libraries. 

How to Use Community Assets

Once you’ve identified the resources available to your organization, you want to make sure they actually get used to addressing the needs that your assessment will identify. 

Many nonprofits and volunteer programs are using an  asset-based approach to community development . This approach prioritizes the resources that already exist in the community, and helps empower its members to become agents of change. 

Community Needs Assessment Surveys and Data Collection

Your assessment should highlight the voices of those at ground level. So, what’s the best way to gather these voices? Surveys!

Interviews, focus groups, and surveys are great data collection tools that will help you understand the perceived and expressed needs of your community. 

Surveys are efficient at collecting lots of information, and they empower participants to get involved in community development. They can also provide both qualitative data (like observations, ideas, and feelings) and quantitative data (like statistics). 

Collecting Qualitative Data

Survey questions that produce qualitative data ask open-ended questions, and may look something like this:

• In what ways do you feel your community supports at-risk youth?
• What services and programs would you like your local library to provide
• What time, skills, or expertise can you offer as a community center volunteer? 
• What parks and recreation services and programs do you enjoy? Which services are relevant to you and your family? Which ones do you feel need improvement? In what ways?
• Has food insecurity affected you or your family in the past year? If so, how?

Qualitative data can provide your organization with a deeper understanding of the challenges and opportunities that exist within your community.

Collecting Quantitative Data

On the other hand, surveys can also give you quantitative data. Quantitative questions have limited answers that can be tallied (or  quantified ), giving you a quick snapshot of a topic. It’s also easier to measure, summarize, and track over time. 

Survey questions that produce quantitative data may look something like this: 

• On a scale from 1-10, how well do you feel your child is supported by public services? 1 = not supported at all, 10 = my child is given everything they need to succeed.
• In the past month, how often have you used your local library’s public services? Very often, sometimes, not very often, or never.
• How many times per month do you volunteer with the community center?
• How many parks and recreation services have you used in the past year? 
• Do you feel your neighborhood has access to enough healthy grocery options? Yes or No?

The drawback of this kind of data is that you may get a more limited understanding of an issue than if you were to learn about people’s thoughts, stories, and ideas. 

Types of Community Needs Assessment Surveys

You’ll also want to consider the type of survey that best suits your organization’s needs. Generally, there are three types of surveys:

• Case Study Surveys - These surveys collect information from a portion of a group of people that represent the voices of a larger group or community. Case studies are more in-depth and provide qualitative data and stories to help inform your assessment. They are effective in providing data on perceived needs.
• Sampled Surveys - These surveys ask a sub-group of people to answer questions that you provide. Sample surveys, when performed correctly, should reflect similar results if you would have surveyed the entire group, making sampled surveys more efficient. 
• Census Surveys - To conduct a census survey, you will distribute your questionnaires to every member of the population you’re hoping to learn about. Census surveys give you the most accurate information but will require more significant resources to conduct, especially if your population is vast. Therefore, a census survey is more effective when conducted in smaller groups, such as all parents at a particular school as opposed to all residents of a city. 

The type of survey you choose will depend on the  types of needs  you want to assess, as well as your organization’s capacity for distributing and collecting surveys.

Download a free survey template

Listening sessions and public forums.

Listening and participating in community gatherings like town meetings, PTA meetings, and other forums are a great way to learn about perspectives on local issues. In these cases, you or a member of your team will simply  listen  and record information that you feel is pertinent to your assessment. 

This type of information gathering is useful for understanding perceived and expressed needs.

Direct or Participatory Observation

Sometimes, it can be helpful to understand a need or challenge firsthand. Participatory data gathering requires your team to take part in an activity, observe a gathering, or speak to community members directly in a way that is less formal than a survey. 

You’ll need to take detailed notes, and it may help to bring a recording device with you. To collect data, visit your community’s spaces, like senior centers, shelters, and schools to observe, speak with those at the ground level, and participate in programs that already exist.

The drawback of this method is that information is subject to participant bias, as every individual may perceive an experience differently. For this reason, multiple people representing a range of backgrounds and viewpoints should participate in the data collection process. Additionally, each voice should be weighed equitably. 

Using Existing Data

Gathering quantitative data can be especially time-consuming. Luckily, there is plenty of community-based data collected by experts available to you already. You may look for statistics regarding demographics, as well as incident rates, prevalence rates, and growth over time specific to the needs that emerge. The following resources are great places to start:

• U.S. Census
• Public health data
• School district records

Many local libraries house a wealth of information specific to your community. Whether you’re looking to address graduation rates or community health, quantitative data can support qualitative findings and validate anecdotal evidence.

Community needs assessments can inform any type of community development. So, whether you’re a volunteer manager or nonprofit development officer, you’ll want to gather your team to create an  action plan  that drives your initiative forward. 

The outcomes of your assessment and resulting recommendations can usually be organized into three categories: 

Here's a free action plan template for your community needs assessment

Policy or guidance.

These are laws or policies that work to change behaviors. 

Example Through public records, a local nonprofit discovers that 80% of the district’s children under the age of 18 are food insecure. The nonprofit creates a program that campaigns to lower the household income threshold to receive free school lunches. As a result of these efforts, the school board enacts new policies and increases its lunch program budget. 

Larger System Changes

These are strategies that result in larger systemic changes to social norms, institutions, or standard practices. 

Example A survey reveals that 30% of low-income families with school-aged children aren’t aware of their children's eligibility for free school lunches. So, a local organization campaigns to target awareness and reaches out to community families, helping them to apply for benefits. 

Social, Economic, or Physical Changes

These are changes designed to influence people’s behavior. 

Example Through conversations with local pediatricians, a nonprofit after-school program learns that many of the community’s school-aged children aren’t getting enough of the nutrients they need to thrive. So, they implement a fundraising campaign that will provide children who participate in their after-school programming with healthy snack options.

The type of action you will take should be deeply rooted in the findings of your assessment. 

Your process for creating an action plan may look something like this:

• Choose the key findings you want your program to focus on. 
• Identify an intended activity or response for each key finding, all working toward addressing the need. 
• Denote a champion responsible for carrying out each activity and establish clear deadlines. 
• Determine indicators of success. Indicators of success are metrics indicating that your program has completed the activity or accomplished a goal. 

The table below is one way to organize your action plan:

A community needs assessment usually results in a community needs assessment report that summarizes data, findings, and recommendations. 

How to Organize Your Assessment Findings

Before you write your report, you’ll need to gather the data from your interviews, surveys, and observations. 

What trends and patterns do you notice? To help make sense of your data, you can organize it into the following categories:

• Strengths  - The internal strengths of your organization, team, stakeholders, and initiative. Example Your organization maintains robust community partnerships that work collaboratively to serve low-income youth.
• Challenges  - The  internal  weaknesses or threats facing your organization or team.  Example Time constraints for volunteer management staff and lack of volunteer retention strategy lead to higher turnover rates and lower return on investment. 
• Needs  - The external challenges, needs, and gaps in service that exist in the community. Your program’s mission should work to address these needs and fill gaps. Example Youth programs tend to halt after graduation; there is a lack of follow-up support for low-income women above school age.
• Opportunities  - The  external  strengths and resources in the community available (or potentially available) to your organization.  Example  Programs directed toward low-income women in similar communities experienced an increase in funding last year.

Community Needs Assessment Report Outline

After you compile your data, you’ll be able to populate a report that summarizes your method, findings, and recommendations. 

The report should include the following sections:

• Key Players : Overview of assessment participants and program partners involved.
• Methodology : Summary of the methods used to collect data. 
• Participation:  Description of the demographic and number of individuals represented in the data collected. For example,  How many individuals responded to your survey? How many focus group sessions were held? 
• Strengths and Limitations : What are the strengths of the needs assessment and its results? How are the needs assessment and its results limited? What challenges were faced during the process of conducting a needs assessment? 
• Data and Key Findings : This section will make up the bulk of your report. Discuss the gaps, strengths, and challenges discovered in the community needs assessment. Present data and case studies. What opportunities did you uncover?
• Recommendations and Next Steps:  Based on key findings, what are your recommendations for addressing community gaps and needs? How will your proposed program address these needs? What information do you want to communicate to stakeholders?

Free download

Don't forget your free community needs assessment kit.

Includes an assessment checklist, as well as everything you need to plan and complete a community needs assessment for your organization.

Check out these further resources, examples, and toolkits for planning and implementing your own needs assessment:

Additional Resources for Community Organizations

Community Asset Mapping Toolkit

Asset-Based Community Development

Community Needs Assessment Resource Guide

Steps for Conducting a Community Needs Assessment

Successful community-based organizations understand the importance of community assessment. When organizations like yours assess needs within a community, you develop a deeper understanding of what matters to its members and the improvements they want to see. Conducting a community needs assessment will highlight the strengths of your community and allow you to enact positive change.

Addison Waters is a Content Writer at Galaxy Digital, the best volunteer management software for managing, tracking, and engaging volunteers. Addison holds a Master of Creative Writing from Durham University. She lives in Massachusetts with her husband, son, and dog.

More by Addison Waters ›

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Free Download: Community Needs Assessment Questionnaire and Report Outline

Make sure you are addressing your community's most pressing needs with our community needs assessment questionnaire & report outline.

Community Needs Assessment Guide with Examples

We take a look at why community needs assessments are so important, how to conduct and analyze your findings, plus look over an example action plan.

The late nights, the stressful days, the tiny budgets and endless to-do lists are all worth it when you see the positive impact your organization makes on the community.

So what if you could leave an even bigger impact, just by doing a bit of research in advance?

A community needs assessment is a systematic review of the existing programs in the community to determine if there are any gaps.

The results of the assessment can identify where needs are not being met and may help you design a new program, or shift focus slightly so you and your volunteer team can better serve the community.

A community needs assessment is not a quick process, but it is well worth the time and effort. 

So let’s take a look at why community needs assessments are so important, how to conduct an assessment and analyze your findings, plus look over an example action plan to help you get started. 

What is a community needs assessment?

Community Needs Assessments seek to gather accurate information representative of the needs of a community. Assessments are performed prior to taking action and are used to determine current situations and identify issues for action. Needs assessments establish the essential foundation for vital planning,” according to learningtogive.org .

A finalized community needs assessment will:

• Identify the essential resources that are already available within the community.
• Identify the essential resources missing.
• Determine how best to use, develop, or obtain those resources.

What are the 3 main categories of community needs assessment?

A final outcome will usually determine that changes need to be either:

1. Policy, law or guideline changes to help change behavior.

This may mean campaigning to change laws that mean all drivers under the age of 23 must have a blood alcohol level of 0.0 at all times, in response to an increase in youth car accidents.

2. System changes that may affect social norms, institutions or standard practice

This may mean bringing in more alcohol-free drink options, increasing advertising targeting young drivers around the dangers of drink driving.

3. Environmental changes that include social, economic or physical changes designed to influence behaviors.

This may see taxi fares reduced for youths, or non profits organizing free courtesy buses home from local drinking establishments.

Why are community needs assessments important to volunteer organizations?

The usual mission of non profit volunteer organizations is to better serve the community, however communities are not a set construct. They are continually changing, from the average age of the population, the ethnic composition, unemployment rate, as well as general social, cultural, and economic changes which alter the character of a community. 

So by performing a community needs assessment, non profit organizations can effectively determine the current community needs and work towards solving them.

While in the past, non profits may not have had the experience or resources to undertake strategic planning, many are now recognizing that a little bit of planning goes a long way.

So a community needs assessment has become a key tool, alongside volunteer management software and volunteer management plans , to help non profits maximize their impact. Strategic planning can also help them stay competitive, attract more volunteers and donors, and plan effectively for the future. 

What are community needs?

Firstly, we want to explain what is ‘community needs’?

When we talk about a ‘community’ it’s easy to think of a geographical area. And while this may be the typical community that non profits operate in, there are other ways to define a community, and thus assess its specific needs: 

• Demographics, such as age, gender, race, income level, disabilities
• Places such as community center users, religious associations, schools
• Views and beliefs such as environmentalists, vegans or dog owners.

We can categorize community needs into four major categories:

• Perceived needs: Things that members of the public think they need, and may vary greatly from person to person.
• Expressed needs: These are the things that have been voiced, whether it be to a public official, on a Facebook group or at a community meeting. While they may not be universal, they are real needs.
• Absolute needs: The basics such as clean running water, power, food, safety. If any of these are lacking, they should be an absolute priority.
• Relative needs: These are the things that contribute to a more equitable society. It might be providing laptops for families without one, breakfast at schools for children who don’t eat at home, or visiting dog walkers for elderly residents.

What are examples of community needs?

Community needs and their importance vary greatly between different groups. For example, young mothers probably won’t be worried about the development of a new senior citizens center, however they would find a new playground redevelopment important.

When we’re talking specifically about the needs of a residential community, they can fit into any of the four categories above. According to the National Community Survey (The NCS) in the US, below are the top 10 needs that matter most to residents. They are ranked in order of priority.

Nearly all residents rank safety as top priority in their community. Safety doesn’t necessarily tie in with high crime rates, as things such as graffiti, messy streets, dark alleyways and news articles can all influence perceived safety.

2. Economic health

Good jobs, shops, services and restaurants all rate highly as factors relating to economic independence. However, the more of these services that are available, the higher the cost of living, so this needs to be balanced.

3. Education

No doubt one of the biggest community needs is access to quality education, for both children, adolescents, and older adults. 

4. Natural environment

As people search out clean air, water, open space and nature, communities with easy access to these natural environments are highly rated. And as remote work becomes a growing trend, we’re seeing more and more people move away from cities in search of green space - which creates new needs. 

5. Image/ reputation

People judge the quality of a community by how others view it. Therefore, residents want to see municipalities spend resources on marketing, events, streetscapes, historical attractions, and other community building programs.

6. Appearance

The presence of things such as rubbish, weeds, graffiti, construction, bad roads and other eyesores negatively affect community ratings.

7. Sense of community

Creating opportunities for locals to gather, whether it be at formal events and clubs, parks or cafes, are all big needs in the community. It’s never too late to create these places where people can connect in person.

8. Health and wellness

Across all age groups, residents want to live in places where they can live healthy lives. This includes access to good quality, healthy food, medical services, fitness centers, walking trails and other wellness centers such as swimming pools, spas and allied health services. 

9. Mobility

While mobility – walking paths, cleverly designed streets, lack of congestion and public transport – is important, it is something most people are willing to compromise on in return for safety, economic prospects and good facilities.

10. Built environment

The built environment, housing, town planning and green spaces define the quality of the community. Residents like to feel the area they live in was designed to maximize their quality of life. 

How to conduct a community needs assessment

Conducting a community needs assessment is all about getting out there and speaking to your clients, stakeholders, community partners and members.

There are many ways to consult your community, so you can choose the best processes that match your resources, time and financial situation. But first, you need to define your scope of research.

Define your scope

One of the hardest parts of a community needs assessment is narrowing your focus. If your assessment uncovers many issues in your community, you may be tempted to try to address all of them at once.

However, you will only end up spreading yourself too thin, and wearing out your team and volunteers . So it’s important to define your scope before you start a community needs assessment. This will help you focus your audience and research.

Really think about your organization's skills, mission, volunteer resources and connections  already at your disposal. For example, if your organization addresses food relief in your local area, then taking on a new project rescuing animals will not be the best use of time and resources. However, if your assessment determines that residents also struggle with loneliness, you may be able to combine food relief with social visits and coffee chats by utilizing your existing network and program. After all, many community needs are interconnected, so there may be opportunities to address other gaps without losing focus of your mission. 

Now, let’s take a look at some different research methods to find out exactly what your community needs.

Research and interviews

You can start gathering quantitative information by reading through existing government records, census data, newspaper stories, other agencies and researching on the internet. You may find some research has already been done in this area.

Also, speak to ​influential people in the area such as government officials, school records, community leaders and other non profit organizations and ask them about the important issues in the community and what they think is needed.

• Not too resource intensive
• Can be done over time
• Good background information to guide your next steps
• More problem than solution focused
• Not specific to your area

Questionnaires and surveys

Questionnaires and surveys are two data collection methods that provide a great way to collect information about your area if there isn’t any existing research available. If you have an existing database, you could email the survey to your clients and supporters, or if you are operating in a geographical area, you could deliver a letter with a link to the online survey, or hand it out at shops or markets.

It is likely that a majority of people will not respond, so hand out as many as you can to anyone who shows interest. Once you have numerous responses, you can start seeing trends in the data and you’ll get an idea about key issues. 

Designing the survey is important, and it will differ depending on your goals. If you just want to gauge general community needs, your questions will differ from a survey to gauge information about your organization.

Here are a few sample questions you might like to use:

Demographic info:

• Family status
• Income level
• What do you know about our organization?
• How would you like to see (region/organization/program) change in the next five years?
• Are there needs or gaps in our programs and services that are not being met at the moment?
• Are there any changes taking place in the community that concern you? What are they? What might be done about those changes?
• What programs do you know of that people are trying in other places that we should try in this community?
• What factors are most important to you in a community?
• Any additional comments?
• A cost-effective way to get a lot of information
• Can collect a diverse range of responses
• May not get many responses
• No opportunity to create dialogue
• May be biased results based on survey design

Focus groups

Focus groups really allow you to deep dive into the community’s needs and discuss them. The trick is to gather a wide selection of people - clients, diverse volunteers , community members, other stakeholders, so you can take them through your ideas and get valuable feedback before you make any major plans. Gaining their insight will allow you to adjust your program or operations based on feedback, as well as identifying any potential issues or gaps. 

Make sure to have a facilitator who is able to ensure the session runs smoothly, and they can move the discussion along when needed. Also bring a list of questions, topics or plans to get direct feedback on.

Focus groups do take a bit of organization, and traditionally attendees are given some sort of financial compensation for their time. You may also want to record them to go back over any great insights.

• You can invite a wide variety of people
• You can ask open-ended questions
• Get feedback before implementing changes
• Hard to organize and get people to attend
• You’ll get a lot of opinions, not facts
• Resource intensive

Hosting a community or public forum is a great way to ensure they feel part of the process, and that they have been consulted and heard. Community forums can be extremely valuable and encourage positive steps towards finding solutions that meet a need. The experience, advice, and local knowledge that you gain can be extremely effective, and hard to gain in other avenues.

It’s important to gather as many people from various backgrounds as possible, including other non profit or volunteer charity organizations who may want to address similar topics.

Have a community leader or someone from your organization lead the discussion, with roving microphones to allow the crowd to be heard.

• Great community buy-in
• You can think things through productively as a community
• A lot of work to organize
• Hard to get individual opinions
• Group-speak
• Can go off-topic

Observation

A great way to get unbiased, direct from the source qualitative data is by observing people. You may want to visit places such as aged care facilities, hospitals, schools or community centers, observing and speaking with the visitors. 

This sort of data collection will help you identify gaps or needs that even the community themselves may not even be aware of.

Make sure you ask lots of questions and participate in services and programs.

• Qualitative data
• Very useful findings
• Very individual
• Time-consuming

Analyze your findings

After you’ve collected a large amount of data, it’s time to bring together all your interviews, research, observations and survey responses and analyze it.

Start by sorting your data into groups so you can begin to identify trends and patterns in responses. You may want to use a SWOT template to help you sort out the responses. It also helps to conduct the session as a group with other team members or stakeholders. 

After brainstorming, create a final prioritized list of points in our SWOT analysis template. List the factors in each category from highest to lowest priority.

Identify any areas that appear as strengths of your community. This might be other non profit organizations who are operating in the area, services, community projects such as parks or events, school results or health outcomes. Make note of any strengths that continually pop up in the data or any that are particularly related to your cause.

Identify any gaps in the community services that are currently available. Perhaps residents are continually mentioning that there are not enough places to walk safely, or children have nowhere to play outside. Or maybe the data findings outline the lack of jobs for teenagers, or lack of maternity services for mothers. These weaknesses will help you identify gaps and guide your next steps.

Opportunities

Identify opportunities that already exist within your community that you can take advantage of as you make plans. Opportunities might include partnering with other organizations, taking learnings from similar non profits operating in other geographical areas, extending existing services, or funding schemes you can apply for.

Note down any threats or challenges that appear in the data. These are the things that could derail your plans or make it challenging to operate. This could include changes to funding, distrust in the community, lack of available volunteers, a changing population, or other external factors threatening the safety of the community.

Make a plan

The final step in the community needs assessment is to make a plan of attack.

Based on the survey results and the strengths, weaknesses, opportunities and threats identified, you should be able to identify the major community gaps and needs. 

The community needs assessment should conclude with recommendations as to what gaps your non profit organization will address. Consider how you will address them, why is your organization the best to do that, and how will you communicate with stakeholders?

It’s also important to consider how you can use your existing volunteer network to run the program, or how you will recruit more volunteers . 

A complete volunteer management plan and volunteer management software such as Rosterfy will be essential towards ensuring the new program will be effective and sustainable.

Don’t forget to communicate your new program with as many people as possible to ensure it has a successful launch. Recruit volunteers, ask existing volunteers to share with their networks, issue a press release, emails, social media announcements and at community events. The more engagement you can generate, the more reach and impact you’ll make. 

Community needs assessment example

Creating an action plan is the document that will guide your internal actions, so everyone knows exactly what needs to be done, by when, who is responsible, and what are the indicators of success.

We’ve created a community needs assessment example action plan below for a fictional non profit organization.

From their community needs assessment, they identified that the community is recording poor health outcomes in the 18-30’s age group. They found that these people, both male and female, are lacking sufficient health and fitness activities and the obesity level is rising within this group.

So the fictional non profit organization Fit4Life is launching a new service aimed at engaging this group in fun, free and accessible exercise activities.

Conducting a community needs assessment is an important tool that non profit organizations can use to identify gaps and plan services accordingly.

And while it does take a lot of time and effort to conduct a community needs assessment, you don’t need to start completely from scratch.

There are plenty of great resources out there that can help guide your research and give you the basic structure to follow. Check out these resources to help you get started:

• Australian Institute of Family Studies : This resource is for practitioners and policy makers who want to learn more about the needs assessment process or how to conduct a needs assessment.
• Community Needs assessment workbook by American CDC : This workbook effectively guides you through planning for a community needs assessment including the questions to ask, how to review and rate data, develop and prioritize strategies for improvement, and creating an action plan. It’s helpful for any non profit organization.
• Community Toolbox from Kansas University : Another great tool that will guide you through a community needs assessment as a group. Simply download and follow.
• Rural Health Information Hub : Rural communities have limited resources to address many health-related needs, so this evidence based toolkit helps frame rural health programs.

We’ve also got plenty more great resources on the Rosterfy blog . 

Keep reading more about volunteer management :

• Non profit event management: The ultimate guide for success
• How to write a volunteer job description
• 10 ways to promote volunteer diversity and inclusion

About Rosterfy

Rosterfy exists to connect communities to events and causes they are passionate about through volunteer and paid workforce management technology. Our proven end to end technology allows charities, events and organizations to recruit , register , screen , train , manage and report with ease, replacing manual processes with automations to better engage and retain your volunteers.

If you’d like to learn more about how Rosterfy can help you recruit and manage a diverse team of volunteers, why not book a demo of our product today?

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6 Community Needs Assessment-Process and Tools

Dr. Mahbub Hasan MSW, Ph.D.

• Community Needs and Resources
• Analyzing Community Problem
• Tools in Community Needs Assessment and Planning
• Sources of Information for Community Needs Assessment

Introduction

The community needs assessment is an essential task and step in community development, and the community worker should have skills in identifying community needs and community needs assessment for any community initiatives. This chapter will define key concepts and processes in community needs assessment and discuss using tools to understand needs and voices.

Material in this chapter is adapted from: Berkowitz & Wadud (2022, July 11). Developing a Plan for Assessing Local Needs and Resources .  Community ToolBox .  Licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 United States License.

1. Community Needs and Resources 

Needs are the gap between what a situation is and what it should be. Resources are those things that can be used to improve the quality of community life.

1.1 Why should you identify local needs and resources?

• To understand the environment.
• To understand public opinion.

1.2 Who benefits from identifying needs and resources?

• Those experiencing the problem.
• Service providers.
• Community leaders.
• Community workers

1.3 When you should identify needs and assets:

• You are planning to start a program.
• You are implementing an initiative.
• Efforts are being reviewed.

1.4 What are the phases of developing your plan?

• Brainstorming: developing preliminary ideas.
• Using what you already have to answer your questions.
• Finalizing questions.
• Identifying your target population.
• Deciding what methods to use.
• Deciding what is missing.
• Deciding if you have the resources to conduct a survey.

1.5 Tools for Collecting Data

• Listening sessions.
• Public forums.
• Assets mapping: One mapping method is to find a large street map of your community, with few other markings (you can probably print one out from Google Maps or some other similar site.) Then just mark with a dot, tag, or push-pin (maybe color-coded by type) the geographic location of the groups and organizations you have found.
• Needs assessments tools’  existing data . This is the research you might do to unearth the information in census and other public records, or to find information that’s been gathered by others.

Interviews and focus groups .  Open-ended questions (those which demand something more than a yes or no or other simple answer), follow-ups to interesting points, and a relaxed atmosphere that encourages people to open up are all part of most assessment interviews. A  focus group  is a specialized group interview in which group members are not told exactly what the interviewer wants to know, so that they will be more likely to give answers that aren’t influenced by what they think is wanted.

Direct, and sometimes participant, observation . Direct observation involves seeing for yourself.  Do you want to know how people use the neighborhood park on weekends? Spend a few weekends there, watching and talking to people.

Surveys . There are several different kinds of surveys, any or all of which could be  used as part of a community assessment .

1.6 Interview Tips

• Start with small talk.
• Explain your motives.
• Ask for a definition of the community.
• Follow up on leads and go on to subjects and areas you haven’t reached yet.
• Ask who else you should talk to.
• Let interviewee end the interview.
• Thank interviewee for his/her time.

2. Analyzing Community Problem

Problem can occur any moment in a community. Some of the community problem may include access to clean drinking water, child abuse and neglect,  domestic violence,   ethnic conflict, health disparities,  hunger,  lack of jobs, lack of affordable housing, poverty etc.

Criteria you may consider when identifying community problems:

• The problem occurs too frequently  (frequency )
• The problem has lasted for a while ( duration )
• The problem affects many people ( scope, or range )
• The problem is disrupting to personal or community life, and possibly intense ( severity )
• The problem deprives people of legal or moral rights ( equity )
• The issue is perceived as a problem ( perception)

Video: Issue Analysis Technique 1 Root Cause

Source: YouTube, https://youtu.be/Ej73eqhO0Wg

3. Tools in Community Needs Assessment and Planning

3.1 Identifying the focal issue with ‘Problem Tree Analysis’ technique

Source: YouTube, https://youtu.be/-j-_Y7D35H4

• Identify a problem in your community based on the community consultation. 
• Analyze the root causes of the problem. 
• What are the consequences of the problem? 

This activity will help you to understand the root causes of community problems and plan projects/actions to address them. Your project should address the root causes, which are expected to bring positive changes in the community.   

3.1 What is SWOT Analysis? Strength, Weaknesses, Opportunities, Threats

Source: YouTube, https://youtu.be/WI1qXpaAbJs

Question for Reflection:

• When should you do a SWOT analysis?

4. Sources of Information for Community Needs Assessment

Various sources can be used for writing a community needs assessment report. The preliminary information should come from your community consultation. To support issues and problems discussed in the community, you should use data from credible sources. Libraries are always a vital information source; you can visit the library in person or access various online library resources. I am providing some references for collecting information for your community needs assessment.

• Data collected from community
• Government statistics/statistics Canada.
• Neighbourhood profiles of the city or municipality.
• News stories from mainstream media
• Academic articles
• Relevant Books and publications
• Reports written by NGOs or local community agencies
• Publications of research agencies

5. Case Studies

Video 1: Community Development-Needs Assessment by ActionAid Bangladesh. 

Source: YouTube, https://youtu.be/IyCMIjFQLGc Together In Change is a video on the community needs assessment process of ActionAid, an international development agency working in over 45 countries worldwide. This 13 minutes documentary was made in 2002, which was conceptualized & coordinated by Dr. Hasan of ActionAid International. The community was located in a rural and poverty-prone area of Bangladesh. This community needs assessment video was used for recruiting sponsors from Greece, and over 600 individual sponsors were recruited within six months. Each sponsor used to donate $30/per month, which raised $216,000/year for an integrated community development project focused on land rights, women’s entrepreneurship, and children’s education.

• Who conducted the community needs assessment?
• What were the issues identified by the community? 
• What tools and processes were followed in this assessment?

Video 2: Community Development Needs Project – Scarborough North Students of Social Service Worker program of Centennial College created this video as part of their community needs assignment.

Source: YouTube, https://youtu.be/nwpGJ3OEnXs

Question for Reflection: 1. What were the process and tools  utilized by Centennial students?

Key Takeaways and Feedback 

We want to learn your key takeaways and feedback on this chapter.

Your participation is highly appreciated. It will help us to enhance the quality of Community Development Practice and connect with you to offer support. To write your feedback, please click on Your Feedback Matters .

Berkowitz, B. & Wadud, E. (2022, July 11). Section 1. Developing a Plan for Assessing Local Needs and Resources. Community ToolBox. Retrieved from https://ctb.ku.edu/en/table-of-contents/assessment/assessing-community-needs-and-resources/develop-a-plan/main

Community Development Practice: From Canadian and Global Perspectives Copyright © 2022 by Dr. Mahbub Hasan MSW, Ph.D. is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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Article contents

Community needs assessment.

• Mary Ohmer Mary Ohmer University of Pittsburgh
•  and  Emily Underwood Emily Underwood University of Pittsburgh
• https://doi.org/10.1093/acrefore/9780199975839.013.73
• Published online: 11 June 2013
• This version: 23 March 2022
• Previous version

Community assessments in macro social work practice focus on identifying the needs and assets of a community that can be mobilized for community improvement and change. Macro social workers engage with residents and community members as partners in conducting and utilizing the findings from community assessments. The first section describes the values and principles underlying community assessments. This is followed by a discussion of approaches for conducting community assessments. The overall approach to community assessment discusses the shift in community assessment from focusing mainly on needs and deficits to understanding both community assets and needs. Two specific approaches to community assessment are then described in greater detail, including the consensus organizing approach to conducting a community analysis and the asset-based community development approach to conducting asset mapping. This section is following by an overview of the key methods for collecting and reporting data for a community assessment.

• internal resources
• external resources
• community capacities
• consensus organizing
• asset-based community development (ABCD)
• community practice
• community research
• macro social work

Updated in this version

Content and references updated for the Encyclopedia of Macro Social Work.

Community Assessment Values and Principles

In the field of social work, conducting a community assessment can be a valuable exercise in creating positive impacts for both individuals and their communities. The information that is gathered from a community assessment can be used to address important issues in subsystems including the physical environment, social services, healthcare, education, transportation, and education, while also improving community coping and problem solving (Beverly et al., 2005 ). Community assessments of this nature incorporate many of the values of the social work profession including service, social justice, the importance of human relationships, integrity, and competence (NASW, 2017 ). This approach to community assessment allows community members to participate in decision-making processes around issues related to economic opportunity, resources, social supports, and policy making. At the same time, community assessments can also enhance current relationships and efforts to address these types of issues in targeted communities. Community assessments can also serve as a method for analyzing current systems and as the basis for strategic planning and developing interventions (Beverly et al., 2005 ). Community assessments are inclusive approaches to macro social work because they take into consideration both individual and communal experiences and knowledge in order to empower communities and enhance community outcomes.

Approaches for Conducting Community Assessments

Overall framework.

Community assessments help social workers identify the needs and the resources in a community that can be mobilized to improve quality of life. While social workers historically have focused more on identifying the “needs” of the community in a general sense, we have shifted over time to understanding the needs from the perspective of community residents, stakeholders, and others impacted by specific issues. Furthermore, instead of focusing only on deficits, the lens has widened to identify and include community assets or resources that can be leveraged to create change. This change was partly a result of social work scholars and organizers called on social workers and others in the helping professions to change their ways. Specifically, Specht and Courtney ( 1994 ) in their book, Unfaithful Angels: How Social Work Has Abandoned Its Mission , criticized social workers for focusing too much on peoples’ “needs” and “problems” and for using mostly clinical and psychotherapeutic interventions to address the needs of mainly white, middle-class people. They called on social workers to become partners with communities to address systemic change through social justice and community-level interventions with underserved and disenfranchised people. Around the same time, Kretzmann and McKnight ( 1993 ) argued that the negative images often produced by focusing only on needs creates a map of the community that is often perceived as the whole truth; however, these images are only part of the truth about the actual conditions of a troubled community. Assessing only needs creates an incomplete picture of a community that leads to problem-focused solutions instead of solutions that leverage the assets and strengths of the community (Kretzmann & McKnight, 1993 ). The former approach takes the power away from the community, wherein they see themselves as having special needs that can only be addressed by outsiders with professional expertise to deal with their problems. Kretzmann and McKnight ( 1993 ) argue for an alternative path that focuses on community strengths and assets that leads to policies, solutions, and interventions that focus on the capacities, skills, and assets of lower-income people and their neighborhoods. Table 1 summarizes and compares the differences between traditional needs assessments that focus more on problems and community assessments that examine assets and needs.

Table 1. Comparing Needs Assessments to Community Needs and Resources Assessments

Source : Adapted from Ohmer and DeMasi ( 2009 ).

According to the Community Toolbox ( n.d. ), needs are the things that are missing or the gap between what a community is and what it wants to become. Needs can be concrete things needed by people, groups, or the entire community, such as clean water or fresh produce; or they can be social needs like more participation in local organizations or political needs such as increased voter registration. Community resources or assets are the people, organizations, institutions, physical assets, and relationships that can be leveraged to improve communities (Community Toolbox, n.d. ; Ohmer & DeMasi, 2009 ). Community resources include the capacities and skills of people, the things that are working and creating quality of life, strong social connections, community wealth, and effective local organizations (Community Toolbox, n.d. ; Homan, 2016 ; Ohmer & DeMasi, 2009 ). Resources or assets can include individuals, organizations and institutions, buildings, landscapes, equipment—anything that can be used to improve the quality of life (Community Toolbox, n.d. ).

Several arguments can be made for focusing on both needs and resources, including two in particular. First, this approach allows for a deeper understanding of the community, including the community’s unique history, culture, social relationships, political and economic structures, as well as conflicts and sources of tension and disagreement. Understanding how the community works is key to developing strategies for community change. Second, community residents and stakeholders are encouraged to understand their own strengths and how to leverage them to address their needs. This is an empowering approach that builds more sustainable community capacity. Third, the process more easily allows residents and key stakeholders to develop priorities as well as realistic action plans for program or system improvements (Community Toolbox, n.d. ; Ohmer & DeMasi, 2009 ). Two specific approaches for community assessments, the consensus organizing approach and asset-based community development , represent the overall frameworks discussed in this section.

The Consensus Organizing Approach to Assessment: The Community Analysis

Low-income communities have been surveyed and studied over the years by outside agencies and government (Ohmer & DeMasi, 2009 ). Sometimes residents are part of the process, but many other times they are not. Needs assessments can be important tools to identify issues in communities, but they too often focus on community weaknesses versus strengths. Community needs assessments and surveys may also be used by agencies to support or justify the status quo and their programs, or demonstrate needs so that the agency can secure funding (e.g., a survey that shows a high incidence of domestic abuse in a community, which is then used by an agency to get funding for domestic violence programs).

Consensus organizing focuses on facilitating trusting relationships among residents and between residents and external resources based on mutual interests and values. This process leads to enhancing the community’s bonding and bridging social capital and their capacity to address some of their most difficult problems (Eichler, 2007 ; Ohmer & DeMasi, 2009 ). Consensus organizing has been used over the past 40 years to facilitate resident-driven initiatives to advance social justice and equity around a range of community issues, including equitable development and violence prevention (Beck et al., 2012 ; Brown & Stalker, 2020 ; Eichler, 2007 ; Ohmer, 2016 , 2020 ; Ohmer & DeMasi, 2009 ; Ohmer & Owens, 2013 ). Macro social workers using consensus organizing implement an in-depth community analysis to find out “how a community works” and to build relationships with and engage residents and other community stakeholders (Ohmer & DeMasi, 2009 ). Some of the most important components of this type of community analysis are identifying people in the community and finding out their self-interest—that is, what they care about and what kinds of community problem-solving efforts they might be motivated to get involved in. One of the distinguishing characteristics about that community analysis is that both internal resources and external resources are assessed, focusing not only on the assets and potential contributions of community residents and stakeholders but also on the potential assets and contributions of external stakeholders and resources. In other words, the assessment uses a parallel process to leverage resources and assets inside and outside the community to address community-identified needs and issues (Ohmer & DeMasi, 2009 ). While many needs assessments are directed by outside agencies, consensus organizing flips this approach by empowering residents to identify their owns needs and assets and by matching residents with outside resources who also care about and have a self-interest to address similar issues. Needs assessments and other kinds of surveys and analyses can be valuable tools to understand a community; however, in consensus organizing, these tools are developed and implemented with the community (Ohmer & DeMasi, 2009 ).

The community analysis has three major components: (a) understanding a neighborhood’s history, culture, characteristics, strengths and demographics; (b) understanding and building relationships with the internal resources in a neighborhood, that is, the people who live, work, provide services, and operate businesses there; and (c) identifying, understanding and building relationships with external resources, that is, the businesses, government officials, institutions, and philanthropists that can contribute to community change that is directed by the community (Ohmer & DeMasi, 2009 ). These components are explained in Table 2 .

Table 2. Steps in Conducting a Community Analysis

Asset-based community development.

Asset-based community development (ABCD) is a method for understanding a community that requires participation of the community’s residents. The focus of this type of assessment is to “empower communities to identify and address their own problems through the assets that are available to them” (Blickem et al., 2018 , p. 2). Kretzmann and McKnight ( 1996 ) developed this alternative strength-based method of assessment in response to the more traditional models which focus on identification of community deficits. The goal of ABCD is capacity building based on existing resources and individual strengths (Kretzmann & McKnight, 1996 ). This shift in perspective can make a significant difference in the resources needed to address community issues as well as the efficiency by which they are utilized. Moreover, this approach reaffirms the work that is already being done in neighborhoods (Kretzmann & McKnight, 1996 ). Through its primary method of asset mapping, ABCD places an emphasis on creating sustainable networks through person-centeredness and relationship building and “aiding the process of translation of experiential knowledge into a communally available resource” (Harrison et al., 2019 , p. 4).

According to its creators, asset-based community development process relies on the following characteristics:

Community development strategy starts with what is present in the community, the capacities of its residents and workers, the associational and institutional base of the area—not with what is absent, or with what is problematic, or with what the community needs. Development strategy concentrates, first of all, upon the agenda building and problem-solving capacities of local residents, local associations, and local institutions. One of the central challenges for asset-based community developers is to constantly build and rebuild the relationships between and among local residents, local associations, and local institutions. (Kretzmann & McKnight, 1996 , p. 27)

With these characteristics ideas in mind, ABCD draws upon psychological and social theories in determining the criteria which define “assets” and for categorizing the assets into three levels: (a) primary building blocks or personal assets (includes motivation and self-efficacy); (b) secondary building blocks/collective assets (e.g., parks, libraries, grocery stores), and (c) potential building blocks, or assets which originate and are controlled external to the community (e.g., social welfare access) (Harrison et al., 2019 ). Additionally, social capital, such as connectedness, social networks, and reciprocity are all important considerations to be included in the asset map. Putnam ( 1993 ) defines social capital as a form of social organization that includes trust, norms, and networks that can improve the efficiency of society by facilitating coordinated actions. Putnam ( 2000 ) later characterized social capital in two ways: bonding social capital, which is based on relationships of mutual trust found between neighbors; and bridging social capital, which is based on connections between residents and individuals and organizations external to the neighborhood. Both of these forms of social capital are important to include when assessing community assets and strengths.

Asset maps can be created using multiple strategies, including engaging community members around a map, conducting focus groups or interviews with individuals or stakeholders to identify and locate assets, or simply taking a walk around the community being assessed (Mosavel et al., 2018 ). Asset mapping can be an effective way to facilitate participation and efficacy within communities. Processes such as identification of visible assets, noticing patterns of interactions among those assets, as well as the accessibility of assets can make valuable contributions to developing a community asset map (Mosavel et al., 2018 ). Once assets have been identified, they can be categorized and used to build connections that multiply their power and effectiveness, while also targeting institutions that are not yet being utilized to bolster efforts (Kretzmann & McKnight, 1996 ).

It should also be noted that ABCD offers the additional strength in its inclusivity, and its emphasis on the perspectives of nonspecialists, including youth, seniors, and the differently abled (Blickem et al., 2018 ). The analysis of asset maps can offer keen insight into issues such as access to food and transportation, opportunities for greenspace transformation and improved health outcomes, and other issues that communities might seek to enhance. Figure 1 provides a template to use when conducting an observational asset assessment by walking throughout the neighborhood.

Figure 1. Template to identify assets identified through a community walk.

Methods for Conducting Community Assessments

Data collection methods.

The Community Toolbox ( n.d. ) and Ohmer and DeMasi ( 2009 ) identify multiple methods for collecting data for Community Assessments, including: (a) using existing data (census data, public records, existing reports of information gathered by other organizations, websites, etc.); (b) one-on-one meetings and interviews with key stakeholders, and informal and formal leaders (people respected in their communities); (c) small focus groups or listening sessions to learn about the community and their perspectives on issues, resources, assets, barriers, and solutions, including what has worked and not worked in the past); (d) direct observation of the community (e.g., walking and/or windshield surveys; Google street view) and/or participant observation (e.g., participating in a community meeting, attending a community event, spending time in local parks, or going to a local coffee shop); (e) surveys (e.g., written surveys, online surveys; in person or via email, text, phone, etc.); (f) asset maps focusing on community resources and strengths (e.g., these are like the maps conducted when using asset-based community development approaches). Sometimes these maps have already been developed by the local community, so check with your community partner to see if they have already created an asset map (see, for example, an asset map for Pittsburgh where you can learn about the assets in specific communities and neighborhoods); (g) public forums and town hall meetings where information can be shared about the results from a community assessment, as well as to get feedback and ideas. These types of forums are typically larger meetings with residents and key stakeholders organized by local organizations or by your organization in collaboration with already identified community partners.

Dissemination and Action

When producing reports of community assessments, it is crucial to keep the audience in mind. Some reports may be utilized in an academic setting, and alternatively or additionally, results of the assessment are presented to nonacademic laypersons. In general, reports should be written at a high-school reading level, free from jargon, acronyms, or other technical language (Royse et al., 2009 ). While passive voice is often used with academic writing, using an active voice may be preferable in creating a community assessment report that is an engaging narrative for the audience. Active voice is generally shorter than passive voice; for example, “Over 100 residents attended the community forum” versus “the community forum was attended by over 100 residents.” It is also necessary to consider the purposes of both the community assessment and the report in mind when creating a summary. Is this a document that will be shared with the public, or kept for internal organizational use? Will it be used for making programming and resource decisions, or will it be used to present the outcomes objectively so that the reader can draw their own conclusions? The answers to these questions are better discussed earlier in the process. These will provide guidance as to how the report should be designed and the type of information that should be highlighted.

As a rule of thumb, the outcomes report should contain four sections: the introduction, the methodology, the findings, and a summary (Royse et al., 2009 ). The introduction explains the purpose of the assessment and relevant background information about the issues or subjects of interest that led to the assessment and what the community participants hope to learn. After reading this section, the audience should be able to understand the purpose and rationale for the assessment. The methodology section is the opportunity for the writer to explain processes like how participants were recruited, an overview of any survey instruments that were used, and information such as the number of participants and how those participants are representative of the larger population (Royse et al., 2009 ). The findings/results section is arguably the most critical part of disseminating the assessment findings. Again, it is important to keep in mind the purpose of the project and whether it is the job of the writer/organizer to make recommendations or to report the data as objectively as possible. This portion of the reporting should focus on the objectives of the project rather than a detailed description of every finding. Responsible researchers should also include project limitations or any issues that occurred during the assessment, both for the purposes of sustainability and replicability, as well as transparency and ethical research. The summary is basically an abstract that provides a snapshot of the project and highlights key findings and recommendations. One suggestion is to keep the full report brief, using the appendices for more detailed descriptions of the data and results. In addition to a comprehensive report, a brief executive summary and/or an infographic would be helpful for dissemination to a wider audience.

Community assessments and the resulting report can be used to develop action plans for addressing community issues. For example, a consensus organizer builds on the relationships developed through the community analysis to engage a core group of residents in developing an action plan and designing and implementing win-win projects (Ohmer & DeMasi, 2009 ). Action plans should include the overall goals for improving the neighborhood and specific objectives and projects related to each goal. Successful action plans typically have four major ingredients: (a) community support and buy-in, (b) real and tangible roles for residents and stakeholders, (c) criteria to evaluate progress, and (d) internal and external resources engaged and invested in the community.

Win-win projects feasibly and quickly address one or more of the key goals and priorities in the action plan in ways that will garner widespread community support, engage the self and mutual interests of residents and external stakeholders, and tangibly and visibly illustrate the community’s strengths and progress toward their overall goals. Action plans and win-win projects should be used to build partnerships based on mutual self-interests that can be sustained over a long period of time. Consensus organizers employ two key principles for building and sustaining partnerships (Ohmer & DeMasi, 2009 ). First, self-determination is key to community organizing but also to macro social work practice. Essentially, self-determination means that those most affected by problems should lead efforts in finding solutions. The second principle is contribution, which means that macro practitioners should engage a broad base of people to participate and contribute to devising solutions to problems. These strategies and principles are key to building on community assessments to strengthen community capacity and sustainable and positive neighborhood change.

Throughout the community assessment process, it is important to understand that conflicts and sources of tension can exist in communities despite the ability to find common ground on some issues. Therefore, it is important to anticipate and build in time for disagreements among residents and between residents and key stakeholders, individually or as a group. Disagreements can also occur between residents and macro social work professionals who may be assisting with the assessment process. It is important to discuss with the organizational leaders in advance how to handle differences and potential conflicts. For example, ownership issues can occur about who has access to and/or who owns the data gathered during a community assessment. If this is a potential problem, then a data sharing agreement of some kind could be developed as part of the initial steps in the community assessment process to clarify questions or concerns about data access and ownership. Understanding potential sources of conflict and working with community partners and organizational leaders in advance to develop ways to address these conflicts is also key to a successful community assessment process.

Community assessments are important tools for macro social workers to use to engage community residents and stakeholders, as well as external stakeholders, to identify the community assets, strengths, and capacities necessary for addressing community problems and fostering sustainable community change efforts. Social workers have been criticized in the past for focusing too much on the needs and deficits in the community at the expense of community assets or resources. Too often needs assessments are conducted in a top-down fashion and are used to raise resources for agency programs and initiatives. Macro social workers now have extensive tools and resources to conduct community assessments that provide a more comprehensive picture of a community that can be used to create action plans and raise and leverage resources both inside and outside the community. There are also extensive resources available for social work educators on ways to incorporate macro content into the curriculum, including methods for conducting community assessments. For example, the Council on Social Work Education’s ( 2018 ) Specialized Practice Curricular Guide for Macro Practice is a resource that provides examples of macro content related to the CSWE competencies, including readings and course assignments. Understanding how to conduct a community assessment is clearly important for macro social work students, but it is also important for students in clinical MSW programs, as well as BSW programs. All social workers need to be prepared to conduct community assessments that genuinely engage the community, build on their strengths, and promote community change.

• Beck, E. , Ohmer, M. L. , & Warner, B. (2012). Strategies for preventing neighborhood violence: Toward bringing collective efficacy practice into social work. Journal of Community Practice , 20 (3), 225–240.
• Beverly, C. J. , Mcatee, R. , Costello, J. , Cheroff, R. , & Casteel, J. (2005). Needs assessment of rural communities: A focus on older adults. Journal of Community Health , 30 (3), 197–212.
• Blickem, C. , Dawson, S. , Kirk, S. , Vassilev, I. , Mathieson, A. , Harrison, R. , Bower, P. , & Lamb, J. (2018). What is asset-based community development and how might it improve the health of people living with long-term conditions? A realist synthesis. SAGE Open , 8 (3).
• Brown, M. E. , & Stalker, K. (2020). Consensus organizing and CBPR to address social-structural disparities and promote health equity: The Hope Zone case study. Family and Community Health , 43 (3), 213–220.
• Community Toolbox . (n.d.). Section 1: Developing a plan for assessing local needs and resources .
• Council on Social Work Education . (2018). Specialized practice curricular guide for macro social work practice . Council on Social Work Education.
• Eichler, M. (2007). Consensus organizing: Building communities of mutual self-interest . SAGE.
• Harrison, R. , Blickem, C. , Lamb, J. , Kirk, S. , & Vassilev, I. (2019). Asset-based community development: Narratives, practice, and conditions of possibility—a qualitative study with community practitioners. SAGE Open , 1 (11).
• Homan, M. S. (2016). Promoting community change: Making it happen in the real world (6th ed.). Brooks/Cole.
• Kretzmann, J. , & McKnight, J. P. (1993). Building communities from the inside out: A path toward finding and mobilizing a community’s assets . Institute for Policy Research.
• Kretzmann, J. , & McKnight, J. P. (1996). Assets-based community development. National Civic Review , 85 (4), 23–29.
• Mosavel, M. , Gough, M. Z. , & Ferrell, D. (2018). Using asset mapping to engage youth in community-based participatory research: The We project. Progress in Community Health Partnerships: Research, Education, and Action , 12 (2), 223–236.
• National Association of Social Workers (NASW) . (2017). Code of Ethics .
• Ohmer, M. L. (2016). Strategies for preventing youth violence: Facilitating collective efficacy among youth and adults. Journal of the Society for Social Work and Research , 7 (4), 681–705.
• Ohmer, M. L. (2020, August 24). Youth-adult partnerships to prevent violence . Journal of Intergenerational Relationships , 1–20. Advanced online publication.
• Ohmer, M. L. , & DeMasi, K. (2009). Consensus organizing: A community development workbook: A comprehensive guide to designing, implementing, and evaluating community change initiatives . SAGE.
• Ohmer, M. L. , & Owens, J. (2013). Using photovoice to empower youth and adults to prevent crime. Journal of Community Practice , 21 (4), 410–433.
• Putnam, R. D. (1993). What makes democracy work? National Civic Review , 82 (2), 101–107.
• Putnam, R. D. (2000). Bowling alone: The collapse and revival of American community . Simon & Schuster.
• Royse, D. , Staton-Tindall, M. , Badger, K. , & Webster, J. M. (2009). Needs assessment . Oxford University Press.
• Specht, H. , & Courtney, M. H. (1994). Unfaithful angels: How social work has abandoned its mission . Free Press.

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Seven Steps for Conducting a Successful Needs Assessment

When launching a public health program, one of the first things to do is conduct a needs assessment. A needs assessment helps you determine what needs to be accomplished to reach your project goals . This assessment of needs then informs a project’s overall plan and approaches by helping you identify targeted strategies and prioritize resources.

Needs assessments serve as incredibly powerful tools for decision making, resource allocation, and ultimately reaching programmatic goals. They can be utilized across a range of settings (e.g., community, school, hospital, state) to shed light on a variety of topics, such as what programmatic actions should be taken to improve breastfeeding rates in a hospital or increase kindergarten readiness across a state. It's important to conduct needs assessment at the onset of the project, so that programs are appropriately tailored to the individuals and communities you serve.

Not sure where to begin? To help you get started, we've compiled the seven tips below. Following them will ensure that your needs assessment planning, analysis, and subsequent actions are efficient and effective.

Step one: Clearly define your needs assessment objectives

When defining your objectives, ask yourself: Why are you conducting the needs assessment and what do you plan to do with the findings? For example, if you are working on a program seeking to increase breastfeeding initiation among first-time mothers in a community, your needs assessment objectives may include:

• Understand breastfeeding knowledge and intentions of first-time mothers in your community
• Understand perceived assets and barriers to breastfeeding among first-time mothers in your community
• Assess assets and barriers related to the provision of breastfeeding support in local hospitals and after discharge
• Determine necessary training and supports to increase breastfeeding among first-time mothers in your community

Concretely identifying a few, key objectives at the onset will help you identify your needs assessment activities—including who to collect data from and what questions to ask. The objectives in the breastfeeding example show that the needs assessment should collect data from first-time mothers as well as from health care providers and, possibly, lactation consultants and social service providers in the community. The objectives also suggest that survey and/or focus group questions should target topics including, but not limited to, knowledge, intentions, assets, and barriers related to breastfeeding.

Step two: Be realistic about your resources and capacity

Consider how much time, money and staff capacity you can devote to the needs assessment. For example, do you need to assess the current state of your program and implement changes within three months, or do you have an entire year to examine your program’s landscape? Also, how many staff are working on the project and what percentage of their time are they devoting to the project? The availability of resources will greatly impact the needs assessment activities you are able to conduct.  If a needs assessment must be conducted quickly and/or with few staff resources, a simple online survey to key stakeholders serves as a powerful (and often free!) tool to collect data critical to informing programmatic efforts. Teams can also tap into secondary publicly available data, such as the National Survey of Children’s Health or the CDC WONDER databases. 

Step three: Identify target audiences and data sources

Given your objectives and resources, consider the target audiences and data sources that will help you assess your needs. Is it most effective to administer a survey to a wide range of community members, to hold several focus groups with hospital administrators, examine existing reports, or directly observe project participants? Sometimes you’ll need to conduct several, complementary needs assessment activities to collect data for a range of stakeholders.

Consider, also, the competing priorities of your target audience and how to encourage them to participate in your needs assessment. If sending surveys, include an introductory sentence that shows your appreciation and why the survey responses matter, and be prepared to send multiple reminders to increase response rates. If conducting focus groups, be gracious and consider providing snacks, water, or other incentives to participants to thank them for their time and contributions. Helpful new tools can also increase participation. Photovoice is a tool that helps people use videos and photos to share their environment and experiences with others, which can then inform the needs assessment. This tool can be especially powerful for engaging communities that may have been less likely to participate due to language barriers, poverty, or other social determinants.

Step four: Think small and big when summarizing results

You’ve collected the necessary data to achieve your needs assessment objectives. Now, it’s time to dig into that data. Try to summarize and reflect on data for each of your needs assessment objectives individually. Depending on the nature of your data, you may want to develop graphs, tables, and other visuals to display data as well as a narrative describing results.

Then, take a step back, and think about cross-cutting themes that may apply to multiple needs assessment activities, which may help inform priorities for action. For example, in the breastfeeding program example, was there a salient theme, perhaps a barrier to breastfeeding initiation, that emerged when collecting insights from first-time mothers, health care providers, and other social service providers? If so, highlight this finding and ensure recommendations address this cross-cutting theme.

Step five: Get feedback

While developing the needs assessment deliverable, whether it is a formal report, peer-reviewed manuscript or presentation, discuss results with a diverse and inclusive audience—including community members, colleagues, funders, project partners and other target audiences—who may interpret your needs assessment results differently and identify unique recommendations. From an equity standpoint, it is especially important to engage community members as equal partners in understanding and translating results from the needs assessment. This ensures that the people most affected by the program will have power in determining its design.

Step six: Disseminate

You’ve done the work, now share your findings internally and externally. This helps ensure that all project stakeholders are on the same page regarding project priorities and resource allocation. Present your findings at community events, professional conferences and other relevant venues. Your efforts may inform and inspire other public health programs working on similar initiatives, and feedback from others can help you move your work to the next level.

Step seven: Take action

At the conclusion of the needs assessment process, review your original objectives with the final results and recommendations. Doing so will highlight what steps are needed to achieve your goals—whether that’s addressing gaps in knowledge or building capacity among project participants. Then, most importantly, take action and use those findings to develop your project approaches. To ensure that your needs assessment learnings come to fruition, consider developing a workplan that outlines key approaches and strategies, and identifies a team lead and deadline for each

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Chapter 16 Community Assessment

16.1. introduction, learning objectives.

• Describe the characteristics of a healthy community
• Outline the roles of community health nurses and key community settings where they have an interprofessional role in health care services
• Explain resources and tools to use for community health needs assessments
• Apply the nursing process to community health nursing
• Define categories of preventative nursing interventions
• Explain how community resources help support the health needs of the members of the community

Most of your nursing education journey has likely focused on caring for clients in hospitals and long-term care settings. However, nurses also serve important roles in promoting the health and wellness of communities. Throughout history, nurses have served in public health roles and collaborated with community organizations to support health services. Florence Nightingale, the founder of modern nursing, advocated for two foundational components of community health nursing: health promotion and disease prevention. [ 1 ] Examples of current community health initiatives include public educational health sessions, blood pressure screenings, immunization clinics, and crisis intervention related to mental health care. See Figure 16.1 [ 2 ] for an image of a community blood pressure screening.

Figure 16.1

Community Health Screening

In recent years community health nursing has become increasingly important for several reasons:

• There are currently shorter hospital stays and decreasing hospital readmission rates.
• As the average age of the United States population increases, the need for community health services in members’ homes increases.
• As the ability to successfully manage chronic conditions (including both physical and mental illness) improves, the need for outpatient health services also increases.
• As the usage of telehealth and virtual medical care expands, so does the need for community member support and patient education.

This chapter will introduce the roles of community health nurses, explore community health needs assessments, and discuss how nurses collaborate with community resources to support clients’ physical and mental health care needs.

16.2. COMMUNITY HEALTH CONCEPTS

Community health nursing.

Nurses working in a community setting include public health nurses, school nurses, and parish nurses, to name a few.

Public health nurses  work across various settings in the community such as government agencies, community-based centers, shelters, and vaccine distribution sites. They provide disease prevention and health promotion services, such as working with mothers and children to improve nutrition, operating immunization clinics, and leading public health education initiatives such as smoking cessation campaigns. Public health nurses also prepare to respond quickly to public health emergencies such as natural disasters or epidemics. [ 1 ],[ 2 ] Emergency preparedness is further discussed in the “ Environmental Health and Emergency Preparedness ” chapter. See Figure 16.2 [ 3 ] for an image of a community health nurse providing health screenings in a maternal and child health clinic.

Figure 16.2

Health Screenings

School nurses  work with over 56 million school-age children and adolescents. They provide direct care for chronic health problems and administer medications prescribed during school hours. They also provide mental health care, a need that has grown during the COVID-pandemic. Their work also affects the larger community. For example, school nurses may help develop disaster plans that coordinate activities in the school with the larger neighborhood. [ 4 ],[ 5 ]

Parish nurses  use their nursing skills for church or parish members in paid or volunteer positions. They provide health education, screening, advocacy, and referrals to other services in the community. [ 6 ]

Barriers for Community Health Nurses

Community health nurses serve important roles in identifying priority health needs of a community, as well as planning and implementing preventative health initiatives. However, community health nurses may face unique barriers when providing care to individuals, families, and community members. Three barriers are referred to as gaining entry, role negotiation, and confidentiality:

• Gaining Entry:  Community health nurses may be considered “outsiders” as representatives of the established health care system and may not necessarily be trusted by community members. It is vital for community health nurses to build trust and supportive relationships. When working with individuals and families, nurses should assess specific community issues affecting that individual’s health or their access to health care and then address those issues in their nursing care plan. Nurses can also investigate if there are community resources available to refer the client and/or their family members for additional services. See Figure 16.3 [ 7 ] for an image of Red Cross volunteers working with caregivers of clients receiving palliative care.
• Role Negotiation and Confidentiality:  Community health nurses must separate their roles as data collectors, health professionals, and neighbors. These roles can be difficult to differentiate when the nurse is assessing community health needs and providing nursing interventions for a population of individuals within their own home community. These individuals may include family members, friends, neighbors, or peers. Trust must be established and confidentiality assured according to legal and ethical parameters of nursing practice. Nurses should also establish a sense of partnership and encourage clients to participate in planning preventative health strategies for themselves and their families.

Figure 16.3

Setting Up Support Groups for Caregivers

Community Health

Community health nursing is based on several underlying concepts such as encouraging healthy living, preventing illness, promoting rehabilitation, evaluating the effectiveness of community resources, and advocating for improved overall community health. [ 8 ],[ 9 ] In this manner, community health nurses pursue health equity.  Health equity  means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing potential obstacles to obtaining and maintaining optimal health such as lack of access to health care services, good jobs with fair pay, quality education and housing, and safe environments. [ 10 ] Community health nurses address these conditions that are also known as social determinants of health.

Social determinants of health (SDOH)  are the conditions in which people are born, grow, work, live, and age. Research shows that the SDOH can be more important than health care or lifestyle choices in influencing health and account for 30-55% of health outcomes. [ 11 ] See an illustration of SDOH in Figure 16.4 . [ 12 ] SDOH can contribute to  health inequities , defined as avoidable differences in health status seen within and between communities. In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health. According to the World Health Organization, SDOH can influence health equity in positive and negative ways [ 13 ]:

Figure 16.4

• Social Determinants of Health
• Income and social protection
• Unemployment and job insecurity
• Working life conditions
• Food insecurity
• Housing, basic amenities, and the environment
• Early childhood development
• Social inclusion and nondiscrimination
• Structural conflict
• Access to affordable health services of decent quality

Health disparities  are health differences that are linked with social, economic, and/or environmental disadvantages. Health disparities adversely affect groups of people who often experience greater obstacles to health based on individual characteristics such as socioeconomic status, age, gender, culture, religion, mental illness, disability, sexual orientation, or gender identity. [ 14 ] These groups are often referred to as “vulnerable groups,” and their care is further discussed in the “ Vulnerable Populations ” chapter.

As community health nurses strive to promote health equity, they assess SDOH, health disparities, and health inequities that are present in communities. They often begin by analyzing the context of the community because these characteristics can affect how community members respond to public health initiatives. The context of a community includes the following factors:

• For example, is this a rural community that requires long-distance transportation to health care services?
• For example, are there buses or ride share services available for members to reach health care services?
• For example, is there an area of the community located next to a factory contributing to air pollution?
• For example, is there an area where it is common for several multi-generation family members to live together in one residence?
• For example, do public parks commemorate war veterans?
• For example, what relationships do the school board members have with community members?
• For example, does the community have a tradition of celebrating Memorial Day with a parade and public tributes at a local cemetery?
• For example, is there a YMCA or other services in the community that promote physical activities for youth and other members of the community?
• For example, is there an urgent care clinic in this community that can be accessed by bus service?
• For example, is this a working class community whose members primarily work in a few local factories?
• For example, how does the mayor of this city communicate with members of the community?
• For example, is there a town board that meets regularly and collaboratively makes decisions affecting planning and zoning of the community?
• For example, is it assumed in this community that neighbors will help clean up the neighborhood after storm damage occurs to several homes?

According to the CDC, a  healthy community  is one in which local groups from all parts of the community work together to prevent disease and make healthy living options accessible. Working at the community level to promote healthy living brings the greatest health benefits to the greatest number of people. It also helps to reduce health gaps caused by differences in income, education, race and ethnicity, location, and other factors that can affect health. [ 15 ]

Community Health Needs Assessment

Community health needs assessment  is a systematic process to identify and analyze community health needs and assets in order to prioritize these needs, plan, and act upon significant unmet community health needs. [ 16 ] A community health assessment gives nurses and community organizations comprehensive information about the community’s current health status, needs, and issues. This information can be used to develop a community health improvement plan by justifying how and where resources should be allocated to best meet community needs. [ 17 ] Community health needs assessments are performed and reported at national, state, county, and local levels.

National Health Needs Assessments

Healthy People 2030 addresses the most current national public health priorities. It is published by the United States Department of Health and Human Services Office of Disease Prevention and Promotion. See Figure 16.5 [ 18 ] for an illustration related to using Healthy People 2030 objectives and leading health indicators to assess community needs data, plan, and evaluate community health interventions.

Figure 16.5

Healthy People 2030

A set of evidence-based Healthy People objectives are published every ten years based on current national data. Objectives are classified by categories [ 19 ]:

• Health Conditions
• Health Behaviors
• Populations
• Settings and Systems

Examples of Healthy People 2030 community objectives include the following [ 20 ]:

• Increase the number of community organizations that provide preventative services
• Increase the rate of bystander CPR and AED use for nontraumatic cardiac arrests in public places
• Increase the proportion of adult stroke survivors who participate in rehabilitation services

Leading Health Indicators (LHIs) are a subset of high-priority Healthy People 2030 objectives to drive action toward improving health and well-being. Most LHIs address important factors that impact major causes of death and disease in the United States. They help organizations, communities, and community health nurses focus their resources and efforts to improve the health and well-being of all people. There are 23 LHIs that cover the life span from infants, children, adolescents, adults, and older adults. See a list of LHIs in Table 16.2 .

Leading Health Indicators Across the Life Span

Healthy People 2030 Resources

View  Healthy People 2030 Objectives ,  Community Objectives , and  Leading Health Indicators .

State Needs Assessments

States perform health needs assessments to develop state funding and program priorities for community health. For example, the Wisconsin Department of Health Services (DHS) performs a mental health and substance abuse needs assessment every other year. Data in this report includes the following:

• Prevalence of Needs:  The prevalence of disorders, conditions, and associated problems for the entire population and subpopulations
• Access to Services:  Determination of which and how many services are received by individuals and exploration of barriers to access
• Service Workforce and Capacity:  Examination of the mental health and substance use services workforce, including the number of providers of these services and the geographic dispersion of the workforce across the state

Another example of a state needs assessment related to mental health is the Behavioral Health Gaps Study funded by the Wisconsin DHS to assess gaps and needs in the behavioral health service system for individuals with mental health and substance use disorders. Key gaps documented in this study included shortages in child and geriatric psychiatrists; shortages in mental health inpatient beds and residential facilities for treating substance use; inadequacies of the medical transportation system; a need for improving crisis stabilization services in the community that focus on reducing contact with police officers; shortages in medication-assisted treatment providers and clinics; long waitlists across the service array; shortages in competent translation services; and the need to provide wraparound services, particularly for consumers with families. [ 21 ]

Explore your state’s health needs assessments. Examples of health needs assessments in the state of Wisconsin are as follows:

Department of Health Service’s  Mental Health and Substance Abuse Needs Assessment PDF

The Behavioral Health Gaps Report for the State of Wisconsin PDF  completed by University of Wisconsin-Madison Population Health Institute

County Health Rankings

County health rankings are created annually by the University of Wisconsin Population Health Institute for counties across the country. [ 22 ] These rankings provide a snapshot of a community’s health and can be used as a starting point for implementing change to promote health equity in communities. See the following box to explore the health ranking for your community.

Visit the  Explore Health Rankings  web page from the University of Wisconsin Population Health Institute to view the health ranking of your community.

Local needs assessments.

Local communities perform health needs assessments and develop specific health initiatives for their community members. For example, the Eau Claire County Health Department Needs Assessment was used to create a county health plan. In 2021 the top health priorities were documented as drug use, mental health, alcohol misuse, obesity, and healthy nutrition. See Figure 16.6 [ 23 ] with an image related to data from a county mental health needs assessment.

Figure 16.6

Mental Health Assessment

Explore your community’s health initiatives. View the example of  Eau Claire City-County Health Department Needs Assessment .

Hospitals’ community health needs assessments.

Tax-exempt hospitals are required to conduct community health needs assessments according to the Patient Protection and Affordable Care Act (i.e., the Affordable Care Act). Hospitals are required to adopt implementation strategies to meet the community health needs identified through their needs assessment. This collaboration among hospitals and community partners expands the community’s capacity to address health needs through a shared vision and creates a foundation for coordinated efforts to improve community health. [ 24 ]

View examples of hospitals’ community health needs assessments:

Mayo Clinic’s Community Health Needs Assessment PDF

Community Health Needs Assessments by HSHS Affiliated Hospitals in Wisconsin and Illinois

16.3. APPLYING THE NURSING PROCESS TO COMMUNITY HEALTH

Community health nurses apply the nursing process to address needs of individuals, families, vulnerable populations, and entire communities. See Figure 16.7 [ 1 ] for an illustration of the nursing process in community health nursing.

Figure 16.7

Nursing Process in Community Health Nursing

The community health nurse typically begins a community health needs assessment by determining what data is already available. [ 2 ]As previously discussed in the “ Community Health Concepts ” section, national, state, county, and local health needs assessments are widely available.  Secondary analysis  refers to analyzing previously collected data to determine community needs.

Community health nurses may also engage in primary data collection to better understand the community needs and/or study who may be affected by actions taken as a result of the assessment. [ 3 ]  Primary data collection  includes tools such as public forums, focus groups, interviews, windshield surveys, surveys, and participant observation.

Public Forums

Public forums  are gatherings where large groups of citizens discuss important issues at well-publicized locations and times. Forums give people of diverse backgrounds a chance to express their views and enhance understanding of the community’s specific needs and resources. Forums should be planned in a convenient location with accessibility to public transportation and child care. They should also be scheduled at convenient times for working families to gain participation from a wide range of populations.

Focus Groups

Focus groups are a systematic method of data collection through small-group discussions led by a facilitator. Participants in focus groups are selected to represent a larger group of people. Groups of 6-10 people with similar backgrounds or interests are interviewed in an informal or formal setting. Focus groups should be scheduled at several dates and times to ensure a broad participation from members of the community. Here are advantages of focus groups:

• Community member involvement in assessing and planning community initiatives is encouraged.
• Different perceptions, values, and beliefs by community members are explored.
• Input can be obtained from specific subpopulations of the community. Example of subpopulations include young mothers caring for infants, individuals receiving home hospice care, individuals struggling to find housing, residents of the prison system, individuals coping with mental health disorders, or residents in group homes.

Interviews  are structured conversations with individuals who have experience, knowledge, or understanding about a particular topic or issue.  Key informant interviews  are conducted with people in key positions in the community and have specific areas of knowledge and experience. These interviews can be useful for exploring specific community problems and/or assessing a community’s readiness to address those problems. [ 4 ]

Advantages of interviews include the following [ 5 ]:

• They can be conducted in a variety of settings (e.g., homes, schools, churches, stores, or community centers).
• They are low cost and generally have low dropout rates.
• Respondents define what is important from their perspective.
• It is possible to explore issues in depth, and there is an opportunity to clarify responses.
• They can provide leads to other data sources and key informants.
• They provide an opportunity to build partnerships with community members.
• Data can be compared among local government officials, citizens, and non-government leaders.

Interviews can have these disadvantages:

• Interviews can be time-consuming to schedule and perform.
• They require trained interviewers.
• There is a potential for interviewer bias to affect the data collected during the interview.
• Rapport must be established before sensitive information is shared.
• It is more time-consuming to summarize and analyze findings.

Windshield Surveys

A  windshield survey  is a type of direct observation of community needs while driving and literally looking through the windshield. It can be used to observe characteristics of a community that impact health needs such as housing, pollution, parks and recreation areas, transportation, health and social services agencies, industries, grocery stores, schools, and religious institutions.

View the following YouTube video of a windshield survey [6] :  Windshield Survey Nursing .

Surveys  use standardized questions that are relatively easy to analyze. They are beneficial for collecting information across a large geographic area, obtaining input from as many people as possible, and exploring sensitive topics. [ 7 ] Surveys can be conducted face to face, via the telephone, mailed, or shared on a website. Responses are typically anonymous but demographic information is often collected to focus on the needs of specific populations. Disadvantages of surveys can include the following [ 8 ]:

• Surveys can be time-consuming to design, implement, and analyze the results.
• The accuracy of survey results depends on who is surveyed and the size of the sample.
• Mailed surveys may have low response rates with higher costs due to postage.
• They offer little opportunity to explore issues in depth, and questions cannot be clarified.
• There is no opportunity to build rapport with respondents.

Participant Observation

Participant observation refers to nurses informally collecting data as a member of the community in which they live and work. This is considered a subjective observation because it is from the nurse’s perspective. Informal observations are made, or discussions are elicited among peers and neighbors within the community.

Sociocultural Considerations

When analyzing community health needs, it is essential to do so through a sociocultural lens. Just as an individual’s health can be influenced by a wide variety of causes, community health problems are affected by various factors in the community. For example, a high rate of cancer in one community could be related to environmental factors such as pollution from local industry, but in another community, it may be related to the overall aging of the population. Both communities have a high rate of cancer, but the public health response would be very different. Another example related to mental health is related to various situational factors affecting depression. A high rate of depression in one community may be related to socioeconomic factors such as low-paying jobs, lack of support systems, and poor access to basic needs like grocery stores, whereas in another community it may be related to lack of community resources during frequent weather disasters. The public health response would be different for these two communities.

Nurses must also recognize and value cultural differences such as health beliefs, practices, and linguistic needs of diverse populations. They must take steps to identify subpopulations who are vulnerable to health disparities and further investigate the causes and potential interventions for these disparities. For example, mental health disparities pose a significant threat to vulnerable populations in our society, such as high rates of suicide among LGBTQ+ youth, reduced access to prevention services among people living in rural areas, and elevated rates of substance misuse among Native Americans. These disparities threaten the health and wellness of these populations. [ 9 ]

Key points to consider when assessing a community using a sociocultural lens include the following:

Have the trends of assessment data changed over time? What are the potential causes for these changes in this community?

How does the community’s needs assessment data compare to similar communities at local, county, state, and national levels? What target goals and health initiatives have been successfully implemented in other communities?

What vulnerable subpopulations are part of this community, and what health disparities are they experiencing? What are potential causes and solutions for these health disparities?

Input from members of vulnerable subpopulations must be solicited regarding their perspectives on health disparities, as well as barriers they are experiencing in accessing health care.

Similar to how nurses individualize nursing diagnoses for clients based on priority nursing problems identified during a head-to-toe assessment, community health nurses use community health needs assessment data to develop community health diagnoses. These diagnoses are broad, apply to larger groups of individuals, and address the priority health needs of the community. Resources such as Healthy People 2030 can be used to determine current public health priorities.

A  community diagnosis  is a summary statement resulting from analysis of the data collected from a community health needs assessment. [ 10 ] A clear statement of the problem, as well as causes of the problem, should be included. A detailed community diagnosis helps guide community health initiatives that include nursing interventions.

A community diagnosis can address health deficits or services that support health in the community. A community diagnosis may also address a need for increased wellness in the community. Community diagnoses should include these four parts:

• The problem
• The population or vulnerable group
• The effects of the problem on the population/vulnerable group
• The indicators of the problem in this community

Here are some examples of community health diagnoses based on community health needs assessments:

• Assessment data:  The local high school has had a 50% increase in the number of teen pregnancies in the past year, causing high school graduation rates to decrease due to pregnant students dropping out of high school.
• Community diagnosis:  Increased need for additional birth control and resources for prevention of pregnancy due to lack of current resources, as evidenced by 50% increase in teen pregnancies in the last year and a decrease in graduation rates.
• Assessment data:  Fifty percent of residents of an assisted living facility were found to have blood pressure readings higher than 130/80 mmHg during a health fair last week at the facility.
• Community diagnosis:  Increased need for education about exercise and diet and referrals to primary care doctors for residents of an assisted living facility due to increased risk for mortality related to high blood pressure, as evidenced by a high number of residents with high blood pressure during a health fair.
• Assessment data:  The local high school has had two cases of suicide in the past year.
• Diagnosis:  Increased need for community education regarding suicide prevention and crisis hotlines, as evidenced by an increase in adolescent suicide over the past twelve months.

Outcomes Identification

Outcomes refer to the changes in communities that nursing interventions and prevention strategies are intended to produce. Outcomes include broad overall goals for the community, as well as specific outcomes referred to as “SMART” outcomes that are specific, measurable, achievable, realistic, and with a timeline established.

Broad goals for communities can be tied to national objectives established by Healthy People 2030, as previously discussed in the “ Community Health Concepts ” section.

Healthy People objectives are classified by these five categories [ 11 ]:

SMART outcomes can be created based on the objectives listed under each category. For example, if an overall community goal is related to “Drug and Alcohol Use” under the “Health Behaviors” category, a SMART outcome could be based on the Healthy People objective, “Increase the proportion of people with a substance use disorder who got treatment in the past year.” [ 12 ] Based on this Healthy People objective, an example of a SMART outcome could be the following:

• The proportion of people treated for a substance disorder in Smith County will increase to 14% within the next year.

View the  Healthy People 2030 Objectives  and  Community Objectives .

Planning interventions.

Nursing interventions for the community can be planned based on the related Healthy People category and objective. For example, based on the sample SMART outcome previously discussed, a planned nursing intervention could be the following:

• The nurse will provide education and materials regarding evidence-based screening practices for substance use disorder in local clinics.

Community health nursing interventions typically focus on prevention of illness with health promotion interventions. After performing a community health needs assessment, identifying priority problems, and establishing health goals and SMART outcomes, the nurse integrates knowledge of health disorders (e.g., diabetes, cancer, obesity, or mental health disorders) and current health risks in a community to plan prevention interventions.

There are two common public health frameworks used to plan prevention interventions. A traditional preventive framework is based on primary, secondary, or tertiary prevention interventions. A second framework, often referred to as the Continuum of Care Prevention Model, was established by the Institute of Medicine (IOM) and includes universal, selected, and indicated prevention interventions. Both frameworks are further discussed in the following sections. [ 13 ]

Primordial, Primary, Secondary, Tertiary, and Quaternary Interventions

Preventive health interventions may include primordial, primary, secondary, tertiary, and quaternary prevention interventions. These strategies attempt to prevent the onset of disease, reduce complications of disease that develops, and promote quality of life. [ 14 ]

Primordial Prevention

Primordial prevention consists of risk factor reduction strategies focused on social and environmental conditions that affect vulnerable populations. In other words, primordial prevention interventions target underlying social determinants of health that can cause disease. These measures are typically promoted through laws and national policy. An example of a primordial prevention strategy is improving access to urban neighborhood playgrounds to promote physical activity in children and reduce their risk for developing obesity, diabetes, and cardiovascular disease. [ 15 ] See Figure 16.8 [ 16 ] for an image of a neighborhood playground.

Figure 16.8

Primordial Prevention: Neighborhood Playgrounds

Primary Prevention

Primary prevention  consists of interventions aimed at susceptible populations or individuals to prevent disease from occurring. An example of primary prevention is immunizations. [ 17 ] Nursing primary prevention interventions also include public education and promotion of healthy behaviors. [ 18 ] See Figure 16.9 [ 19 ] for an image of an immunization clinic sponsored by a student nurses’ association.

Figure 16.9

Primary Prevention: An Immunization Clinic

Secondary Prevention

Secondary prevention  emphasizes early detection of disease and targets healthy-appearing individuals with subclinical forms of disease. Subclinical disease refers to pathologic changes with no observable signs or symptoms. Secondary prevention includes screenings such as annual mammograms, routine colonoscopies, Papanicolaou (Pap) smears, as well as screening for depression and substance use disorders. [ 20 ] Nurses provide education to community members about the importance of these screenings. See Figure 16.10 [ 21 ] for an image of a mammogram.

Figure 16.10

Secondary Prevention: Mammograms

Tertiary Prevention

Tertiary prevention  is implemented for symptomatic clients to reduce the severity of the disease and potential long-term complications. While secondary prevention seeks to prevent the onset of illness, tertiary prevention aims to reduce the effects of the disease after it is diagnosed in an individual. [ 22 ] For example, rehabilitation therapy after an individual experiences a cerebrovascular accident (i.e., stroke) is an example of tertiary prevention. See Figure 16.11 [ 23 ] for an image of a client receiving rehabilitation after experiencing a stroke.

Figure 16.11

Tertiary Prevention: Post-Stroke Rehabilitation. Used under Fair Use.

The goals of tertiary prevention interventions are to reduce disability, promote curative therapy for a disease or injury, and prevent death. Nurses may be involved in providing ongoing home health services in clients’ homes as a component of interprofessional tertiary prevention efforts. Health education to prevent the worsening or recurrence of disease is also provided by nurses.

Quaternary Prevention

Quaternary prevention  refers to actions taken to protect individuals from medical interventions that are likely to cause more harm than good and to suggest interventions that are ethically acceptable. Targeted populations are those at risk of overmedicalization. [ 24 ] An example of quaternary prevention is encouraging clients with terminal illness who are approaching end of life to seek focus on comfort and quality of life and consider hospice care rather than undergo invasive procedures that will likely have no impact on recovery from disease.

See additional examples of primordial, primary, secondary, tertiary, and quaternary prevention strategies in Table 16.3a .

Table 16.3a

Examples of Prevention Interventions [25],[26]

In the United States, several governing bodies make prevention recommendations. For example, the United States Preventive Services Task Force (USPSTF) makes recommendations for primary and secondary prevention strategies, and the Women’s Preventive Services Initiative (WPSI) makes recommendations specifically for females. The Advisory Committee on Immunizations Practices (ACIP) makes recommendations for vaccinations, and various specialty organizations such as the American College of Obstetrics and Gynecology (ACOG) and the American Cancer Society (ACS) make preventative care recommendations. Preventive services have been proven to be an essential aspect of health care but are consistently underutilized in the United States. [ 27 ] Nurses can help advocate for the adoption of evidence-based prevention strategies in their communities and places of employment.

Continuum of Care Prevention Model

A second framework for prevention interventions, referred to as the “Continuum of Care Prevention Model,” was originally proposed by the Institute of Medicine (IOM) in 1994 and has been adopted by the Substance Abuse and Mental Health Services Administration (SAMHSA). [ 28 ] See Figure 16.12 [ 29 ] for an illustration of the Continuum of Care Prevention Model.

Figure 16.12

Continuum of Care Prevention Model. Used under Fair Use.

The Continuum of Care Prevention Model can be used to illustrate a continuum of mental health services for community members that includes prevention, treatment, and maintenance care:

• Universal prevention:  Interventions designed to reach entire groups, such as those in schools, workplaces, or entire communities. [ 30 ],[ 31 ] For example, wellness sessions regarding substance misuse can be planned and implemented at a local high school.
• Selected prevention:  Interventions that target individuals or groups with greater risk factors (and perhaps fewer protective factors) than the broader population. [ 32 ],[ 33 ] For example, a research study showed that wellness programs implemented for adolescents who were already using alcohol or drugs reduced the quantity and frequency of their alcohol use and reduced episodes of binge drinking. [ 34 ]
• Indicated prevention:  Interventions that target individuals who have a high probability of developing disease. [ 35 ] For example, interventions may be planned for adolescents who show early signs of substance misuse but have not yet been diagnosed with a substance use disorder. Interventions may include referrals to community support services for adolescents who have violated school alcohol or drug policies. [ 36 ]
• Treatment refers to identification of a mental health disorder and standard treatment for the known disorder. Treatment also includes interventions to reduce the likelihood of future co-occurring disorders. [ 37 ]
• Maintenance refers to long-term treatment to reduce relapse and recurrence, as well as provision of after-care services such as rehabilitation. [ 38 ]

See additional examples of prevention strategies using the Continuum of Care Prevention Model in Table 16.3b .

Table 16.3b

Examples of Continuum of Care Prevention Strategies

Read  A Guide to SAMHSA’s Strategic Prevention Framework  PDF for more about planning prevention strategies for substance misuse and related mental health problems.

Culturally competent interventions.

To overcome systemic barriers that can contribute to health disparities, nurses must recognize and value cultural differences of diverse populations and develop prevention programs and interventions in ways that ensure members of these populations benefit from their efforts. [ 39 ]

SAMHSA identified the following cultural competence principles for planning prevention interventions [ 40 ]:

• Include the targeted population in needs assessments and prevention planning
• Use a population-based definition of community (i.e., let the community define itself)
• Stress the importance of relevant, culturally appropriate prevention approaches
• Promote cultural competence among program staff

Review additional concepts related to culturally responsive care in the “ Diverse Patients ” chapter of Open RN Nursing Fundamentals.

Evidence-based practice.

It is essential to incorporate evidence-based practice when planning community health interventions. SAMHSA provides an evidence-based practice resource center for preventive practices related to mental health and substance abuse. See these resources, as well as examples of evidence-based programs and practices in the following box.

Examples of Evidence Based Prevention Practices related to Mental Health and Substance Misuse [ 41 ]

• Blueprints for Healthy Youth Development : Youth violence, delinquency, and drug prevention and intervention programs that meet a strict scientific standard of program effectiveness
• Evidence-Based Behavioral Practice (EBBP) : A project that creates training resources to help bridge the gap between behavioral health research and practice
• SAMHSA’s Suicide Prevention Research Center (SPRC) : A best practices registry that identifies, reviews, and disseminates information about best practices that address specific objectives of the National Strategy for Suicide Prevention
• The Athena Forum: Prevention 101 : Substance misuse prevention programs and strategies with evidence of success from the Washington State Department of Social and Health Services
• National Institute on Drug Abuse: Preventing Drug Use Among Children and Adolescents : Research-based drug abuse prevention principles and an overview of program planning, including universal, selected, and indicated interventions

View the  SAMHSA Evidence-Based Practice Resource Center .

Implementation.

Community health nurses collaborate with individuals, community organizations, health facilities, and local governments for successful implementation of community health initiatives. Depending on the established community health needs, goals, outcomes, and target group, the implementation of nursing interventions can be categorized as clinical, behavioral, or environmental prevention:

• Clinical prevention:  Interventions are delivered one-on-one to individuals in a direct care setting. Examples of clinical prevention interventions include vaccine clinics, blood pressure monitoring, and screening for disease.
• Behavioral prevention:  Interventions are implemented to encourage individuals to change habits or behaviors by using health promotion strategies. Examples of behavioral prevention interventions include community exercise programs, smoking cessation campaigns, or promotion of responsible alcohol drinking by adults.
• Environmental prevention:  Interventions are implemented for the entire community when laws, policies, physical environments, or community structures influence a community’s health. Examples of environmental prevention strategies include improving clean water systems, establishing no-smoking ordinances, or developing community parks and green spaces.

When evaluating the effectiveness of community health initiatives, nurses refer to the established goals and SMART outcomes to determine if they were met by the timeline indicated. In general, the following questions are asked during the evaluation stage:

• Did the health of the community improve through the interventions put into place?
• Are additional adaptations or changes to the interventions needed to improve outcomes in the community?
• What additional changes are needed to improve the health of the community?
• Have additional priority problems been identified?

16.4. LEARNING ACTIVITIES

XVI. GLOSSARY

A summary statement resulting from analysis of the data collected from a community health needs assessment.

A systematic process to identify and analyze community health needs and assets in order to prioritize these needs, plan, and act upon significant unmet community health needs.

A systematic way of collecting data through small group discussion. Focus group participants are chosen to represent a larger group of people.

Health differences that are linked with social, economic, and/or environmental disadvantages.

A goal of everyone having a fair and just opportunity to be as healthy as possible.

Avoidable differences in health status seen within and between communities.

A community in which local groups from all parts of the community work together to prevent disease and make healthy living options accessible.

Interventions that target individuals who have a high probability of developing disease.

Structured conversations with specific individuals who have experience, knowledge, or understanding about a topic or issue.

Interviews are conducted with select people who are in key positions and have specific areas of knowledge and experience.

A subset of high-priority Healthy People 2030 objectives to drive action toward improving health and well-being.

Data collected to better understand the community’s needs and/or study who may be affected by actions taken for the community. Primary data collection includes tools such as public forums, focus groups, interviews, windshield surveys, surveys, and participant observation. [1]

Interventions aimed at susceptible populations or individuals to prevent disease from occurring. Immunizations are an example of primary prevention.

Risk factor reduction strategies focused on social and environmental conditions targeted for vulnerable populations.

Public gatherings where citizens discuss important issues at well-publicized locations and times.

Public health nurses work across various settings in the community such as government agencies, community-based centers, shelters, and vaccine distribution sites. [2]

Actions taken to protect individuals from medical interventions that are likely to cause more harm than good and to suggest interventions that are ethically acceptable.

Analyzing previously collected data and research about the community to determine community needs.

Interventions that emphasize early detection of disease and target healthy-appearing individuals with subclinical forms of disease.

Interventions that target individuals or groups with greater risk factors for illness (and perhaps fewer protective factors) than the broader population.

The conditions in which people are born, grow, work, live, and age.

Standardized questions that are relatively easy to analyze and are beneficial for collecting information across a large geographic area, hear from as many people as possible, and explore sensitive topics.

Interventions implemented for symptomatic clients to reduce the severity of the disease and potential long-term complications.

Interventions designed to reach entire groups or populations such as schools, whole communities, or workplaces.

A form of direct observation of community needs while driving and literally looking through the windshield.

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing: Mental Health and Community Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022. Chapter 16 Community Assessment.
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Community Health Assessments & Health Improvement Plans

What is a community health assessment, what is a community health improvement plan, why complete an assessment and improvement plan.

A community health assessment (sometimes called a CHA), also known as community health needs assessment (sometimes called a CHNA), refers to a state, tribal, local, or territorial health assessment that identifies key health needs and issues through systematic, comprehensive data collection and analysis. Community health assessments use such principles as

• Multisector collaborations that support shared ownership of all phases of community health improvement, including assessment, planning, investment, implementation, and evaluation
• Proactive, broad, and diverse community engagement to improve results
• A definition of community that encompasses both a significant enough area to allow for population-wide interventions and measurable results, and includes a targeted focus to address disparities among subpopulations
• Maximum transparency to improve community engagement and accountability
• Use of evidence-based interventions and encouragement of innovative practices with thorough evaluation
• Evaluation to inform a continuous improvement process
• Use of the highest quality data pooled from, and shared among, diverse public and private sources

From Principles to Consider for the Implementation of a Community Health Needs Assessment Process [PDF – 457KB] (June 2013), Sara Rosenbaum, JD, The George Washington University School of Public Health and Health Services, Department of Health Policy.

The Public Health Accreditation board defines community health assessment as a systematic examination of the health status indicators for a given population that is used to identify key problems and assets in a community. The ultimate goal of a community health assessment is to develop strategies to address the community’s health needs and identified issues. A variety of tools and processes may be used to conduct a community health assessment; the essential ingredients are community engagement and collaborative participation. — Turnock B. Public Health: What It Is and How It Works. Jones and Bartlett, 2009, as adapted in Public Health Accreditation Board Acronyms and Glossary of Terms Version 1.0 [PDF – 536KB] , July 2011.

The Catholic Health Association defines a community health needs assessment as a systematic process involving the community to identify and analyze community health needs and assets in order to prioritize these needs, and to plan and act upon unmet community health needs.” —Catholic Health Association, Guide to Assessing and Addressing Community Health Needs [PDF-1.5MB] , June 2013.

A community health improvement plan (or CHIP) is a long-term, systematic effort to address public health problems based on the results of community health assessment activities and the community health improvement process. A plan is typically updated every three to five years.

The Public Health Accreditation Board defines a community health improvement plan as a long-term, systematic effort to address public health problems on the basis of the results of community health assessment activities and the community health improvement process. This plan is used by health and other governmental education and human service agencies, in collaboration with community partners, to set priorities and coordinate and target resources. A community health improvement plan is critical for developing policies and defining actions to target efforts that promote health. It should define the vision for the health of the community through a collaborative process and should address the gamut of strengths, weaknesses, challenges, and opportunities that exist in the community to improve the health status of that community. — Public Health Accreditation Board Acronyms and Glossary of Terms Version 1.0 [PDF – 536KB] , July 2011, as adapted from Healthy People 2010 and CDC’s National Public Health Performance Standards Program .

A community health assessment gives organizations comprehensive information about the community’s current health status, needs, and issues. This information can help develop a community health improvement plan by justifying how and where resources should be allocated to best meet community needs.

Benefits include

• Improved organizational and community coordination and collaboration
• Increased knowledge about public health and the interconnectedness of activities
• Strengthened partnerships within state and local public health systems
• Identified strengths and weaknesses to address in quality improvement efforts
• Baselines on performance to use in preparing for accreditation
• Benchmarks for public health practice improvements

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Chapter 3 Sections

• Section 1. Developing a Plan for Assessing Local Needs and Resources
• Section 2. Understanding and Describing the Community
• Section 3. Conducting Public Forums and Listening Sessions
• Section 4. Collecting Information About the Problem
• Section 5. Analyzing Community Problems
• Section 6. Conducting Focus Groups
• Section 7. Conducting Needs Assessment Surveys
• Section 8. Identifying Community Assets and Resources
• Section 9. Developing Baseline Measures
• Section 10. Conducting Concerns Surveys
• Section 11. Determining Service Utilization
• Section 12. Conducting Interviews
• Section 13. Conducting Surveys
• Section 14. SWOT Analysis: Strengths, Weaknesses, Opportunities, and Threats
• Section 16. Geographic Information Systems: Tools for Community Mapping
• Section 17. Leading a Community Dialogue on Building a Healthy Community
• Section 18. Creating and Using Community Report Cards
• Section 19. Using Public Records and Archival Data
• Section 20. Implementing Photovoice in Your Community
• Section 21. Windshield and Walking Surveys
• Section 22. Using Small Area Analysis to Uncover Disparities
• Section 23. Developing and Using Criteria and Processes to Set Priorities
• Section 24. Arranging Assessments That Span Jurisdictions
• Main Section

What are qualitative methods of assessment?

Why use qualitative methods of assessment, when would you use qualitative methods of assessment, how do you use qualitative methods of assessment.

Using qualitative assessment methods rather than purely data-based information is crucial to understanding many community issues and needs. Numbers work well to show comparisons, progress, an statistics of community efforts, but they cannot express motives, opinions, feelings, or relationships. This section discusses how to use qualitative assessment methods and when to implement them into communtiy planning.

Qualitative methods of assessment are ways of gathering information that yield results that can’t easily be measured by or translated into numbers. They are often used when you need the subtleties behind the numbers – the feelings, small actions, or pieces of community history that affect the current situation. They acknowledge the fact that experience is subjective – that it is filtered through the perceptions and world views of the people undergoing it – and that it’s important to understand those perceptions and world views.

There are two major scientific ways of gathering information: quantitative methods and qualitative methods. Quantitative methods are those that express their results in numbers. They tend to answer questions like “How many?” or “How much?” or “How often?” When they’re used to compare things – the results of community programs, the effects of an economic development effort, or attitudes about a community issue – they do it by subjecting all of the things or people they’re comparing to exactly the same tests or to the same questions whose answers can be translated into numbers. That way, they can compare apples to apples – everything or everyone is measured by the same standard. Quantitative measures are often demanded by policy makers; they are considered trustworthy because their results can be measured against one another, and because they leave less room for bias.

Qualitative methods don’t yield numerical results in themselves. They may involve asking people for “essay” answers about often-complex issues, or observing interactions in complex situations. When you ask a lot of people for their reactions to or explanations of a community issue, you’re likely to get a lot of different answers. When you observe a complex situation, you may see a number of different aspects of it, and a number of ways in which it could be interpreted. You’re not only not comparing apples to apples, you may be comparing apples to bulldozers or waterfalls. As a result, researchers and policymakers sometimes see qualitative methods as less accurate and less legitimate than quantitative ones. That can be true, but, as we’ll see, if qualitative methods are used with care, they can also yield reliable information.

Qualitative and quantitative methods are, in fact, complementary. Each has strengths and weaknesses that the other doesn’t, and together, they can present a clearer picture of the situation than either would alone. Often, the most accurate information is obtained when several varieties of each method are used. That’s not always possible, but when it is, it can yield the best results.

There are a number of qualitative methods that can be used in assessment of issues or community needs. We’ll list the major ones here, and look at them in more detail later in the section.

They include:

• Individual interviews . These may be structured interviews, where the questions are determined beforehand, or unstructured conversations that are allowed to range wherever the interviewee wants to go in relation to the general topic. Even in structured interviews, there may be room for both interviewers and interviewees to pursue topics that don’t relate directly to answering the original questions. The difference, however, is that in a structured interview, all those questions are formally asked, and the interviewer does her best to make sure they’re answered.
• Group interviews . These are similar to individual interviews, but involve two or more interviewees at a time, rather than one. (Sometimes, these are unexpected – the interviewee’s mother and sister are present, and insist on being part of the conversation.) Group interviews have some advantages, in that interviewees can act as a check on one another (I remember that happening in a different way…), and stimulate one another’s thinking. At the same time, the interviewer has to be somewhat of a facilitator, making sure that no one person dominates, and that everyone gets a reasonable chance to speak.

A special case of group interviewing is a focus group . This is a group of about 6-10 people, led by a trained facilitator, assembled to answer a specific question or questions. An effort is sometimes made to make sure that group members don’t know one another, so that social pressures won’t influence them. If trained facilitators are available, focus groups can be a good way to get accurate information about an issue.

• Observation . Here, someone actually goes and looks at a place or event, watches situations or interactions, or takes part in the life of the community or a population while recording what he finds as a result.
• Community or other large meetings . These meetings allow a range of people a chance to express their opinions and react to others’. They can draw on a large pool of opinions and knowledge at one time, and uncover disagreements or differences that can then be discussed.
• Interpretation of records, transcripts, etc. This can range from qualitative analysis of quantitative data (like the assumption of the researcher in the introduction to this section that people who are doing well won’t be interested in an adult education program), to using quantitative data as a jumping-off point for qualitative assessment, to case studies (detailed examinations of individual cases). The last are not always useful in assessing community issues or needs, but they can be very effective in convincing policymakers or funders of the importance of those issues and needs.

Many types of qualitative information are turned into numerical results, although not always accurately. The transformation may miss important details, or the information may simply be too complex to fit easily into numerical constraints, unless you can create a computer model or similar number-based framework that has the capacity to take in an enormous amount of variety. There are many software programs – NVivo and Atlas.ti are fairly well-known, but there are many others, including some freeware – that are intended expressly for analyzing qualitative data.

Since qualitative methods give you results that are not always easy to compare, or even to check for accuracy, people who want hard and fast evidence often see them as suspect. In fact, both quantitative and qualitative measures are important and necessary, depending on the situation. When you’re assessing community issues, as we’ve discussed, you’ll often get closest to the complete picture by using both. The problem is convincing those who need to be convinced – policymakers, funders, etc. – that your qualitative measures are reliable.

There is a debate in the research community about how to judge qualitative methods. Some say they should be evaluated by the same standards as quantitative methods. Others maintain that, because they are intrinsically different from quantitative methods, qualitative methods need a set of standards that take into account their philosophical base and the kind of information they yield.

The British government, for instance, has developed a framework for demonstrating qualitative reliability, which includes a set of 18 questions that a qualitative assessment or study should be subjected to (see Tool #1 ).

Guidelines that can help you argue for the reliability of your qualitative assessment include:

• Report accurately and completely . Whether you’re interviewing, observing, or engaging in some other technique, you should faithfully record such details as the time and place of your activity, who was involved, what the situation was, etc. In that way, you can see similarities and differences, and make comparisons where they’re appropriate. The recording of interviews, observations, and other information should be as accurate and nearly complete as possible (e.g., word-for-word for interviews).
• Frame the right questions, and direct them appropriately . Occasionally, it works to go fishing for information, i.e. to start without any idea of what you want to find out In most instances, however, you should know what the important questions are, and where you need to look for answers. The clearer you can be – and the clearer it is that the questions you’re asking will lead to real understanding and effective action – the more credibility your inquiry will have.
• Use qualitative methods specifically to gain information you can’t easily get from quantitative methods . You can quantify how many members of a specific minority live in a particular neighborhood. It’s much harder to quantify a clear understanding of how well they get along with their neighbors, and why.
• Use the method(s) that can best help you answer the questions you’re asking . If you want to know the state of vacant lots in a city, you’re less likely to determine it by asking people than you are by going and looking at the lots themselves. On the other hand, you usually can gain more information about people’s opinions through talking to them than you can from observation.
• Sort out your own and others’ subjective feelings and comments from objective reality, and try to make sure that your findings are objective . It’s easy to get caught up in the passion of interviewees’ opinions, or in your own response to particular conditions. If you want your findings to be reliable, you have to screen out as much of the subjective as possible from what you find and record. (One way to approach this issue is to have more than one person record and analyze each interview or observation, and then to check on how well they agree, both in their recording of the data and in their interpretation.)

Something that’s objective – an observation, statement, opinion, research finding, etc. – is based on reality as it actually is. Scientists, for instance, aim to be objective, and to understand the way things really are, rather than the way the scientists or others want them to be, or think they might be. A subjective observation, statement, opinion, or research finding, on the other hand, is based on the thoughts and assumptions of the person issuing it. A researcher may be so appalled by the conditions in neighborhoods where violence is rampant that she may begin to feel that violence is in fact the only rational response, and slant her research in that direction. Especially in community assessment, objectivity is vitally important. Objectivity in looking at the community will help you understand how to most effectively address issues, maximize and use assets, and solve problems. Understanding your own subjective reactions – to difficult conditions, to particular individuals, to cultural practices – will help you to screen them out, thereby increasing the reliability of your findings.

The basic reason to use qualitative methods is that there are some kinds of questions and some dimensions of community assessment that can be better addressed by them than by quantitative methods. The methods you use should be determined by the questions you’re asking. Since it may be hard to convince policymakers and others that qualitative methods are useful, however, why bother to use them at all? Some of the major reasons:

• They answer some questions that quantitative measures can’t. Quantitative methods may tell you how many people do a certain thing, but they’re unlikely to tell you how or why they do it. Qualitative methods can better answer the how and why questions, and also provide other information in the process.
• They connect directly with the population and the community with which you’re concerned. In assessment, the best sources of information are those closest to what’s being assessed: they experience it more than anyone else. Qualitative methods generally go directly to those sources with more complex questions than quantitative methods.
• They can get at certain underlying realities of the situation. Once again, quantitative methods often don’t answer “why?” questions, while qualitative methods can tell you about the history of the community or issue, who the significant supporters and opponents of various ideas are, whom people in the community listen to, etc. In an assessment situation, these can be crucial pieces of information.
• They can involve the population of interest, or the community at large, in helping to assess the issues and needs of the community. This participation fosters a sense of ownership and support for the efforts.
• They often allow for a deeper examination of the situation or the community than quantitative methods do. Quantitative methods, although helpful, can tend to put people or events in specific categories, ask for yes-no or multiple-choice answers, often eliminating complexity. Qualitative methods allow for following promising directions (“Why do you say that?”), and can lead to the discovery of important information that quantitative results wouldn’t have touched on.
• They allow for the human factor. While the information obtained through qualitative methods is often subjective, it is also often identified as such, and can be analyzed accordingly.

Clearly, there are times when quantitative research will give you the information you need. So when do you use qualitative methods? It depends to a great extent on the question you’re asking. (The first four situations below are based on a USAID guide to using rapid appraisal methods, Performance Monitoring and Evaluation Tips .)

• When what you need is qualitative, descriptive information . Particularly in an assessment situation, what you’re often looking for is descriptive or analytical information that has little to do with quantitative measures. The type of information provided by qualitative methods is often exactly what you’re looking for in community assessment to decide on next steps.
• When you’re trying to understand the reasons and motivations for people’s behavior, or how they operate in particular situations . Why don’t people take advantage of human service programs for which they’re eligible? What are the differences in the ways people of different cultural backgrounds respond to services? These are the kinds of questions you’re likely to want to answer in a community assessment, and they often can’t be answered quantitatively.
• When you’re analyzing quantitative data. As mentioned above, much quantitative data can be analyzed using qualitative methods.

An odd set of numbers – a community that’s decidedly low-income, but where a vast majority of people own their own homes, for instance – might be the springboard for a qualitative examination of why this is so. A number of reasons are possible: The community is largely elderly, and people are living in long-since-paid-for houses they bought 40 or more years ago, when their income was higher and housing was less expensive. One or more local banks have made it a priority to help people buy houses, and provide low-interest mortgages and other subsidy programs to further that goal. While they may be low-income, the members of the community nonetheless scrimp on everything else in order to put away money for a house. This is often the case among immigrants from certain cultures, where people are willing to live very simply for many years in order to save for property and education. The community has been “written off” because of its substandard housing, dangerous streets, and lack of services, and houses as a result are ridiculously cheap. A combination of factors, some of which may not be listed here. By and large, quantitative methods won’t easily tell you the reasons for this unusual situation, but qualitative methods will.

• When you’re trying to develop suggestions and recommendations . Again, this is often the primary purpose of community assessment. How should you design a program or initiative to accomplish a major community goal or deal with an issue? What will people respond to? Qualitative data may give the best information here, or may be used in addition to qualitative information to provide a complete picture on which to base your strategy.
• When you want to involve the community in assessment as directly as possible . Involving community members directly leads to ownership and support of initiatives, and is also likely to generate the best and most effective solutions. Qualitative assessment methods, for the most part, collect information directly from community members themselves, and allow them to fill in the details as much as they can. By and large, being interviewed is more likely to leave someone feeling like part of the process than filling out a survey.
• When you’re doing community-based participatory research (i.e., involving the community directly in planning and implementing assessment). Community-based participatory research often relies greatly on qualitative assessment methods.
• When quantitative data are unavailable or unobtainable.
• When you don’t have the capacity to use quantitative methods . You may not have the proper training, the software or hardware that will make quantitative assessment useful for you, or the time to use quantitative methods properly.

Now that you’re convinced of the importance of using qualitative methods of assessment, how are you going to do it? There’s seldom one right way to do anything, but we’ll offer some steps to take in using qualitative methods, including some guidelines for doing interviews and observations, the two most common methods. (Most of these guidelines hold equally for using quantitative methods as well.)

Start by deciding what it is you want to know.

You may remember that this is also one of the guidelines for qualitative reliability. It may seem elementary, but it doesn’t happen anywhere near as often as it ought to. The importance of deciding what you want to know is that it determines the character of your assessment – what kinds of questions you ask, whom you ask them of, how you’ll go about it, etc. Without that minimal amount of structure, you’re likely to wind up with a confused and unorganized mass of information.

There are many ways to approach a community assessment, and, consequently, many questions you might choose to start your assessment with. You might even use more than one, but it’s important to be clear about exactly what you’re looking for.

Some possibilities:

• What is the most serious issue – either general or specific – the community faces (i.e., what should we turn our attention to?
• What services are most needed in the community? Who most needs them?
• Are people taking advantage of services that currently exist?
• What are the community’s significant assets? How can they be strengthened?
• Are there forces working against the good of the community that should be opposed? (You probably wouldn’t be asking this question unless you thought there were, and had some idea who or what they might be.)
• Who ought to be involved in a prospective coalition or initiative?

Choose the method best suited to finding the information you’re looking for.

If you want to learn about people’s public behavior, you would probably use direct observation. Observing mothers and children in a clinic waiting room, for example, might give you information about the mothers’ anxiety levels or child-rearing practices.

If you want to know people’s opinions or how they feel about issues, some type of interview would be appropriate.

Once you’ve chosen the right method, it’s important to carry it out properly. Be aware of what you can do with the resources you have. You can’t conduct thousands of interviews in a large city, for instance, without considerable money. If you’re a cash-strapped nonprofit, you might look for a grant to fund your interviews, or you might confine your assessment to one neighborhood. Perhaps you’d mobilize volunteers to conduct interviews, or interview groups rather than individuals. It’s better to do a limited community assessment well than a large one badly. In choosing your method, be aware also that, in some cases, quantitative methods may be more appropriate and more likely to tell you what you want to know.

Choose the people who will gather the information, and, if necessary, train them.

With qualitative methods, where contact is often personal, the question of who carries them out can be very important. Academics or others who are perceived by community members as “the other,” whether because of their behavior, their speech, or simply because they’re outsiders, may find it hard to gather accurate and complete information from a population that’s very conscious of class or cultural differences. Often, it makes more sense to train members of the population or others who are known and trusted by – or at least familiar to, in their behavior, dress, and speech –those who are being asked to contribute their opinions and observations.

Data collectors should be fluent in the language and culture of those they are interviewing. If you’re assessing commercial activity in a Hispanic neighborhood, you’ll miss most of what’s really happening unless you understand both the Spanish language and the normal ways in which Hispanic (or Dominican or Mexican or Puerto Rican) customers and merchants relate to one another.

If you recruit members of the community or of a specific population to do qualitative information gathering – because they relate to the population better, because they speak the language, because you’re engaged in a participatory effort, or simply because you think they’ll be good at it – you should provide them with training to make sure that the results they come up with are reliable. Depending on what kinds of methods they’ll be using, some of the elements of a training might be:

• What to record and how : It may not be obvious how important it is to record the time, place, details, and circumstances of an interview, observation, focus group, or larger meeting It may also be necessary, depending on a trainee’s experience, to learn to use a recorder or video camera, and/or to learn how to take efficient notes without losing the thread of the conversation or missing important points in an observation.
• Interview techniques , as well as exactly what purpose an interview serves, and how it fits into the larger assessment picture. The more clearly an interviewer understands not just what to do and how, but why she’s doing it, the better she’s likely to be at drawing out the information she’s seeking.
• Observation techniques : As with an interview, an observation will be far more useful if the observer understands not just what to do and how to do it, but exactly why he’s doing it, and how it will be used.
• Training in other methods : Focus groups, for instance, require specific skills and techniques.
• Training in how to think of themselves as researchers : Like those engaged in community-based participatory research , information gatherers should understand how researchers operate. Objectivity, attention to detail, curiosity, and the continuous processing of information in order to generate the next question or observation are all part of the investigative mindset, which they should be encouraged to develop.

Determine from whom or from where you need to gather information.

It may be that you want to hear from all sectors of the community, but some issues or circumstances demand more specific informants. Some possible interview subjects may be public officials, members of a specific population or cultural group, people from a particular geographic area, or people with certain characteristics (parents of young children, individuals with disabilities, males 18-24, people with high blood pressure).

Knowing whom you need to ask extends to any method in which you talk directly to people – focus groups, large community meetings, etc. Focus groups used by marketers are chosen extremely carefully, for example, with age, gender, income, place of residence, and even such factors as favored leisure activities considered.

Observation may or may not involve people. If it does, the question may not be whom you want to observe, but rather what activity or situation you want to observe. If it’s general – what kinds of street activity take place in various neighborhoods, how people use a public park – it’s not necessary to focus on a particular population, but rather on the place. If it’s more specific – back to commercial activity in that Hispanic neighborhood – you’ll need to be in the right place at the right time.

Gather the information.

Now it’s time for you or the people you’ve chosen to go out and collect the qualitative information you need.

As mentioned above, interviews can be structured or unstructured. In a strictly structured interview, the same questions in the same order are asked of everyone, with relatively little room for wandering off the specific topic. Semi-structured interviews may also be based on a list of specific questions, but – while trying to make sure that the interviewee answers all of them – the interviewer may pursue interesting avenues, or encourage the interviewee to talk about other related issues. An unstructured interview is likely to be more relaxed – more like a conversation than a formal interview.

There are advantages and disadvantages to each approach. A structured interview may make the interviewee focus in on the questions and the interview process, take it more seriously, and thus provide excellent information. Because everyone is interviewed in the same way, a structured interview may be – or at least may look – reliable. It may also make an interviewee nervous, emphasize the differences between him and the interviewer, and lead to incomplete or less-than-truthful answers.

A semi- or unstructured interview may allow the interviewee to be more relaxed, and thus more forthcoming. It also leaves room for pursuing a topic that’s not directly related to the formal list of questions, but that might be important or even crucial. At the same time, because it can be far-ranging, a semi- or unstructured interview – particularly one that doesn’t start with a list of questions – is, or appears, less reliable than a structured one. It also, in the hands of an inexperienced or indecisive interviewer, may allow an interviewee to get sidetracked and never get back to the original questions.

What kind of interview you use depends on the nature of the information you’re looking for, the needs of the people you’re interviewing (e.g., whether comfort is more important than structure), and your own comfort. The author has conducted all three types of interviews, and has found that semi-structured interviews – having clear questions and goals for the interview, but conducting it in an informal way, with room for pursuing tangents and some simple friendly conversation – is generally productive. The following guidelines for interviewing reflect that view.

• Ask the interviewee to choose the space . You might give him a range of suggestions – his home or workplace, the office of a human service agency, a neutral space, such as a café or a park – and go with his choice. The more comfortable he is, the better and more informative the interview is likely to be.
• Choose your clothes for the comfort of the interviewee . In general, your clothes and hers should be similar: if she’s in jeans and a t-shirt, you shouldn’t be in a suit; if you’re interviewing a business executive at her office, you should be wearing a suit. Clothes send powerful messages, and the message you should be sending here is “We’re from the same planet; you can talk to me.”
• Talk beforehand with the interviewee if you’re planning to record or photograph the interview . Get permission before you show up with equipment It’s common courtesy, and it’s less likely to start the interview off awkwardly .

If the results of the interview are likely to be published, even if the interviewee will be anonymous, you might want to get a signed “informed consent” form, indicating that the interviewee understands the purpose of the interview, and gives permission for the material to be published or used in other ways.

• Record carefully the time, place, circumstances, and details of the interview . This includes a description of the location (the neighborhood as well as the space, if you’re interviewing a community member), other people present, any distractions (kids, pets, TV), other factors influencing the interview or the situation. Include a general description of the interviewee (married Hispanic woman, age 25, three children aged 6, 4, and 1).
• Think out and frame your questions carefully, and ask directly for the information you’re seeking . Memorize your basic questions (not necessarily word-for-word, but know what they are), so that you refer to notes as little as possible. Make your questions clear and unambiguous, so that questions aren’t vague or difficult to understand.
• Ask open-ended questions . These are questions that require an "essay" answer, rather than a yes-no response. For example, instead of asking "Did you enjoy being in the program?" you might ask "What was participating in the program like?" Try to give people the chance to answer as fully and thoughtfully as possible.
• Probe . Ask follow-up questions to get at what people are really saying, or to keep them talking about a topic. ("Why did you like it when the teacher asked your opinion?") Don't be afraid to pursue what may seem to be a sidetrack. Sometimes the best or most important information lies off the beaten path.

Some interviewees can manage one-word answers to nearly any question. They might answer "What was participating in the program like?" with “Good.” Don’t be afraid to probe these answers. “What does that mean?” or “How was it good?” might get you a flood of information. If it gets you another one-word answer, keep probing, unless you sense that the person is getting angry or frustrated. Then it’s probably time to move on to the next question, and hope that there’ll be an opportunity to return to this one for a fuller explanation. But be aware that some people are simply quieter – or less reflective – than others. You may never get much more than one-word answers from them.

• Don't cut people off too quickly . Their stories, or what you can read between the lines, may give you information as important as what they tell you directly.

At the same time, be aware when they’ve strayed too far from the topic. There’s a Mark Twain story that consists of the voice of a man telling an anecdote about a three-legged dog. Every other word reminds him of something else – another story – and he gets continually sidetracked, never finishing the story of the dog, or any of the others, either. Beware the Curse of the Three-Legged Dog: gently but firmly direct people back to the topic if they get too far afield.

• Confirm what you're told by checking with others to the extent that you can . Remember that you're getting people's perceptions, which aren't always the same as objective reality. In Rashomon, a film by the great Japanese director Akira Kurosawa, an incident is described from the perspectives of four participants, each of whom sees it totally differently. In fact, the phenomenon of Rashomon lurks everywhere; get everyone's side of the story.

Group interviews are both similar to and different from individual ones. The basic guidelines – being clear what you’re asking, open-ended questions, probing, etc. – still hold, but the group brings its own dynamic to the situation. The interview becomes more of a group discussion , and the interviewer’s concerns must extend to making sure that everyone gets heard, reining in individuals who dominate the discussion, and keeping the focus on ideas and information, rather than personalities. As with other methods, group interviews have advantages and disadvantages. The former include using the energy of the group to generate more information than might otherwise be forthcoming. Members may stimulate one another to come up with more and more useful material, as their thinking is prodded by the memories and conclusions of others. They can also act as a check on the accuracy of the information provided. In addition, the presence of other, often familiar, interviewees may help to break down shyness or nervousness, and create a relaxed atmosphere in which everyone feels comfortable talking. (The skills of the interviewer at making people comfortable – at least partially by being comfortable herself – are important here.) With these potential positives come the possible negatives of conflict, antagonism, or dislike among group members, as well as other negative feelings or history that can disrupt or twist discussion and make an interview all but useless. There are also problems that can arise from members of the group being too friendly: they may spend too much time in chit-chat, and have trouble focusing on the questions at hand. Group interviews may be useful when resources – and, as a result, interviewers – are limited, or when there are a large number of people who should be, or would like to be, interviewed. Groups probably shouldn’t be much larger than five or six, and interviewers should have, or be trained in, basic group facilitation skills .

Observation

What do we mean by “observation?” For our purposes, there are essentially two kinds: direct and participant observation.

Direct observation is the practice of examining or watching places, people, or activity without interfering or taking part in what’s going on. The observer is the proverbial fly on the wall, often unidentified, who does nothing but watch and record what she sees and/or hears. A direct observation to see how people use a public park, for instance, might consist of one or more observers simply sitting in one place or walking around the park for several hours, or even several days. Observers might come back at different times of day, on different days, or at different times of year, in order to understand as much as possible of what goes on in the park. They might occasionally ask questions of people using the park, but in as low-key and unobtrusive a way as possible, not identifying themselves as researchers.

Some kinds of direct observation – those where people are observed in situations they think are private – have the potential of violating privacy. In these instances, ethics generally demands that the observer obtain the permission of those being observed . In laboratory schools, for instance, where teachers are trained and new educational ideas tested, classes are often observed from behind one-way mirrors. In such cases, both the teachers and the parents of the students are generally informed that such observation may happen, and are asked to sign consent forms. They don’t know exactly when observation is taking place, but they understand that it’s part of the laboratory school environment, and are willing to allow it in order both to improve individual teachers’ skills and to foster the development of better educational methods.

Participant observation involves becoming to some extent part of the life of the people you’re observing – learning and taking part in their culture, their celebrations and rituals, and their everyday activities. A participant observer in the park above might introduce himself into the activities he observes – a regular volleyball game, winter cross-country skiing, dog walking, in-line skating – and get to know well the people who engage in those activities. He would also monitor his own feelings and reactions to using the park, in order to better understand how its users feel about it. He would probably ask lots of questions, and might well identify himself as a researcher.

An effective participant observer may take a long time (in some cases, years) to establish himself in this way. There are exceptions to this rule, of course. Some marketing firms and corporations employ trend-spotters as participant observers. Young, hip, and stylish themselves, these observers are able to identify and mingle with adolescent and young adult trend-setters in brief interactions, and determine what products, styles, and behaviors are likely to catch on soon with young people in general. You may able to do something similar, but it helps greatly if you’re already part of the group that you’re interested in observing, or if the group, like public park users, can include anyone.

Both direct and participant observation can be useful in community assessment. A participant observer in that situation is likely to be a member of the group being observed, because of the length of time it can take to establish an outsider as a participant observer. Direct observation is probably more common as an assessment tool.

Regardless of its type, your observation should be conducted so as to be reliable.

Some guidelines for reaching that goal:

• Think carefully about the questions you want your observation to answer . You may be looking at people’s behavior or interactions in a given place or situation, or the nature of social, physical, or environmental conditions in a particular place or circumstance. If you’re clear about what you want to find out, you can structure your observation to get the best information.
• Where and whom should you observe to answer these questions ? You wouldn’t normally look for evidence of homelessness in the wealthiest neighborhood in town, nor would you observe the residents of an Asian neighborhood to find out something about the Hispanic population.
• When and for how long should observation take place ? Observing commercial activity downtown on Sunday morning won’t get you a very accurate picture of what it’s actually like. You’d need to observe at both busy and slow times, and over a period of time, to get a real idea of the amount, intensity, and character of commercial activity.

What should you observe and record? That depends on the questions you’re trying to answer, but some basics include:

• The physical characteristics of the setting(s), including weather, if outdoors.
• The time of day, week, and year.

Clothing reflects the way people choose to present themselves to the world. A mohawk haircut, piercings, and black clothes represent an attitude and, to some extent, a world view, not just a fashion statement. The same is true for an expensive suit, or for an outfit of jeans, wool shirt, and hiking boots. Paying attention to such details can increase both your understanding and the reliability of your observation.

• The activities, events, and/or places or circumstances observed, and a description of each.
• The nature of interactions among people.
• People’s apparent attitudes toward a place, situation, activity, or event – positive or negative, happy, confused, angry, disappointed, etc.

At a neighborhood festival, for instance, an observer could be watching from a window high above the street, from a position just at the edge of the crowd, from within the crowd and the festival goings-on, as a participant in a festival activity, or even as a festival volunteer or organizer. What she would see and hear, what she would experience, and the information she would obtain would be different from each of these viewpoints.

• The observer’s own responses and attitudes, including the physical and psychological comfort of the observation. This should be separate from the recording of the observation itself, and, in the ideal, should not influence the objective recording of what was observed.

How do you record observations? That depends on the nature of the observation and on your resources. Video recording, unless it’s done from a concealed spot, or in a situation where such recording is expected (a tourist site, or that street festival, for example), can change people’s behavior or put the observer under some suspicion. Audio recording is much less obvious, but also provides less information, unless it’s specifically sound information that you’re seeking. In most cases, recording would be done with a notebook and pencil or with a laptop computer. If recording during the observation would be disruptive or out of place, you’d probably wait till after you had left the situation – but as soon after as possible, so as not to forget or confuse details.

Analyze the information.

Once you’ve gathered information by whatever qualitative method, you have to figure out what it tells you . Some of that will be obvious: if you’ve been interested in who uses that public park we were talking about earlier, and your observation tells you that it’s mostly young people, you have an answer to your initial question . Your next questions may be why other groups don’t use the park as much , and whether the fact that it’s largely used by young people keeps others away. When you’ve answered those questions, you may have generated others , or you may have a basis for planning a campaign to get more people using the park.

Make and carry out a plan to address the issue or problem you’ve identified or were concerned with.

The final step here is to use the information and analysis that came from your use of qualitative methods to change the community for the better. All the assessment in the world is useless if it doesn’t lead to some action that’s meant to create positive change.

Qualitative methods of gathering information – methods such as interviews, observation, focus groups, and community meetings that don’t always yield results that can be reduced to numbers, or that are used to capture a level of information difficult to get with quantitative methods – are often extremely useful in community assessment, especially when used together with quantitative methods, which do give numerical results. Qualitative methods can get at the things that numbers don’t, such as the reasons for people’s actions, or community history. They can help to identify community issues and needs, and provide a basis for planning community efforts that lead to long-term change.

Online Resources

The Action Catalogue is an online decision support tool that is intended to enable researchers, policy-makers and others wanting to conduct inclusive research, to find the method best suited for their specific project needs.

Chapter 6: Research Methods in the "Introduction to Community Psychology" describes the ecological lens in community research, the role of ethics, the differences between qualitative and quantitative research, and mixed methods research.

Harnessing Qualitative Data to Advance Health Equity is a presentation on how data has the potential to both paint an accurate picture of what sexual and intimate partner violence prevention practitioners and advocates know is happening on the ground  and  convey that reality to policymakers.

Qualitative assessment of the Washington State Department of Social and Health Services goals provides a summary of the results of focus groups conducted to explore the public's perception of relevant issues. This is a summary, but you can also download a PDF of the full report.

Qualitative Methods  provides brief descriptions of four standard qualitative research methods: participant observation, direct observation, unstructured interviews, and case studies.

Qualitative Research Methods  is a compendium of sites with papers, links, etc. to qualitative research methods.

Print Resources

Berg, B. (2007),  Qualitative Research Methods for the Social Sciences  (6th edn.) Boston: Allyn and Bacon.

Berkowitz, W. (1982).  Community impact . Cambridge, MA: Schenkman Publishing Company, Inc.